Cognitive Behavioral Stress Management Cognitive...

Cognitive Behavioral Stress Management Training for Nursing Students

Ulrik Terp

Ulrik Terp | C

ognitive Behavioral Stress M

anagement Training for N

ursing Students | 2019:31


The overall purpose of this thesis is to examine a new stress management intervention developed for nursing students.

The thesis includes three studies. The aim in the first study was to investigate the feasibility and acceptability of the stress management intervention. The analysis suggested that the feasibility of conducting a full-scale evaluation was confirmed for recruitment, acceptability, data collection, and adherence to the intervention. However, difficulties were also identified. In the second study the aim was to investigate the participants’ experiences from participating in the intervention. The findings indicate that participants developed new and more adaptive coping strategies. Findings emphasize the importance of both theoretical and structural aspects when planning a stress management training intervention. The third study aimed at investigating preliminary psychological effects regarding self-esteem, self-efficacy and stress management competence. Perceived stress management competency was improved and had withstanding effects one year later when compared to a control group. Self-esteem and self-efficacy, both psychological resources, also increased over time after the training program. In summary, this thesis provides insight and knowledge into the challenges and the complexities of developing and implementing a stress management intervention in a nurse education context.

DOCTORAL THESIS | Karlstad University Studies | 2019:31

Faculty of Arts and Social Sciences

Psychology


ISSN 1403-8099

ISBN 978-91-7867-066-6 (pdf)

ISBN 978-91-7867-056-7 (print)



Ulrik Terp

Print: Universitetstryckeriet, Karlstad 2019

Distribution:Karlstad University Faculty of Arts and Social SciencesDepartment of Social and Psychological StudiesSE-651 88 Karlstad, Sweden+46 54 700 10 00

© The author

ISSN 1403-8099

urn:nbn:se:kau:diva-75458

Karlstad University Studies | 2019:31

DOCTORAL THESIS

Ulrik Terp


WWW.KAU.SE

ISBN 978-91-7867-066-6 (pdf)

ISBN 978-91-7867-056-7 (print)

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Doctoral dissertation in Psychology: CBT-based stress management training for nursing students

Ulrik Terp, Department of Psychology, Karlstad University, Sweden

Abstract


The thesis comprises three studies (Study I-III) based on empirical data from a sample of nursing students. The specific aim in the first study (Paper I) was to investigate the feasibility and acceptability of the stress management intervention. The results in the first study suggested that the feasibility of conducting a full-scale evaluation was confirmed for recruitment, acceptability, data collection, and adherence to the intervention. However, difficulties relating to homework were also identified. In the second study (Paper II) the specific aim was to investigate the participants’ experiences from participating in the stress management intervention. Findings indicate that participants developed new and more adaptive coping strategies, which were attributed to the intervention. The participants expressed that they had increased their ability to reflect which led to increased insight and self-reflection. Findings further emphasize the importance of both theoretical and structural aspects when planning a stress management training intervention. A group format delivery in combination with a multi-component cognitive behavioral intervention can be interrelated elements for positive stress-related changes. The third study (Paper III) aimed at investigating preliminary psychological effects regarding self-esteem, self-efficacy and stress management competence. In the third study, perceived stress-management competency among nursing students was improved and had withstanding effects one year later when compared to a control group. Self-esteem and self-efficacy, both psychological resources, increases over time after the training program.

In summary, this thesis provides an important insight into the challenges and the complexities of developing and implementing a stress management intervention in a nurse education context.

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Keywords: Stress management, Health promotion, Higher education, Nursing students, Cognitive Behavioral Training, Feasibility, Acceptability

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Paper I

Terp, U., Bisholt, B., & Hjärthag, F. (2019). A feasibility study of a cognitive behavioral based stress management intervention for nursing students: Results, challenges, and implications for research and practice. (Submitted manuscript).

Paper II

Terp, U., Bisholt, B., & Hjärthag, F. (2019). Not Just Tools to Handle It: A qualitative study of nursing students’ experiences from participating in a cognitive behavioral stress management intervention. Health Education & Behavior, 1-8. https://doi.org/10.1177/1090198119865319

Paper III

Terp, U., Hjärthag, F., & Bisholt, B. (2019). Effects of a cognitive behavioral-based stress management program on stress management competency, self-efficacy and self-esteem experienced by nursing students. Nurse Educator, 44(1), E1-E5. https://doi.org/10.1097/nne.0000000000000492

Reprints were made with permission from the different publishers.

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Preface ................................................................................................................ 7

Introduction ........................................................................................................ 8

Dissertation’s rationale .................................................................................. 11

Stress prevention and health promotion within higher education ............. 12

Interventions aimed specifically at nursing students .................................. 13

Gaps in the literature ..................................................................................... 14

Stress theories ................................................................................................. 17

The transactional model ............................................................................... 18

The job demand-control-support model ...................................................... 19

The effort-reward approach .......................................................................... 22

Kember’s model on perceived workload ..................................................... 23

Modern cognitive research on stress........................................................... 25

Cognitive activation theory of stress (CATS) .............................................. 26

The stress mindset research ........................................................................ 27

The Intervention .............................................................................................. 30

Theory of change – active ingredients of the intervention ......................... 30

Rationale for the length, format and content of the intervention ............... 33

Content and applied exercises ..................................................................... 34

The first session: Introduction .................................................................. 34

The second and third session: Focus on emotions ................................ 34

The fourth and fifth session: Focus on cognitions .................................. 35

The sixth session: Self-compassion ........................................................ 36

The seventh session: Acceptance and Commitment Training (ACT)... 37

The eighth session: The balances of life ................................................. 38

The ninth session: Effective communication ........................................... 38

The last session: Summary ...................................................................... 39

Methods and summary of studies ............................................................... 40

Study I............................................................................................................. 40

Study design and participants .................................................................. 41

Measures and analysis ............................................................................. 41

Results ........................................................................................................ 43

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Study II ........................................................................................................... 44


Data collection ........................................................................................... 45

Method and analysis ................................................................................. 45

Results ........................................................................................................ 46

Study III .......................................................................................................... 47


Data collection ........................................................................................... 47

Measures .................................................................................................... 47

Analysis ...................................................................................................... 48

Results ........................................................................................................ 48

General discussion ......................................................................................... 50

Is the stress management intervention feasible and acceptable to nursing students? ........................................................................................................ 50

Nurse education from a psychosocial point of view – theoretical considerations with potential implications for nurse educators ................. 60

Methodological comments ............................................................................ 64

Reflexivity ....................................................................................................... 64

Self-assessment scales ................................................................................ 66

Future research ............................................................................................. 67

Conclusions .................................................................................................... 68

Acknowledgements ........................................................................................ 71

References ........................................................................................................ 73

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Preface

For over ten years, I have worked as a university teacher and my main job has been to teach in one of the many exciting areas contained in the subject of psychology. Soon after I started working at the university, I became involved in teaching in the nursing program and among the first things I got to teach was about stress. This was successful in many ways because it is a phenomenon that has interested me for many years. After meeting the students, I noticed a great interest early on, but also a need to learn not only about, but also how to relate to the often-difficult phenomena that stress constitutes. In summer 2013, I spent one evening wondering if I should submit a late application to the master's program in psychology that was offered in my own department at the university. The master’s program had a focus on cognitive behavioral therapy and caught my interest. Two years later, I finished my master's degree and was full of new exciting knowledge and clinical skills. During the master's program, I taught in parallel and as the time for my master’s thesis approached, I began to think about opportunities to combine my interests and the need I met among the nursing students regarding the phenomenon of stress. It seemed from my conversations with my nursing students that there was a "real-world problem" and this caught my interest. Many expressed that they felt stressed while feeling that they did not have effective strategies for coping with the stress.

Choosing to work with nursing students has thus both practical and theoretical origins. Practically, based on my early encounter with this group of students, and theoretically based on what I found when I immersed myself in the field from a scientific perspective during my master´s program. Looking back, I am done with my postgraduate education and I have thus spent an additional four years deepening and expanding my knowledge in the field. The dissertation is the result of this work.

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Introduction

This dissertation examines an intervention for nursing students that aimed to train the participants in stress management. The scientific background to this choice is that studies show that stress-related problems are higher among university students than among comparable groups in the general population. This pattern is found in large parts of the world and is therefore important to address (Edwards, Burnard, Bennett, & Hebden, 2010; Ibrahim, Kelly, Adams, & Glazebrook, 2013; Sharp & Theiler, 2018; Winzer, Lindberg, Guldbrandsson, & Sidorchuk, 2018). A meta-analysis by Tung, Lo, Ho, and Tam (2018) showed that for nursing students the prevalence of depression was 34% and Cheung et al. (2016) found that the prevalence of mild to severe depression, anxiety and stress among baccalaureate nursing students were 35.8%, 37.3% and 41.1 % respectively. In a Swedish study that examined the prevalence of depression among nursing students, 5.7 % of the men and 10.7% of the women, reported depression (Christensson, Vaez, Dickman, & Runeson, 2011).

In a comprehensive longitudinal Swedish study Gustavsson, Jirwe, Frögéli, and Rudman (2014) investigated both the occurrence of stress, depression and burnout symptoms during nursing education as well as whether these phenomena change during education. The study found that burnout symptoms increase during education, from close to 30% semester one to 41% semester six.

There is often comorbidity between anxiety and depression, and in both cases, stress contributes in different ways to these problems (Phillips, Carroll, & Der, 2015). This makes stress prevention and mental health promotion an important area of research and of relevance to nurse education and higher education in general (Beanlands et al., 2019; Conley, Durlak, & Kirsch, 2015; Eng & Pai, 2014; Timmins, Corroon, Byrne, & Mooney, 2011; Winzer et al., 2018). The most common sources of stress for nursing students relate primarily to academic, clinical and financial aspects (Blomberg et al., 2014; Pulido-Martos, Augusto-Landa, & Lopez-Zafra, 2012). For many students, it is also common to work full or part-time in addition to their studies, which in turn generates stress and boundary problems (Home, 1997; Robotham, 2012).

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Cowen, Hubbard, and Hancock (2016) and Villeneuve, Heale, Rietze, and Carter (2018) describe how the clinical features of nursing education contribute to increased stress for students. The research further describes how lack of previous experience in clinical work, being unfamiliar with the clinical environment and uncertainty about the care of demanding patients constitute stressors for many nursing students in the clinical context. In addition, studies show that nursing students experience fear of making mistakes, a lack of support from other staff, experiences of not having the knowledge required for the job and fear of being assessed. Nerdrum, Rustöen, and Rönnestad (2009) found that factors in the students' work environment were strongly linked to perceived stress for the students. Both the clarity of the educational structure and the degree of social support the students experienced in the educational psychosocial environment affected the subjectively experienced workload of the students (Nerdrum et al., 2009).

At the individual level, stress can affect academic as well as clinical performance and grades and lead to drop out of education. Further, stress affect relationships with both teachers and other students, reduce students' involvement in social activities and have a negative impact on central aspects self-image and thus impair mental health and quality of life (Bayram & Bilgel, 2008; Conley, Durlak, & Dickson, 2013; Li et al., 2018; Mitchell, 2018; Regehr, Glancy, & Pitts, 2013; Rudman & Gustavsson, 2012). There is a link between stress and the strategies individuals develop and apply to learning. Studies have shown a link between high levels of perceived stress and surface-oriented approaches to learning. In practice, this means that the more stress the individual student experiences, the more superficial learning strategies are applied (Öhrstedt & Lindfors, 2018). Stixrud (2012) also emphasizes how stress affects learning conditions, by negatively affecting the ability to think abstractly, evaluate arguments as well as affecting the will to explore new thoughts and ideas. In addition, modern brain research has shown how stress negatively affects memory function, which further complicates effective learning. (Gagnon, Waskom, Brown, & Wagner, 2019). Studies have also shown how prolonged stress limits the ability to cope with the stress, which thus becomes an additional burden. Lack of coping ability has therefore been described as a risk behavior per se (Byrd & McKinney, 2012). The problem with poorly developed, or ineffective, coping strategies is,

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according to Deasy, Coughlan, Pironom, Jourdan, and McNamara (2015) that risk behaviors often aggregate in clusters. Put differently, risk or problem behaviors rarely come alone. They have negative and potentially cumulative effects on health. Research has shown that stress is often an underlying cause behind the development of multiple unhealthy behaviors, and working actively to strengthen and promote the development of both existing and new psychological resources can therefore be important, not least in an educational context (Dodd, Al-Nakeeb, Nevill, & Forshaw, 2010). Taken together, this means that it is important for students to learn to cope with stress in various ways and to be trained in developing functional and effective stress management strategies (Fernandez et al., 2016; Stixrud, 2012; Timmins et al., 2011).

Extensive international and national research has mapped and investigated specific stressors in nursing education. Much less is known about psychosocial conditions or conditions during the education period. This is even though research has shown that stress-related problems often start during education (Rella, Winwood, & Lushington, 2009; Rudman & Gustavsson, 2012). It is therefore important to conduct research focusing on the psychosocial work environment in education and to develop and test new interventions that can contribute in this area (Gustavsson et al., 2014; Li et al., 2018; Rella et al., 2009; Storrie, Ahern, & Tuckett, 2010). The situation of nursing students is throughout the dissertation considered from a work environment perspective. This is partly because life as a student contains elements that can be regarded as work, e.g. work prior to examinations, participation in teaching and demands on results as well as effective collaboration with others (Kim, Jee, Lee, An, & Lee, 2017; Lin & Huang, 2014). However, the analogy is also made with the support of a legal perspective, as the situation of students, with a few exceptions, is equated with work in the Work Environmental Act (SFS 1977: 1160). In addition, the Higher Education Ordinance emphasizes that the university has an important responsibility for the students' work environment and emphasizes special preventive health care (SFS 1993: 100). An important difference between an employee and a student is the formal responsibility a professionally qualified person has. Furthermore, the situation for students can be compared in different ways with being in a constant reorganization where conditions of importance, such as working hours constantly change and where supervisors are frequently changed, often at short notice,

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which means that there can be relatively large amounts of uncertainty and unpredictability for the worker, i.e. the student. This can affect the conditions for students being able to plan their lives effectively and thus can lead to negative stress. By elucidating students' situation from a psychosocial work environment perspective, awareness of the importance of psychosocial factors regarding mental health and potential ill-health can increase in teachers, clinical supervisors and education managers in nursing education. The starting point for comparing the study situation with a working situation in essential respects is central to the dissertation and from that, theoretical perspectives and analytical frameworks are drawn from both classical and modern stress theories, but also from work and organizational psychological research and theories.

Dissertation’s rationale

Comparing research on stressors in both the academic and clinical contexts, there is significantly less research on different types of interventions that can be applied to meet the development and conditions described initially in the text. The heart of the dissertation consists of an intervention that is created with the aim of being able to meet the nursing student's stress.

Before interventions are implemented on a large scale, it is important to examine the premises for an RCT for various reasons, both practical, economical and scientific. Feasibility studies are therefore needed to investigate both practical and theoretical conditions for moving on when designing, evaluating and implementing an RCT and are therefore an important part of the research process (Abbott, 2014; Craig et al., 2008). According to Abbott (2014), feasibility studies should focus on investigating issues related to recruitment of participants, conditions related to implementing the intended intervention in the context that is relevant, how participants value the intervention and its various parts (acceptability), the responsiveness of the participants, as well as issues related to dropouts. Finally, scales and measurement methods should be examined for suitability. These are the areas the dissertation aims to explore. Further operationalization of the various areas that Abbott (2014) addresses has been made based on Orsmond and Cohn (2015). Feasibility and

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acceptability can, and should, be further investigated both from a participant as well as from a performer’s perspective (Sekhon, Cartwright, & Francis, 2017).

By examining the recipient's perspective, knowledge and insights can be obtained such as the reasons stated by participants for participating, completing or ending the intervention. Examining the participants' perspectives can contribute with knowledge about how the content of the intervention is perceived, and what obstacles and factors of participation participants experience or experienced. By examining participants' perspectives, new hypotheses can also be generated that can be tested in future studies (Berg, Raminani, Greer, Harwood, & Safren, 2008). The performers' perspective touches on aspects related to the actual performance of an intervention. Is it possible to implement the intervention as intended or do unexpected problems arise? These issues can then be considered in the ongoing work and adequate efforts can be directed to address the problems before proceeding with a full-scale RCT.

Stress prevention and health promotion within higher education

The stress-related problems that exist in higher education have been described as a neglected aspect of public health that needs to be addressed more actively and receive more attention (Bayram & Bilgel, 2008; Galbraith & Brown, 2011; Stewart-Brown et al., 2000). There has even been talk of the situation with the increasing mental ill-health in higher education as a "silent epidemic" (Williams, 2014). The fact that there are relatively few studies that deal with the university environment seen from a student and organizational perspective reflects, according to researchers, a figure of thought in which the student is not an important participant but is more regarded as a passive recipient of education (van Dinther, Dochy, & Segers, 2011).

Extensive efforts to curb the increasing stress-related ill health in higher education have been made and evaluated. Researchers have emphasized the importance of investing in creating both physical, mental and social academic environments that promote the mental health of both students and staff (Fernandez et al., 2016).

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Research also shows that only a few of those in need of psychological help receive adequate help, and the need for preventative, broad and easily accessible interventions is therefore emphasized (Bernhardsdóttir & Vilhjálmsson, 2013; Regehr et al., 2013; Winzer et al., 2018). According to Regehr et al. (2013), it is common for universities to rely on student health or similar. This is emphasized as inadequate by the researchers.

Research shows that measured by reduced stress, anxiety and depression, cognitive, behavioral and mindfulness-based interventions show the most positive results (Conley et al., 2013; Regehr et al., 2013). Conley et al. (2013) describe components that, according to research, promote the effectiveness of stress management interventions. On one hand, they contain elements of active supervision and on the other, new behaviors are practiced. In order to learn new behaviors, the participants must, in addition to new knowledge, also be given the opportunity to receive guidance on the new behavior and thus learn skill mastery.

Conley et al. (2013) also highlight the need for further evaluations of the interventions carried out in higher education. This is particularly important since none of the interventions studied in Conleys' review showed any long-term effects. Conley et al. (2015) also discuss how an accessible way to work preventively while promoting health can be through interventions aimed at strengthening personal and interpersonal skills. Competences that in turn create the conditions for positive academic achievement, which according to Conley et al. (2015), is the foundation of all academic education.

Interventions aimed specifically at nursing students

In the case of interventions aimed specifically at nursing students, research has shown mixed results. Many interventions have shown positive results measured in improved problem solving, self-management skills, well-being and work performance (Beanlands et al., 2019; Jones & Johnston, 2000). Studies further show that effective interventions contain elements aimed at increasing participants’ self-awareness and reflective ability (Eng & Pai, 2014). According to Jones and Johnston (2000), it is important that interventions contain

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practical elements, train specific coping skills, are student-centered, work with real life applications and allocate sufficient time for participants to have the conditions to learn new behaviors, attitudes and stress management strategies. Finally, effective interventions are characterized by working to change maladaptive cognitions (reappraisals) as well as helping the participant acquire new stress management skills, so-called skills training (Galbraith & Brown, 2011; Liu, Ein, Gervasio, & Vickers, 2019; Turner & McCarthy, 2017).

Gaps in the literature

In a systematic review, Jones and Johnston (2000) identify a number of areas where there are deficiencies or knowledge gaps in prevention research aimed specifically at nursing education. According to Jones and Johnston (2000), more research is needed to investigate interventions that target primary level, see Figure 1 below. Furthermore, Jones and Johnston (2000) calls for research that touches on and examines the psychosocial aspects of the students' work environment is lacking. The researchers summarize their study by addressing the need for interventions that combine individual and organizational levels, thus addressing multiple levels simultaneously.

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Galbraith and Brown (2011) concur with Jones and Johnston (2000) conclusion that there is a lack and need for more multimodal interventions, i.e. interventions targeting multiple levels of an education at the same time.

In the most recent review study conducted on stress prevention in nurse education, Turner and McCarthy (2017) follow up the studies by Jones and Johnston (2000), Galbraith, and Brown (2011) and agree in large part with their conclusions. They agree both regarding which interventions have proven to be effective as well as regarding the methodological deficiencies identified in previous studies. Turner and McCarthy (2017), in their review, highlight only a few aspects that were not highlighted in previous studies. It is, according to Turner and McCarthy (2017), problematic that the majority of the studies in the literature are conducted in the USA, Canada or the UK. More studies from other parts of the world are needed given that the spread of the problem is not limited to the said countries. Turner and McCarthy (2017) also highlight the need for more interventions with a clear and well-described theoretical base.

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Both Berg et al. (2008) and Craig et al. (2008) highlight the need for more qualitative studies, as research in the stress as well as the stress management field is dominated by quantitative research. Research shows that some interventions produce effects, but quantitative studies provide little knowledge of what happens and contributions to how these effects, or missing effects, can be understood (Nielsen & Randall, 2013). In addition to knowledge about participants' experiences of participating in interventions, new hypotheses are also needed based on the knowledge that qualitative studies can contribute (Berg et al., 2008).

Finally, both Turner and McCarthy (2017) and Winzer et al. (2018) highlight the need for studies investigating the long-term effects of interventions. With the exception of Frögéli, Rudman, Ljótsson, and Gustavsson (2018), there is very limited research that deals with long-term follow-up of the impact of interventions on the participants.

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Stress theories

The theoretical selection of stress theories in the thesis is based on several factors. First, the ambition with the theoretical framework is to enable a discussion about what the core of the concept of stress consists of. The diversity that exists in stress research is both its strength and weakness. The founder of the stress concept, Selye (1973, p. 692), expressed almost fifty years ago what is still the case in many ways;” Everybody knows what stress is and nobody knows what it is”. There are many different research traditions in stress research and each focus defines and measures the concept in partially different ways. This contributes to some of the difficulties that stress research has to deal with (Slavich, 2018). Stress is, to use the Epel et al. (2018, p. 146) formulation, not a “monolithic” concept. Stress can be experienced and measured on several different levels, form the physiological, psychological and social levels and researchers believe there is no ‘gold standard’ either in terms of definitions or measuring the concept (Epel et al., 2018; Slavich, 2018). Some of the methodological challenges and difficulties that this lack of consensus on the term entails are evident, among other things, in the measurement methods used, where biological (objective) and psychological (subjective) measures are not always related in a logical way (Mauss, Levenson, McCarter, Wilhelm & Gross, 2005). In addition to the different levels of the concept, stress can also be of a different nature. For example, it can be important if a stressor is acute or chronic as well as of high or low intensity (McEwen, 2000, 2007). Thus, there is, therefore, no consensus around which aspects are most central to our understanding of the concept, but in a conceptualization of the concept Goodnite (2014, p. 72) raises three distinctive characteristics that define a scientific, thus differing from a layman, definition of the term:

1. The application of tension, force, or pressure (a stimulus) to an organism.

2. The appraisal of the stimulus as overwhelming. That is, the organism perceives an inability to meet the challenge.

3. A measurable response by the organism to the stimulus.

The stress theories that will be used as a theoretical framework in the dissertation, and presented and problematized within the framework for the intervention, have been chosen using two conditions. Firstly,

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that the theory are well established in stress-research. Secondly, it should be possible to discuss proposals for future interventions within the framework of the dissertation context. Selected theories have thus been chosen with the intention of being able to apply both to educational practice and by being useful and relevant to the intervention.

The transactional model

One of the classics of stress research is the model developed by Lazarus and Folkman (1984), the so-called transactional model. A central assumption in the model is that it is the interaction between the individual and the environment, not the events themselves, that affects our experience of stress (Lazarus & Folkman, 1984). Lazarus and Folkman (1984, p. 19) define stress as follows”Psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.” From this perspective, stress is regarded as an individual phenomenon because individuals can perceive the same objective stress differently. Reactions to the same objective stimuli can also result in significantly varied responses in different individuals. One point of departure in the model is that individuals interpret an event or a stimulus in three, theoretically separate, steps. Cognitive factors, and subjective aspects, are thus of great importance.

In the first step, the individual makes a primary appraisal, which means that a situation is interpreted as either threatening and harmful or as challenging. In the second stage of the interpretation process, secondary appraisal, the individual's assessment of his / her own ability to handle the situation in question effectively is performed. The third step is called reappraisal and describes how our interpretations change depending on the new information that is constantly being added. Lazarus and Folkman's (1984) classic definition has been used actively and has been included as an important starting point in the intervention. The rationale for this is their definition that emphasizes subjectivity. It is the individual's interpretation of a situation that is central to the experience, the difference between a ”stress reaction” and a ”non-stress” reaction is defined by both a conscious and

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unconscious assessment of a stressor, and the resources required handling the stressor. These theoretical starting points allow an exploration, problematization of both their own, others’ interpretations, and the potential significance of interpretations that these differences may entail. Furthermore, based on Lazarus and Folkman's definition of stress, it is meaningful to discuss, and in a group, to problematize which aspects of demands / threats, assets and resources are influential. This individual and collective parallel exploration has been of central importance in the intervention.

The theory is one of the first to start from humans and is not based on animal research, as much of the theory of stress research does. A very important difference between animals and humans, is the human cognitive ability to imagine and interpret events both in the past (by rumination), in the present, and in the future (by worrying) (Brosschot, Pieper, & Thayer, 2005; Capobianco, Morris, & Wells, 2018). This is a difference of central importance for our understanding of the phenomenon of stress, but also has implications for interventions aimed at training stress management.

The job demand-control-support model

One of the most cited theories in the field of work- and organizational psychology is the job demand-control-support (JDCS) model developed by Karasek Jr (1979), Karasek, and Theorell (1990). According to this model, psychosocial stress is explained using three variables. These are psychological job demands, including workload and time pressure, and work decision latitude such as control over the work tasks and general work activity. The third variable consists of perceived social support from colleagues and supervisors. This results in a model with four categories, see figure 2. The four different categories are high strain (high demand/low control), Low strain (low demand/high control), Active (high demand/high control) and passive (low demand/low control) (Karasek & Theorell, 1990; Magnavita & Chiorri, 2018).

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In a systematic review Nieuwenhuijsen, Bruinvels, and Frings-Dresen (2010) found strong evidence that high job demands, low job control, low co-worker support and low supervisor support predicted the incidence of Stress Related Disorders (SRD). Thus, there is a well-documented correlational relationship between these factors in the work environment and the risks of cardiovascular problems and premature death. The model's theoretical points of departure have also been supported in other review articles (Häusser, Mojzisch, Niesel, & Schulz-Hardt, 2010; Kivimäki & Kawachi, 2015; Theorell et al., 2016). An important aspect of the model is that, in addition to being a way of categorizing work situations, it also constitutes a motivational psychological model. This makes it relevant in an educational context. Favorable conditions for learning arise, according to the model, when both demands and influence are high. These variables are therefore important to consider when organizing the work environment when it comes to promoting health and well-being at work (Kivimäki & Kawachi, 2015).

The Job Demand-Control-Support (JDCS) model has been applied in a nurse education context with the purpose of studying the nursing

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students’ well-being. Researchers investigated the students’ well-being along with the perceived levels of control, support and demands for each individual student during their academic and work place environments (Tuomi, Aimala, & Žvanut, 2016). Tuomi et al. (2016) measured the students twice during their education and found that most of the students did not change positions during their education. When the students were assessed the second time just before graduation, 48.2 % perceived their study situation as low strain, characterized by having a strong feeling of study control in combination with a perception that their knowledge and skills were underestimated or unused. In this case, according to theory, there is a danger that the student ends up less satisfied and potentially frustrated. Seventeen percent perceived the same study situation as high strain. This meant that the students perceived their study situation as demanding, and without control over the situation. One consequence, applying the theoretical perspective from the model, is that students might experience considerable mental strain. This has a potential negative impact on learning and other vital aspects, as discussed previously. Twenty-two percent of the participants experienced that their education activated them. Students in this category perceived high control over the study and perceived this as demanding. According to theory, the highest level of active learning should occur among students in this category. Active learning and student well-being are, according to studies, tightly connected (Cotton, Dollard, & De Jonge, 2002). Finally, Tuomi et al. (2016) found that 12.6 % of the students perceived that the education passivated them. In this case, students did not find their study demanding, nor do they find that they were in control. Tuomi, Aimala, Plazar, Starčič, and Žvanut (2013) conclude that the JDCS model provides useful information to management and thus has the potential to help when planning and improving nursing study programs, in the context of this dissertation, the nurse education faculty and the clinical staff affiliated with them.

In a similar study that also used the JDCS model in a nursing student context, Magnavita and Chiorri (2018) tested the moderating role of social support at work. They found, in line with the theory, that higher levels of social support were associated with lower levels of work impairment (Magnavita & Chiorri, 2018). Magnavita and Chiorri (2018) emphasize that social support is one effective way of reducing the stress of nursing students. From a social support perspective,

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problems like loneliness, social isolation or socially related problems become a problem and a significant stressor per se. This is a potential problem not only on a personal level, but also because a lack of social support may prevent nursing students in developing the interpersonal skills that are important when working as a nurse (Magnavita & Chiorri, 2018; McIntyre, Worsley, Corcoran, Harrison Woods, & Bentall, 2018; Paans, Robbe, Wijkamp, & Wolfensberger, 2017). Just like Tuomi et al. (2016), Magnavita and Chiorri (2018) also found that approximately one in five (18 %) were classified as active students, which according to theory is the condition when students are motivated to develop new behavioral patterns. In Magnavita’s study, 37 % were classified as passive (Magnavita & Chiorri, 2018).

The effort-reward approach

Another of the “Grand theories” in stress research is the Effort-Reward imbalance model developed by Siegrist (Nowrouzi, Nguyen, Casole, & Nowrouzi-Kia, 2016). This theory assumes that social reciprocity is a fundamental principle in social transactions, as in most workplaces. Social reciprocity is, according to this theory, one of the most central aspects of the work contract and an important part of what Siegrist calls our evolutionary grammar (Siegrist, 2005, 2010). Working roles contain different opportunities for learning new skills, mastering difficult tasks and offer the chance to meet demands that create a sense of responsibility and commitment (Siegrist, 2005). When we work, we expect to get something in reward such as money, job security, positive self-esteem and constructive feedback. Stress expressed in terms of this theory occurs when there is a perceived imbalance between the efforts put into a job, high gain, and the rewards from these efforts, low reward, thus causing a failed reciprocity, and a violation of core expectations. Research has shown that there is an association between effort-reward imbalance and indices of cardiovascular health (Eddy, Wertheim, Kingsley, & Wright, 2017).

Siegrist (2010) emphasizes that, as in some other stress theories, subjective appraisals are a central aspect of the stress response with relevance for both their potential emotional and psychobiological impact. Just as in the work place, there is also a social contract in an educational setting. Some aspects of the “currency” are different,

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whereas others are similar between being an employee and a student. Expectations for social reciprocity are thus present and a natural part of most social interactions. In addition, in many cases, and in line with Siegrist’s research and empirical findings, violations against the expected social contract may have negative consequences. As shown in studies from a higher education context, there is often a gap between the expectations and perceived demands communicated by the teacher and the students’ own preferences and perceptions. This can relate to student relevant aspects such as teaching, assessment, feedback and other aspects of the social interaction, these being relevant aspects from an effort-reward perspective (Byrne et al., 2012; Sadler, 2010; Sander, Stevenson, King, & Coates, 2000). Both Karasek and Theorell’s as well as Siegrist’s models were presented and discussed from a student perspective during session 8 of the intervention.

Kember’s model on perceived workload

An interesting and highly relevant example for the educational setting is a study by Kember (2004). Kember examined how the nature of student workload, a concept highly relevant to stress, and the perceptions of workload were formed. In this study one of the participants studied for 64 hours a week but had a workload rating only a little above mean. Another student in the same study worked with his/her studies for 13 hours but had the highest perceived workload score in the study and was thus stressed. Kember (2004) concludes, that perceptions of workload are not the same thing or synonymous with time spent on task, but only weakly influenced by them. This is an important notion to have in mind when discussing stress in an educational context. In a quantitative study Kember and Leung (2006) examined which variables could explain these differences in the students’ perceived workload. This resulted in a model, see figure 3.

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As can be seen from the model, Kember found three factors in the students’ psychosocial work environment that had the greatest impact on how students perceived their workload. Kember and Leung (2006) found that different variables in the teaching and learning environment influenced the students’ perception of workload. These are aspects related to teaching, teacher-student relationships and student-student relationships. These factors were found to be interrelated. First, the teaching, based on a coherent program of courses with a transparent relationship between components, a focus on understanding of key concepts, alignment with assessments that test understanding and promote active learning strategies for the students. Another aspect of this variable that is highlighted by Kember and Leung (2006) is that

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teachers accept responsibility for motivating and stimulating interest. The second variable concerns the teacher-student relationship and includes, for example, developing a warm and supportive relationship to the students. Finally, Kember and Leung (2006) discuss the importance of the student-student relationships. This can be promoted by group discussions, assignments and projects.

One interesting and important result of this research is that it describes how the teaching and learning environment can produce demanding work of high quality while workload is still considered reasonable by the students. This is an important finding when investigating stress related problems discussing psychosocial aspects of the work environment. It is also in line with other research that stresses the importance of the individual teacher for the organizational and psychosocial aspects described, as well as the psychological well-being of students, thus highly relevant from a stress perspective (Zepke & Leach, 2010).

Modern cognitive research on stress

Both the Karasek -Theorell and Siegrist models can be described as balance theories (Meurs & Perrewé, 2011). In simplified terms, based on these models, stress can be regarded as caused by various forms of imbalances that need, and can, be corrected. According to this approach, a present stressor leads to a response which then decreases or disappears as the stress decreases or disappears. The process is linear in this regard. Recent research has investigated which factors contribute to initiating and sustaining stress reactions over a long period of time, even and perhaps most importantly, when no concrete threat or something dangerous is present (Brosschot et al., 2005; Capobianco et al., 2018). Particular attention has been paid in various respects to the importance of cognition and unconscious processes in this process. A key assumption is that it is not primarily temporary stressors that cause individuals to develop stress-related ill health. The main problem is the long-term physiological activation of the stress system caused by thoughts of what has occurred or will occur; i.e. rumination and worry. Brosschot, Gerin and Thayer (2006, pp 408-409) argue that, unlike traditional stress research focused on stressors, the most important factor in our understanding of stress is “what is in

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the mind”. According to Brosschot et al. (2006), stress research is starting to shift its scope from reactivity, during stress, to prolonged activity before and after stressors. If interventions are to be developed that consider this focus in stress research, they should include elements of methods that can train participants in these relevant aspects. The psychological opposite of worry and rumination is mindfulness because mindfulness involves disengagement from perseverative thinking and has a positive physiological and psychological impact on the individual (Brosschot et al., 2006). In the intervention developed for nursing students as described in this dissertation, mindfulness has been an element of the stress management training.

Cognitive activation theory of stress (CATS)

A stress theory that can help to both describe and explain these conscious and unconscious internal cognitive processes is Cognitive activation theory of stress (CATS). The Norwegian Researchers Holger Ursin and Hege Eriksen primarily created the theory, and it claims to be valid across species and cultures (Reme, Eriksen & Ursin, 2008). CATS offers a systematic insight into the psychological mechanisms that explain when the stress alarm is activated, but also when it becomes maladaptive. The theory has its background in extensive research with both animals and humans, both in the laboratory environment and in studies outside laboratories, including with parachutists (Ursin & Eriksen, 2004; Ursin & Eriksen, 2010). CATS is largely based on the biologically orientated stress research that Selye started from the 1930s onwards, although CATS is primarily interested in the psychological aspects. Like Selye, the starting point in CATS is that stress is fundamentally an adaptive response and thus fundamentally an important, healthy and necessary mechanism for our survival (Selye, 1973; Ursin & Eriksen, 2004). Stress arises, according to CATS, whenever there is (or is judged to be) “a discrepancy between what is expected or the ‘normal’ situation (set value) and what is happening in reality (actual value)” (Ursin & Eriksen, 2004, p. 572).

According to CATS, the brain is always active, constantly processing, and comparing the stimuli the individual is exposed to in relation to previous experiences of the same or similar situations. These are complex cognitive evaluation processes and include constant learning.

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What happens affects how you relate to the same or similar situations in the future and what you expect in different situations (Ursin & Eriksen, 2010). Expectancies are crucial and learning is regarded as the acquisition of expectancies, according to CATS. Thus, the crucial concept in CATS is expectancy (Reme et al., 2008).

Further, according to CATS, the perceived probability of being able to reduce the difference between the set value and actual value affects the extent to which the arousal system is activated. What makes the theory a cognitive theory is, among other things, the great focus and importance attributed to cognitive aspects. The response that occurs in an individual includes both a stressor, but above all an experience of this stressor, as well as a response and above all an experience of this response that contributes to the potential development of ill health. It is, according to CATS, the individual’s experience of the demands they are subjected to and the expectation of whether they will succeed or not, which determines whether the body’s physiological stress response is activated. What, according to the theory, creates or contributes to the development of stress-related illness is whether the physiological activity does not decrease but remains active for a long time (Ursin & Eriksen, 2010). Stress management interventions should, based on CATS, focus on cognitive elements that enable both increased awareness of these processes as well as training in developing and/or modifying existing but dysfunctional patterns to describe some possible components. In sessions, four and five, focus was specifically related to these aspects presented in CATS literature.

The stress mindset research Another line of research also investigating the cognitive aspects and the importance of how individuals perceive stress, as well as the bodily reactions associated with it, is the stress mindset research. In a study with a large sample (n= 28,753) Keller et al. (2012) examined the relationships between the amount of perceived stress, the perception that stress affects health, and health and mortality outcomes. Their results showed an interaction between the perceived amount of stress and the perception that stress affects health negatively. The respondents who reported that they perceived both a lot of stress and that stress affected their health negatively had, according to this study,

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a 43 % increased risk of premature death (Keller et al., 2012). These personal beliefs associated with stress, Crum, Salovey, and Achor (2013) call stress mindset. In general, according to this line of research, individuals hold a personal belief that stress has either debilitating (“stress-is-debilitating mindset”) consequences for health-related outcomes like productivity, performance, learning, well-being and growth, or a (“stress-is-enhancing-mindset”) that is the belief that stress has enhancing consequences for these same outcomes (Crum et al., 2013).

These findings have been further developed and supported by experimental studies exploring differences in stress responses due to framing and reappraisal. In a study, Jamieson, Nock, and Mendes (2012) examined if the way individuals think, the stress mindset, about bodily responses can improve physiological and cognitive reactions to stressful events. Jamieson et al. (2012) randomly assigned participants to a reappraisal condition, where they were instructed to think about their physiological responses during a stressful task as functional and adaptive. The control conditions were either no instruction or to reorient their attention. The results showed that compared with controls, the reappraisal condition exhibited more adaptive cardiovascular responses, increased cardiac efficiency, lower vascular resistance and decreased attentional bias (Jamieson et al., 2012). In recent studies Casper, Sonnentag, and Tremmel (2017) and Ben-Avi, Toker, and Heller (2018) studied work-related aspects of both a positive and a negative stress mindset. Casper et al. (2017) investigated if, and how, workload anticipation was related to approach- or avoidance coping and how the employees stress mindset moderates these differences in coping. Casper et al. (2017) found that employees react differently. Employees with a positive stress mindset used approach coping efforts to a larger extent than the employees with a negative stress mindset. The approach coping efforts in this study were also found to relate positively to vigor and task performance, and thus had positive psychological consequences. Ben-Avi et al. (2018) investigated how an individual’s stress mindset influences the judgement of others’ stress. Ben-Avi et al. (2018) found that the participants in their study projected their own stress mindset to others and this had several consequences in the study. Individuals holding a stress-is enhancing, or positive stress mindset, were found to be less likely to judge a fictive person experiencing a heavy workload described

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in their experiments as suffering from burnout or having somatic symptoms.

Thus, the studies by Jamieson et al. (2012); Keller et al. (2012); Crum et al. (2013) and Casper et al. (2017) point out some of the potential positive intra-personal advantages of holding a positive stress mindset. Ben-Avi et al. (2018) add to this new line of stress research by paying attention and highlighting some potentially negative inter-personal aspects of holding a positive or stress-is-enhancing mindset. The research by Ben-Avi et al. (2018) is in line with a previous finding that shows that people tend to, egocentrically, project their own psychological states when judging others (Krueger, 2008).

This makes it a matter of collective interest for nurse educators to reflect upon the way the concept of stress is thought of, communicated and framed to students and among colleagues and the perceptions and narratives being reproduced in this specific context. As pointed out by Kirkegaard and Brinkmann (2016) the way employees communicate about stress in workplaces invites individuals to engage in some coping practices, and at the same time, limits the use of others.

To summarize, stress is a difficult concept because it can refer to both the dependent and the independent variable, but also to the process (Cooper, Dewe, & O'Driscoll, 2001). Stress research has, as described initially in the chapter, also varying focus and direction, from life-cycle perspective to everyday stress (daily hassles), directed towards acute versus chronic stressors, to name a few such areas.

The purpose of this chapter has been to describe and problematize part of the concept and thus highlight some of the problems it entails in researching stress-related issues. The ambition has been, in addition to description and problematization, to be able to use the theories to varying degrees, both as a framework for describing nursing students' psychosocial work environment, but also as a rational for why these theories were treated in the context of the intervention.

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The Intervention

The core of this dissertation is the intervention and can constitute an example of a secondary level effort (LaMontagne, Keegel, Louie, Ostry, & Landsbergis, 2007). The intervention aims to, based on both classic and modern CBT-based theories, models and exercises: 1) teach participants new behaviors regarding stress management, 2) increase participants' self-awareness and psychological flexibility, and 3) contribute to the participants getting theoretical knowledge that they can translate into stress management.

Theory of change – active ingredients of the intervention

The theoretical basis of the intervention consists of cognitive behavioral therapeutic (CBT) theory. CBT can be considered as an overall theoretical perspective with several different directions. That which unite the different directions is that they have been empirically shown to be effective for various psychological problem areas including stress-related problems (Hofmann, Asnaani, Vonk, Sawyer & Fang, 2012; Westbrook, Kennerley & Kirk, 2011). CBT consists of many theoretical foundations and principles. The behavioral principle says that what an individual does has a significant impact on what he thinks and feels. According to classical learning psychological theory, negative reinforcement is central to the development of dysfunctional behavior (Maia, 2010). Avoiding short-term discomfort has short time benefits, but is maintaining long-term dysfunctional behavior. This means that emotional, cognitive and behavioral exposure is central to the learning of new functional behaviors. Changing behaviors is or can be a way of changing thoughts and feelings (O’Donohue & Fisher, 2012). The continuum principle states that mental problems are best understood as exaggerations of normal mental processes and not pathological conditions qualitatively distinct from normal states. Mental problems, therefore, are based on this principle, one end of a continuum, not another qualitatively different dimension. From this follows the notion that mental health problems can happen to anyone – the therapist included (Westbrook et al., 2011). The here-and-now principle says that in treatment work, as a rule, but not always, it is fruitful to start

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from the present situation rather than in the past. Focusing on behaviors that maintain behavior (here and now) is, according to this principle, more effective than examining the causes of behaviors once created. The system interaction principle states that it is meaningful and helpful to investigate how the interaction between thoughts, feelings, behaviors, bodily reactions and the surrounding environment looks. One model, the five-factor model, has been used to further deepen and illustrate this latter principle (Kuyken, Padesky & Dudley, 2009).

Furthermore, CBT rests on the principle of empirical outcome testing. This means that it is of central importance to investigate how dysfunctional behaviors change as a result of active conscious training. Finally, within the framework of a CBT perspective, dysfunctional behaviors are assumed to be caused by misinformation and dysfunctional information processing (Westbrook et al., 2011).

The theoretical foundations are further specified, elaborated and applied in relation to the more general foundations of CBT described above, see Figure 4. Traditional and modern cognitive-behavioral therapies share a common goal of behavioral adaption (Mennin, Ellard, Fresco, & Gross, 2013). Behavioral adaption is, according to Mennin et al. (2013), about developing a behavior that makes an individual better suited to prosper in important life domains. To promote this goal three corresponding change principles are active: context engagement; attention change and cognitive change, as well as six common therapeutic processes. These processes consist of behavioral exposure; behavioral activation; attention training; acceptance/tolerance; decentering/defusion and; cognitive reframing (Mennin, Ellard, Fresco, & Gross, 2013). Both content and structure of the intervention are based on this goal, behavioral adaption, as well as its principles and processes.

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Table 1 below describes the overall theoretical content of the intervention in relation to these goals, principles and processes.

Table 1. The theoretical base, applied principles and processes of the intervention

Main Theoretical focus Practice Main change principle

Main therapeutic process

1. IntroductionA brief description of the stress concept and of basic principles of CBT and of the intervention som helhet

2. Focus on emotions Why do we have emotions? Five factor model Attention change Attention training

3. Focus on emotions Acceptance and coping What do we need to accept? Attention change Acceptance/tolerance

4. Focus on cognitions The transactional model Decision balance Cognitive change Cognitive refraimingDefusion

5. Focus on cognitions Procrastination Worksheets with examples Cognitive change Cognitive refraiming

6. Self-compassion What is self-compassion? To create a compassion-self Cognitive change Cognitive refraiming

7. Acceptance and commitment therapy Psychological flexibility Life-compass Context engagement

Cognitive changeBehavioral exposureDefusion

8. The balances of life Demands - controlEffort Identify obstacles for change Context engagement Behavioral actiovation

9. Effektivecommunication Communicate beaviors Identify difficult situations from

a communication perspective Context engagement Behavioral exposureBehavioral activation

10. Summary

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Rationale for the length, format and content of the intervention

The most common length of stress management interventions in a higher education context is five to eight weeks (Winzer et al., 2018). The intervention of the thesis is ten weeks. An important starting point in planning the intervention is to consider that it takes time to learn new behaviors and that this should be reflected in the design of the intervention. Furthermore, the choice of the scope of the intervention is also based on a basic group psychological assumption that it takes time to develop an atmosphere where participants feel relaxed and comfortable with the context, which is an important premise for sharing their thoughts, feelings and experiences of relevance to the intervention. In addition to sharing experiences with others, the group format also enables the exploration and development of social skills and abilities, because interaction with other individuals with varying experiences and personalities is a central aspect (Wheelan, 2005).

The rationale for choosing theoretical content is based partly on the assumption that people have different preferences regarding theoretical starting points and partly on the assumption that ability to understand varies among individuals. Not all theoretical starting points and explanatory models fit all, and they also require different things from the participant to varying degrees. Another rationale for inclusion in the intervention is that each session has strong theoretical support. An additional explanation why the intervention looks like it does regarding content is due to chronology. The intervention starts with the theoretical content that is oldest and during the intervention, the timeline is moved towards the present regarding the theoretical content. The newer theoretical content is based in various respects on the older theoretical foundations. Further, the theoretical basis has its origins in clinical research, but since the purpose of the intervention has been explicitly to build on and enhance existing resources, training is the focus and therefore the ‘T’ in therapy is replaced by the ‘T’ in training.

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Content and applied exercises

The first session: Introduction

During the first session, time was spent framing and defining central points of departure as well as the concepts of stress and health and providing an in-depth background to the intervention. Lazarus and Folkman's transactional model and definition of the concept of stress were described and discussed. The definition of Lazarus and Folkman (1984) was used during the intervention. Central assumptions in CBT were also described concisely, see above. The work and purpose of homework assignments were also described and motivated at the outset (Kazantzis et al., 2016). Finally, all sessions were presented regarding content and order.

The second and third session: Focus on emotions

Session two and three focused on the function of emotions. Three exercises took place to train participants to observe and even encounter different emotions. The first exercise constituted a mindfulness exercise designed to allow participants to be aware of the different temporary feelings they had at that moment. The difference of being emotionally aware, unaware or on” auto-pilot”, was discussed from a stress perspective. In the second exercise, the participants worked with a case aimed at training participants to describe different emotions and cognitions as well as to then explore as many ways as possible to handle the described situation using the five-factor model as a foundation. These alternatives were then compared externally for the disadvantages in each respective alternative. In the third session, the reasoning and emotions begun in session two were further explored. The concept of acceptance, central to the intervention, was introduced and defined.

The definition used reads "Acceptance means choosing to see, have, and endure with both inner and outer reality effectively and in the direction of your values and goals" (Kåver, 2007, p. 32). The concept was discussed from a stress perspective and an exercise was conducted in which many different areas were discussed that are, or may be,

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subject to acceptance by humans. Participants were asked about what they were struggling with and what would be different if they accepted it? The purpose of the exercises was to create increased awareness of their own reaction patterns and of new alternative approaches.

The fourth and fifth session: Focus on cognitions

On the fourth and fifth sessions, focus was on some of the cognitive aspects that are relevant from a stress perspective. As stated above, cognition has played a prominent role in some of the most central theories in the field of stress. During session four and five, the participants’ knowledge of the meaning of cognition was deepened by being presented stress from a cognitive perspective. The significance of the interpretation made at a given moment was emphasized and discussed. This also made the question of the amount of influence one can have on an interpretation possible. Are certain situations and contexts by definition stressful? Where is stress? When does stress start and end? Is there always room for alternative interpretations? What difference does it make to think, and act based on different alternative approaches? What distinguishes individual interpretations that lead to increased vulnerability to negative stress versus an interpretation that does not? How do we learn which response to use? Theoretically, the cognitive perspective was deepened by giving participants a review of standard models in the traditional CBT tradition (Westbrook et al., 2011).

An applied exercise was conducted in which the participants had to fill in the form ‘decision balance’ where different conceivable stress reactions were analyzed based on short and long-term negative and positive consequences. The purpose was, among other things, to show how negative reinforcement often maintains dysfunctional behavior because in the short-term it is functional. Subsequently, the phenomenon of procrastination was reported, which may constitute a problem relevant from a cognitive stress perspective. The exercises that were carried out were aimed at transferring and applying the knowledge from the different models to this specific problem area. Participants were also encouraged to use knowledge from the earliest times of the intervention to identify more clearly how interactions between emotions and cognitions affect behavior. The sessions were

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concluded by having the participants jointly reflect and discuss possible CBT perspectives of the problem raised during sessions four and five.

The sixth session: Self-compassion

The theoretical content of the intervention consists of parts from so-called traditional CBT. However, to represent a new and theoretically updated alternative, modern theoretical contributions were also represented. On the sixth session, self-compassion was introduced, which is an example of such a theoretical field that has shown positive results for both clinical samples and students (Beaumont, Durkin, Martin & Carson, 2016; Leaviss & Uttley, 2015). A central point of departure in this theory formation is that people often aggravate their situation by being strongly self-critical and hard on themselves, against other people and existence at large (Gilbert & Procter, 2006). This can, from a stress perspective, mean that challenging and sometimes difficult situations become even more difficult for the individual by strong self-criticism and shame being important components in maintaining psychological problems. The concept of self-compassion was presented as an internal psychological equivalent of the external support that functioning social contacts make up.

By practicing compassion, we can develop our ability to deal with stress and cultivate emotions such as curiosity, interest and care and warmth in relation to ourselves and others. Thus, participants build up a more functional internal support (Gilbert, 2010). During the sixth meeting, an exercise was conducted in which the participants were allowed to listen to a recording (an audio file that was included with the book that formed part of the theoretical basis of the session) with the aim of developing a "compassion self" (Andersson & Viotti, 2013). The session ended by allowing participants to integrate previous theoretical content with the theme of the day.

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The seventh session: Acceptance and Commitment Training (ACT)

The seventh meeting was devoted to a compressed description of the basic principles on which the ACT perspective rests. Like the compassion theme, ACT, although in many respects having old roots, is part of modern CBT and during the seventh meeting, a classic CBT and ACT perspectives regarding how to theoretically look at stress were described and compared. Within ACT, an important starting point is that what causes problems and suffering for people is the attempt to control their own feelings and thoughts (Hayes, Strosahl, & Wilson, 2012). Control, according to ACT, is thus the problem, not the solution. Fundamental to mental health is, according to an ACT perspective, psychological flexibility. Psychological flexibility is defined as” contacting the present moment as a conscious human being, fully and without needless defense - as it is and not as it says it is – and persisting with or changing a behavior in the service of chosen values” (Hayes et al., 2012, pp. 96-97).

The concept is a central aspect of health. Psychological inflexibility is strongly connected to physical ill health (Kashdan & Rottenberg, 2010).

Psychological flexibility rests on three pillars, openness, presence and commitment. Openness means being able to adopt a non-judgmental and accepting attitude even regarding experiences and situations in life that are painful, as well as the ability to be free from disturbing inner and outer experiences. Presence is about the ability to experience the present and the ability to have perspective on the self and its narrative. Commitment, finally, is about living in contact with, and being able to sustain, behaviors based on personal values (Hayes et al., 2012). The theoretical content of the meeting was practiced by the participants doing an exercise, the Life Compass, which aimed to identify the participants' own personal values, i.e. what matters most to them in different spheres of life and to explore how they can live in an increased direction towards these values and what possible significance this change could bring from a stress perspective.

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The eighth session: The balances of life

As stated in the chapter on the concept of stress, several of the most prominent theory formations in stress research are what could be categorized as balance theories (Meurs & Perrewe, 2011). During the eighth meeting, the balances that are present in both Karasek and Theorell’s as well as Siegrist’s models were presented (Bakker, Killmer, Siegrist, & Schaufeli, 2000). Furthermore, as an important aspect of the balance concept, the importance of effective recovery and the difference between passive rest and recovery (reactivation) were highlighted (Sonnentag & Fritz, 2015). After a brief review of the theories’ central points of departure, the participants conducted an exercise aimed at mapping the participants’ own specific situation based on the classical theoretical models. Questions were asked about which requirements the participants experience, which requirements are most difficult to relate to, what the participants feel that they lack control/influence over, how they relate to having or not having sufficient control/influence and what experienced rewards were seen from the participants’ perspectives as students?

Furthermore, the question was asked what does the concept of balance mean to the individual participant? Are there any other balances other than those mentioned that are important? The session ended with participants working in smaller groups on questions about how what they had learnt during previous sessions could help participants live a more balanced life. Any obstacles and gains with a change in behavior were analyzed and discussed.

The ninth session: Effective communication

The second to last session of the intervention was devoted to the concept of communication. Various communication patterns were initially reported and the relevance of these patterns from a stress perspective was discussed. The starting point for the session was that effective communication is a workable skill, a valuable resource for both private and professional relationships (Speed, Goldstein, & Goldfried, 2018). To further increase relevance, a health care-related example taken from an article was presented that found that during a

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40-year professional life, an oncologist conducted between 150 000 and 200 000 consultations with patients and their relatives (Fallowfield & Jenkins, 1999). Differences in communicative skills were discussed based on various health care-related examples, e.g. communication with parents and relatives but also with occupational categories within the health care profession. Communication behaviors were described on the basis of a continuum where appeasement and dominance constituted the extremes and mutual respect and integrity constituted a well-balanced compromise between these extremes (Almén, 2007; Speed et al., 2018).

This time, the applied part of the session was a call to the participants to identify people, situations and contexts where it was difficult for the participant to communicate effectively. Then questions were asked about what it would mean if the participant succeeded in developing this skill? What would be different, for example in terms of self-image, well-being and the view of others? Like other meetings, the session ended with participants being invited to summarize what they learned during the current session and a new home assignment was planned.

The last session: Summary

The final session differed from the other meetings in that there was no theoretical element under the leadership of the group leader. Instead, the session was dedicated to the participants summarizing the intervention. After initially working individually to summarize all sessions, this task was then also carried out in small groups. Finally, each group presented its summary and reflections and thoughts on differences and similarities between the groups were raised in the whole group.

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Methods and summary of studies

In this chapter, the studies carried out are described and summarized.

The overarching aim of the dissertation was to investigate:

1) The feasibility and acceptability of the intervention (study I),

2) The participants’ experiences of the intervention (study II), and

3) Measure preliminary psychological effects (study III)

Study I

The first study aimed at investigating the feasibility and acceptability of the newly developed stress management intervention. Investigating these aspects is an important part of the research process that aims to investigate the preconditions for progressing with an RCT (Abbot, 2014; Craig et al., 2008). According to Orsmond and Cohn (2015), feasibility and acceptability studies aim to answer the basic question – can it work? Therefore, in the first study, the purpose was to investigate various aspects of both feasibility and acceptability that can generate valuable knowledge for a more comprehensive study where the effects of the intervention can be investigated on a larger scale. A number of different factors concerning feasibility and acceptability are important to investigate early in the research process. Therefore, questions related to recruitment, sample characteristics and the acceptability of the intervention itself were investigated. Furthermore, it is important to investigate and gain knowledge of how measurement procedures work in practice and how different scales are suitable for use in this context. Additional aspects of feasibility and acceptability that are relevant to research are about examining the resources required to conduct a study as well as what qualifications are required to have good prerequisites for conducting the study effectively (Orsmond & Cohn, 2015).

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Study design and participants Issues related to recruitment aspects and intervention acceptability were examined in three different samples. These samples were the intervention group, a group that was offered to participate, but who declined this offer (non-participants) as well as a group that chose to participate but who dropped out or participated on less than five sessions (dropouts).

With the intention of conducting preliminary evaluations, a pre-, post-, and a one-year follow-up was conducted for the intervention group. A control group was used for the one-year follow-up comparison between the intervention and control group. Both quantitative and qualitative data were analyzed. A mix of standardized scales was used to attain quantitative data. The research team created a scale to measure reasons for dropout. To maximize the information gathered, the fixed answers in the measurements were complemented with an open-ended question that was analyzed qualitatively.

Both Swedish and international research have shown that stress in nursing education increases during the course of the education and for Swedish conditions the increase is greatest between semesters two and four. Therefore, semester two was chosen to implement the intervention and students in semester four who did not participate in the intervention were chosen to form a control group (Deary, Watson, & Hogston, 2003; Gustavsson et al., 2014). Otherwise, there were no systematic differences between the samples in intervention and control groups. All groups followed the same course- and program plans.

Measures and analysis Data were collected and analyzed regarding recruitment capability and sample characteristics. This was carried out for the intervention group, the dropout and control group respectively. A survey to assess recruitment obstacles and to find out different reasons for not participating was created. Two different versions were used. The version for the non-participants consisted of eight questions. The extended version of the survey aimed at the dropout group and

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consisted of 14 items, both scales had four scale steps. The ambition with this procedure was to develop knowledge about perceived barriers and obstacles to participation. This can potentially accumulate knowledge that can be useful when planning for recruitment. The Client Satisfaction Questionnaire (CSQ-8) developed by Larsen, Attkisson, Hargreaves, & Nguyen (1979) was used to assess the participants’ acceptability of the intervention. This scale is frequently used for the purpose of measuring participants’ overall satisfaction with the quality of interventions and CSQ-8 shows good psychometric properties (Miglietta, Belessiotis-Richards, Ruggeri, & Priebe, 2018). To gather more recruitment relevant information, we also asked the participants questions about their attendance and about adherence. Taken together, this information was used and operationalized as a complementary measure of acceptability. By combining the data assessed we aimed to answer questions highly relevant for both feasibility and acceptability. Other important aspects of feasibility studies are the investigations of the measures used. It is important to investigate if scales are sensitive enough and if they assess the most relevant aspects of the phenomena. Given these investigations new or modified measures needed for the intended population can be discussed (Orsmond & Cohn, 2015). The measures used in the studies in this thesis were based on a literature review. Only instruments with satisfying psychometric properties used previously with nursing students were used.

Descriptive data emanate from comparisons of means using t-tests or one-way ANOVAs when applicable. All analyzes used significance level 5% and were conducted using the IBM/SPSS 25 software version. When studying if the intervention affected the participants in the long-term, we asked an open-ended question in the one-year follow up. This procedure with open-ended questions (OEQs) makes it possible to collect data that is difficult to assess through fixed response formats (Fielding, Fielding, & Hughes, 2013). Thirty-three participants answered the question. The qualitative data were then analyzed using the six phases of thematic analysis according to (Braun & Clarke, 2006).

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Results

With regard to recruitment capacity, study I showed that of nearly 400 potential participants, just over 17% chose to participate in the intervention. Of the analyzes conducted with the aim of identifying systematic differences between those who chose to participate and those who chose not to participate in the intervention, the analyzes showed no significant differences between the groups regarding gender, age, social background, parents’ level of education or regarding the time respondents spent respectively on studies and work outside the course. The group that chose to participate in the intervention was thus representative of the intended target group, nursing students. In study I, we also examined perceived barriers and reasons for not participating in, and for interrupting the intervention. The analyzes showed that the most common reason for not completing the program was mainly related to participation in regular teaching. Other reasons stated, but to a lesser extent, were leisure activities and work in addition to the studies. Correspondingly, the group that chose not to participate in the intervention was examined. Analyzes showed that the main reasons corresponded to the reasons given by those who did not complete the intervention. The main reason therefore consists of ordinary teaching as well as other leisure activities. Quantitative and qualitative methods were mixed and to gain further knowledge about the reasons for not participating and/or cancelling, an open-ended question was asked that 26 people answered. The responses supplemented the other data by emphasizing the importance of geographical distance. Geographic distance thus constitutes a barrier to participation.

The analysis conducted by CSQ-8 showed that the participants were generally satisfied with the intervention. A clear majority were very satisfied and would to a large extent recommend the intervention to others. Of the variables studied, it was the question area that had the lowest rating as to whether the intervention met the needs of the participants. In the second survey, participants answered a question about the extent to which they worked on the homework assignments that belonged to the intervention between each session. Homework assignments form a central part of the intervention and this issue thus constitutes one important aspect of engagement with the intervention.

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The analyzes showed that the clear majority, 53 out of a total of 61 participants, did not work regularly with homework assignments. Only 6 participants indicated that they worked regularly with the homework.

The analysis of the intervention effect on the participants showed positive results for all scales with the exception of the pure procrastination scale and the perceived stress scale, where significant differences were not obtained between the first and second measurements.

This indicates that the interventions affected the participants positively regarding the assessed psychological measures, but further studies with higher statistical power need to validate these findings.

In the one-year follow-up an open-ended question was asked about if and potentially how the participants were affected by the intervention looking back in retrospect one year after it had finished.

Thirty-three participants answered and several described how the theoretical content of the intervention contributed to developing an understanding of stress and stress responses, which served as support and help in everyday life. Overall, the analysis shows that the participants were affected by participating in the intervention in several different ways. The participants described how they became calmer and better at sorting and prioritizing things according to importance and urgency. They further described how they developed an ability to reflect and improve skills in stress management. This increased reflective ability together with extended theoretical knowledge were described as underlying the perceived change.

Study II

Study design and participants

The second part of the dissertation was aimed at examining the participants' experiences of having participated in the intervention and thus gain in-depth knowledge of this perspective. Semi-structured interviews were conducted that were analyzed based

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on an inductive content analysis according to Graneheim and Lundman (2004).

Data collection

Convenience selection was applied and out of potentially 37, 14 of the participants chose to be interviewed. A booking schedule was handed out after the last session where those who wanted to participate in the study signed up on the list. The inclusion criterion was that they participated on at least five occasions. One man and 13 women, 20-38 years old, mean age 26.43 (SD = 6.68) years, gave their voluntary informed consent, both in writing and orally to participate in the study. Participants’ age and gender distributions were similar to those of Swedish nursing students in general (Rudman, Omne-Pontén, Wallin, & Gustavsson, 2010). The interviews were carried out in a secluded room at the university in 2015. The interviews lasted 20 to 50 minutes and were audio-recorded. Two research assistants transcribed all interviews verbatim.

Method and analysis

The interviews were analyzed using inductive qualitative content analysis in line with the aim of identifying variations concerning differences and similarities in the data (Graneheim & Lundman, 2004). By using inductive content analysis, interpretation can be performed on several levels, which is an important aspect of analyzing texts that describe individuals' experiences (Graneheim & Lundman, 2004). To gain an overall understanding of the content, the printout of the interviews was read in its entirety several times. Then the text was read again but with the purpose of discovering meaning-bearing entities and manifest meaning. Meaning units corresponding to the aim of the study were then extracted. In the next step, the meaning-bearing units were condensed, and a code was assigned. The codes were then interpreted and compared for the purpose of identifying similarities and differences, which were then categorized in the next step. Then the categories were critically compared and analyzed in order to find an underlying latent meaning that could then be formulated into a theme.

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Results Analyzes of the interviews resulted in a theme: Turning points. The theme consisted of four categories: More in touch with reality, Increased self-confidence, Improved communication skills, and A new way of reflecting. A turning point is a form of learning and development that in different ways changes the current thinking, feelings and behavioral patterns and which has its origin in an experience or insight. In study II, participants described how they could see things from other people's perspectives to a greater extent than before, which led to a greater understanding of both their own and others' behavioral patterns.

In the first category, which was named ‘More in touch with reality’, participants described how the intervention made them more in touch with reality. This was shown in the analyzes through the participants' subjective descriptions of how they handled the challenges and difficulties of everyday life. This increased contact with reality and was described by some participants as an intense presence in the present. In the following category, increased self-confidence, participants recurrently reflected on what it meant to them being an accepted member of the intervention group. Several participants expressed that they had an initial concern about feeling deviant or unusual in comparison with the other group members. These new reflections were in contrast to the initial way of thinking when starting the stress management intervention and led to a positive feeling of community. The third category was labeled, improved communication skills. Several participants described that the intervention taught them to open up and developed their ability to put words to thoughts and emotions. They described how it had become easier, both to express what feels good and what does not feel right. Thus, the participants experienced that their communication skills were strengthened during the intervention. Finally, in the last category, a new way of reflecting, the participants expressed how the participation in the intervention resulted in increased self-knowledge. Several participants expressed that one of the ways this developed skill was increased was by an increased ability to ask oneself fundamental existential questions. They also described how they experienced an increased sense of control, which in the interviews was described as having positive emotional, cognitive, behavioral and physical consequences.

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Study III

Study design and participants

In the third study a quasi-experimental design was used. In the intervention group, measurements were made before, after and one year after the end of the intervention. At the one-year follow-up, the intervention group was compared with a control group. The inclusion criterion for joining the intervention group was to have participated in at least five sessions. No significant differences regarding demographic variables were found between intervention (n = 29) and control group (n = 44).

Data collection

Intervention group data were collected on four occasions (fall 2014, 2015 and spring 2015 and 2016. Control group data were collected on one occasion (fall 2014).

Measures

In order to measure the participants´ self-rated stress management competency a visual analogue scale was created by the research team. The scale consisted of a 100 millimeter horizontal line on which the respondents were to mark an X as a response to the statement “My present stress management competency is good” with anchor points from “Totally disagree” to “Totally agree”. A higher value on the SMCS indicates a higher perceived competency to manage stress according to the participant. The use of visual analogue scales is well established and should be used as a complement when, as in the case with study III, also using other scales (Torrance, Feeny, & Furlong, 2001). Beside the stress management competency scale the general self-efficacy, and the Rosenberg self-esteem scale we also used.

In order to measure the participants´ self-rated stress management competency a visual analogue scale was created by the research team. The scale consisted of a 100-millimeter horizontal line on which the

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respondents were to mark an X as a response to the statement “My present stress management competency is good” with anchor points from “Totally disagree” to “Totally agree”. A higher value on the SMCS indicates a higher perceived competency to manage stress according to the participant. The use of visual analogue scales is well established and should be used as a complement when, as in the case with study III, also using other scales (Torrance, Feeny, & Furlong, 2001). Beside the stress management competency scale the general self-efficacy, and the Rosenberg self-esteem scale were also used. General self-efficacy is the perception of handling stressful and challenging demands (Bandura, 1977). The general self-efficacy scale was developed by Schwarzer and Jerusalem (1995) and is frequently used in research as satisfactory psychometric properties (Luszczynska, Gutiérrez-Doña, & Schwarzer, 2005). The scale consists of ten items and uses four-step Likert scales. The Rosenberg self-esteem scale is widely used and accepted in studies focusing on stress (Mimura, Murrells, & Griffiths, 2009; Robins, Hendin, & Trzesniewski, 2001). The scale consists of ten items and uses four-step Likert scales.

Analysis The dependent variables in this study were; self-rated stress management competency, self-esteem and general self-efficacy. Time was used as a within-group variable and the stress management intervention as the manipulation. In order to analyze differences for the intervention group pre-, post and one year follow ups were employed. When comparing the one year follow up with the control group respectively, dependent ANOVAS and independent t-test were used.

Results

The analyzes that were conducted showed that the participants' self-assessed stress management skills increased from the first measurement to the second and at the third measurement, one year after completion of intervention for all 29 who participated in the

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intervention. However, the analysis showed no significant differences in SMSC when comparing the second and last measurement. When comparing the intervention and control groups, the analysis showed that the intervention group had significantly higher values than the control group. Further, the analysis shows that GSE increases both from the first to the second and from the first to the third measurement for the intervention group. However, the analysis shows no significant change when comparing the second and third measurement. N significant changes in GSE were found when comparing the intervention and the control group. For self-esteem, an increase between the pre-intervention and one year follow up measurement were found and the analysis also showed significant changes between the post intervention and one year follow up measurement. However, no significant changes were found between the pre- and post-intervention measurement. When comparing the intervention and control group the analysis showed that the intervention group scored significantly higher on RSES. In this study we found that our CBT-based training program can be effectively provided in a group format. We also found that in our pilot study, perceived stress-management competency among nursing students was improved and had withstanding effects one year later when compared to a control group. However, the results need to be replicated with a larger sample and with a better statistical power (Craig et al., 2008). These results may indicate though that psychological resources, in this study, stress management competency, self-esteem and self-efficacy, increased over time.

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General discussion

Is the stress management intervention feasible and acceptable to nursing students?

Our studies aimed at investigating three different aspects from a feasibility and acceptability perspective. In Study I, questions related to recruitment to the intervention were investigated. Our results showed that about 17% of those offered a place agreed to participate. The reasons stated by the students for not participating were mainly concerned with an experienced conflict in relation to their own studies, i.e. the regular teaching. A few students cited a lack of interest or need as a reason to refuse participation. This raises questions. If stress-related problems are a problem of the kind described in the introduction, why did relatively few students choose to participate in a stress management intervention when offered the opportunity? From a practitioner perspective, there are some conceivable threads to consider when planning a similar intervention. First, the framing itself of the intervention may be important. The research emphasizes that those who are most in need of help at the same time are often the least likely to use the resources that already exist (Deasy, Coughlan, Pironom, Jourdan, & Mannix-McNamara, 2016). Therefore, the thresholds for participation should be low. One possible way to create greater relevance for the intervention could be to be clearer than in the recruitment effort before the intervention, emphasizing the health promotion aspect.

The starting point was to promote and develop psychological resources by developing and building on the existing resources of the participants. The purpose was not to cure or treat anyone. Berg et al. (2008) emphasize the importance of providing a clear rationale regarding the focus of an intervention to enable the potential participant to take a position both philosophically and practically on the content and form of the intervention. This was something that was done, but maybe not sufficiently detailed. Another aspect to consider that concerns recruitment is whether an intervention of the kind described in this dissertation should form part of regular education, i.e. institutionalized, or run as a project, as it did during the study? Is it within the university's mission to train students in stress management?

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The question is beyond the purpose of the dissertation to answer but based on the results of the studies it may still be worth discussing. An argument for introducing the opportunity to participate in the type of interventions described in this dissertation may be based on the fact that in higher education objectives as expressed in regulations, in addition to preparing for vocational and continuing education, postgraduate and postgraduate education, are also aimed at personal development (SOU2015:70). Training and helping students develop knowledge; understanding and practical skills to deal with stress-related problems on a well-established theoretical base can possibly be linked to this goal.

From work and organizational psychological literature, it is well known that the effects of interventions, whether directed at individuals or towards organizations as a whole, often die out if they do not become a permanent part of the work environment, i.e. if they are not institutionalized (Nielsen & Noblet, 2018). Furthermore, there are researchers who believe that it is the responsibility of nurse education to prepare future nurses in stress management and to adapt curricula according to these needs (Beanlands et al., 2019; Fernandez et al., 2016; Onan, Karaca, & Unsal Barlas, 2019). Not least from the perspective that nursing students after completing their education will serve as role models when meeting patients who may have stress-related problems. A poorly developed stress management ability in nurses can have negative consequences for both the quality of the patient's care and for the nurse.

In terms of acceptability, Study I further showed that the participants were consistently satisfied with the intervention. Based on this overall result, work on the implementation of a full-scale RCT can be continued so that the effects of the intervention can be studied in more detail. However, a couple of problem areas were identified which should be taken into consideration when planning. The first, and possibly also the most important problem identified in study I was about intervention fidelity. A central aspect of CBT is the element of homework assignments. A theoretical starting point on which the intervention is based is that it takes time to learn new abilities and skills. It is, according to basic CBT theory, between sessions that the most important work of training new abilities and skills takes place, not primarily during the session. In Study I, it was discovered that the

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majority of participants did not complete the work on homework assignments as intended and this needs attention.

Therefore, a suggestion on how this problem can be addressed for upcoming trials is to further extend leadership with one person so that each group is led by two leaders. Thus, it is possible to create better conditions to ensure that the planning of the homework is given the time needed. The question of what qualifications are recommended and how an intervention should be organized is also a central aspect of feasibility which is about resources. Resources are usually limited and therefore it is important to use existing resources as efficiently as possible. Where there are psychologist and psychotherapist courses, there are usually psychology training clinics. Based on our studies, it is suggested that prospective psychologists and psychotherapists (or equivalent) may lead the interventions. In addition to using existing resources effectively, future psychologists and psychotherapists gain important experience and competence, not least in managing groups. There is research showing that the treatment results for a prospective psychologist are as good as for a more experienced person (Nyman, Nafziger, & Smith, 2010). One explanation for this is that the prospective psychologist or psychotherapist during his/her education is part of a supportive training environment with supervision and thus surrounded by people with adequate competence. Psychological training clinics are, according to Dyason, Shanley, Hawkins, Morrissey, and Lambert (2019, p. 4) "quiet achievers" and represent a potentially large resource that could contribute to the work of stress-related problems in higher education in general and in nursing education in particular. The majority of the universities in Sweden that have a psychology program also have a nursing education.

Study II aimed at investigating the participants' experience of participating in the intervention. Most of the participants described how they developed new behaviors and felt more balanced. The analysis also revealed that participants perceived themselves to be more observant than before and more aware of existing, less functional, behavioral patterns. This result is in line with previous studies in which participants in similar interventions also experienced an increased understanding of themselves and others, an increased awareness of thoughts and feelings, and an increased balance between different parts of life (Bernhardsdottir, Champion, & Skärsäter, 2014; Frögéli, Djordjevic, Rudman, Livheim, & Gustavsson, 2016). It seems possible

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that these changes described by the participants are due to a combination of factors. Some of these possibilities will be discussed and synthetized through the lens of Burlingame’s model of therapeutic group treatment (figure 5) as well as through Mennin’s model (figure 4), focusing on the formal change theory aspect in Burlingame’s model, as described below.

Burlingame’s model, which is a general model of evidence-based group properties, can thus be used as an organizational framework for a discussion about some of the results. According to the model, there are a number of components that each potentially affect the outcome of an intervention or treatment.

These components consist of; the theoretical basis for the intervention, the participants themselves, structural factors, the leader and various processes that can be attributed to the group. These components interact and can change over time. One of the aspects in the models of Burlingame, MacKenzie, and Strauss (2004), is the formal change theory. In our newly developed stress management intervention, the theoretical foundation was a multi-component mix of traditional and modern CBT. The overarching goal, and thus the common denominatorbetween so-called traditional and modern CBT is, according to Mennin at al.(2013), behavioral adaption. Behavioral

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adaption is, in summary, about optimizing the adaption to circumstances that arise in the life individuals live. To explain and discuss a positive behavioral adaption three change principles and six therapeutic processes are used. The first principle is context engagement and this principle, a hallmark of CBT, is about assisting and encouraging participants to engage in new internal or external contexts in order to develop more adaptive and flexible responses to stressful situations.

In order to develop this behavioral pattern, it is important to increase the awareness about aspects in the environment and about the cognitive and emotional aspects involved. Behavioral exposure and behavioral attention were thus one important part of the stress management intervention that was related to this change principle and the associated therapeutic processes. Stress relevant illustrations were discussed and analyzed regularly in order to emphasize the practical consequences of differences in these aspects. This may have contributed to the development of the participants’ increased awareness about the mechanisms involved in functional- and dysfunctional stress management, and thus an important part of the positive change many participants described, both in the short-term as well as in the one-year follow-up. Attention change is the second principle in Mennin’s model and attention training, and acceptance is the therapeutic processes assisting this principle. The ability to direct, and redirect, attention to situational demands is of essential importance for behavioral adaption. In the stress management intervention, the processes of attention training and acceptance were used and trained from the second session and the following sessions. Every session started with a moment of focusing on the current emotional and cognitive focus of each participant.

The acceptance concept was applied in a wide range of examples in order to investigate the potential difference for each participant developing a more acceptance-oriented approach. The results of study II indicate that this increased acceptance affected the participants in several areas, as earlier described. Mennin’s third change principle, cognitive change, and its therapeutic processes, defusion and cognitive reframing, was also a prominent part of the intervention and thus a possible part when discussing our findings from a theoretical perspective. Cognitive change refers to the ability to change perspective on an event and/or to reinterpret situations in one´s life. Mennin et al.

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(2013) highlight three different ways of reinterpretations, realistic-, positive-, and compassionate reappraisal. These were all explicitly focused in several sessions and we found examples in our data in study II emphasizing the positive change recurring when using a more compassionate voice toward oneself in everyday life. Just adding or changing the tone used when talking to oneself can make an important difference.

In addition to the theoretical starting points of intervention and the mechanisms of change, there are structural aspects that may also be of significance for the outcome of the participants (Study II). According to Burlingame et al. (2004), how often and how long the sessions last, the group's size, framing and cultural factors may have significance for the outcome. The intervention consisted of ten two-hour sessions, usually one week apart. The rationale for the number of sessions is based on the assumption that changes take time. Creating favorable conditions for the development of new or developed behavioral patterns is therefore an important aspect to consider when planning interventions.

In a comparable Swedish study by Frögéli et al. (2016), like the participants in our studies, the participants’ presence in the present increased and the participants' perceived stress decreased. Unlike our study, which consisted of ten two-hour sessions, the intervention in the Frögéli et al. (2016) study was six times two hours, which, according to Winzer et al. (2018) is common. The question of the structural forms of interventions is interesting and important to continue to investigate. One problem that research has identified is that changes achieved by participating in interventions rarely exist in a longer-term perspective (Kwasnicka, Dombrowski, White, & Sniehotta, 2016). A possible explanation for this can, according to Kwasnicka et al. (2016), be that the motives that make an individual choose to participate in an intervention differ from the motives that sustain the change.

Research shows that a combination of different factors affects the extent to which new behaviors become permanent or not. Behaviors that become habits and that are also reinforced by others in the environment are more likely to persist, according to Kwasnicka et al. (2016). In addition to the importance of making the newly learned behavior a habit, Kwasnicka et al. (2016) also, state the importance of being able to "monitor" and regulate oneself. When faced with the

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difficulty of applying a new behavior in a situation one can both identify this difficulty and create effective strategies for dealing with the difficulty itself. One of the results of our studies was that, according to the analyzes, the participants' reflective ability developed positively. A change that according to both Eng and Pai (2014) as well as Paans et al. (2017) has a positive impact on clinical competence, both as a nurse and in the clinical features during the training.

Based on the combined findings of the studies, it can be argued that 10 weeks creates good conditions for long-term change and development of already existing psychological resources, although these findings need to be confirmed in new studies before being stated with stronger support.

Findings in Study I further provide support for the chosen format and format described within the framework of this dissertation for an upcoming RCT. When discussing and explaining the psychological outcome of the intervention, still using Burlingame's model as a conceptual frame, there are also factors that can be linked to the participant. The participant does not come to the first meeting as a blank sheet but brings with them values, expectations, knowledge, motivation to participate, social skills and other aspects that are important for the outcome.

Data on descriptions found in Study I showed that participants were demographically representative of nursing students in Sweden in general and that no significant skills exist between those who completed and those who did not complete interventions (Rudman et al., 2010).

There are also aspects of importance related to the leadership qualities of the group leader when discussing the outcomes of an intervention. The interpersonal approach taken by the leader is seen to parallel the importance of the therapeutic alliance in individual therapy and is thus of significant importance for the psychological outcomes and for cohesion (Bieling, McCabe, & Antony, 2006). Burlingame et al. (2004) emphasize the importance of the group's leader being warm, tolerant and empathetic. McAllister, Withyman, and Knight (2018) further emphasize that it is important that the group leader is not overly didactic but needs to be knowledgeable about interpersonal behaviors that promote participants' participation. These skills need to be trained as the risk is otherwise great that the effort risks becoming traditional,

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i.e. one-way and knowledge-focused (McAllister et al., 2018). Since all aspects of Burlingame's model go through the group leader, it is a central aspect to consider.

Finally, Burlingame discusses the small-group processes, per se, as one aspect with impact on therapeutic outcomes. This highlights that the group are a potent source of change (Burlingame et al., 2004). This aspect, that social groups per se have a potential to cure, is routinely overlooked, especially in CBT, which is often seen as individualistic according to Haslam, Haslam, Jetten, Cruwys, and Bentley (2019). This group aspect was found in the analysis in Study II where the significance of participants attributing to each other was discussed. The group was described as both a teacher, a source of security and as a confirmatory mirror by several participants. These findings are in agreement with Koutra, Katsiadrami, and Diakogiannis (2010) and Bernhardsdottir et al. (2014), findings that also emphasized the importance and benefits of the group format. The intervention group became a "group in the group" for several of the participants and this in itself can have a positive impact on the individual's well-being, and affect psychological outcomes, thus providing a stronger rationale for the group format. Previous studies have shown a clear link between perceived social support, context, and well-being (Ditzen & Heinrichs, 2014; Kim et al., 2017; McIntyre et al., 2018; Yıldırım, Karaca, Cangur, Acıkgoz, & Akkus, 2017).

The results in Study II further showed that the participants developed and changed in their thinking and in the approach to the problems and challenges of everyday life. Analyzes showed that this was partly due to developed reflective ability, increased theoretical knowledge and aspects that could possibly be attributed to the factors discussed above. The theoretical principles, processes and application exercises of the intervention, consisting of conversations, reflections, repetition, training and feed-back, may together have contributed to increased behavioral adaptation and increased psychological flexibility for the participants.

The intervention's arrangement with its multi-theoretical and practical variation was chosen to increase the probability of individuals in a heterogeneous group finding something that matches and provides each individual participant with something valuable and applicable as private person, student or future nurse. Criticism has been directed at

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interventions, such as those based solely on mindfulness, assuming they do not offer sufficient breadth in managing stress (Beanlands et al., 2019). This problem was addressed by creating a multi-component intervention.

The core of all the elements is to be able to contribute knowledge and skills for increased psychological flexibility and thus increased ability for behavioral adaptation. Through theoretical training with many practical elements individually, they train themselves to look at and express thoughts, feelings, behaviors and situations in ways that have not been done before, can influence and change habits and established attitudes. Doing this together with others in a group can contribute with additional effects. By training as participants in the intervention did the potential for psychological flexibility and thus their own ability to deal with difficult emotional reactions is increased (Maguire & Pitceathly, 2002; McCloughen & Foster, 2018). These abilities have been shown to have a positive impact on both mental health and clinical competence. In addition, according to studies, a well-developed reflective ability indicates excellent nurses (Eng & Pai, 2014; Kashdan & Rottenberg, 2010; Paans et al., 2017).

The aim with study III was to investigate and measure preliminary psychological effects regarding self-esteem, self-efficacy and stress management competence. Preliminary, due to the circumstance that a larger sample and thus higher statistical power as well as randomization is needed, in order to draw more well-founded statistical conclusions about effects (Abbott, 2014; Craig et al., 2008; Orsmond & Cohn, 2015).

There is a well-established connection between how an individual view himself in various respects and mental well-being. The perception that an individual has about himself can either act as a buffer against stress or contribute negatively, and thus constitute a vulnerability factor in itself (Saleh, Camart, & Romo, 2017).

Self-beliefs are not a homogenous concept but contains many concepts and scales, e.g. self-esteem, which involves an affective reaction about how a person feels about her- or himself, and self-efficacy, which involves a cognitive judgement of personal capacity, which overlaps in different ways (van Dinther et al., 2011).

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Study III showed that the participants' self-efficacy and confidence increased after the intervention. This can affect confidence in one's own ability on a general level. In addition to increased self-confidence, the results also showed that those who participated in the intervention estimated their own stress management skills higher after the intervention than before. General self-efficacy (GSE) or self-esteem (SE), do not constitute focus, but the important thing about the concepts is how, according to the literature, they affect and relate to other variables relevant to the dissertation. These results can be of importance to the participants. An experience of lowered stress levels in combination with increased confidence in their own ability and competence to handle the stress that arises can probably have a positive impact on learning. This can create favorable conditions already during the training to influence the future transition to the profession in comparison with those who experience high levels of stress and have less confidence in their own ability and competence to handle stress. Good faith in one's own ability to manage stress may also make a difference to the individual nursing student who will unite the many different and often contradictory demands, so-called dissonant imperatives, that he/she faces. In Study II, it was found that several participants described how their communication skills developed as a result of participation in the intervention. Previous research has shown the importance of confidence in one's own ability for the ability to communicate effectively in the work of a nurse (Leonard, Graham, & Bonacum, 2004). Patients' information needs are often large and at the same time, the ability to absorb information may be altered due to the impact of the disease. Therefore, the nurse's communicative ability becomes important. For example, being able to create a trusting relationship and being able to assess patients' abilities to make important decisions themselves becomes a central competence that can have a crucial impact on the effects of treatments and patient safety (Edwards et al., 2010; Fallowfield & Jenkins, 1999; Pfrimmer, 2009).

Another communicative aspect where self-esteem has proven to be important is feedback. In a study by Rector and Roger (1997), it was found that people who had estimated low self-esteem reacted in a way that corresponded to depressed patients when they received negative feedback. Participants in the study responded to negative feedback by overgeneralizing. This is interesting from an educational perspective, given how frequent feedback on work is done, both academically and

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clinically, during the training period. Therefore, various aspects related to our self-beliefs affect both how feedback is used and processed and form the basis for which coping strategies are applied.

Another area where self-esteem and self-efficacy have proved to be important, with relevance from both a student and nurse perspective, is problem solving. A study by Yıldırım et al. (2017) found that there was a clear difference in the respondents who were divided into low and high levels regarding self-esteem, measured in the same way as in study III with RSES. A characteristic of the individuals categorized as having high self-esteem was that they used effective problem-solving strategies as opposed to the group categorized as having low self-esteem. Those with low self-esteem were distinguished by their use of avoidance behaviors to a much greater extent than the group with high self-esteem. The nursing students’ coping strategies in Yilidirim’s study were thus clearly influenced by their self-confidence and Yildirim et al. (2017) argue that self-esteem is a key factor on stress related coping.

Nurse education from a psychosocial point of view – theoretical considerations with potential implications for nurse educators

Previous research has highlighted the need for interventions that focus on both the individual and the organization (Byrd & McKinney, 2012; Kompier, Cooper, & Geurts, 2000; McVicar, 2003). The intervention has been aimed at strengthening, building and developing the participants' psychological ability and capacity to thereby ultimately create and maintain adaptive strategies in relation to stress. However, strengthening and developing existing resources does not change the circumstances in which stressors originate. Therefore, in order to change stressors, one needs to address the organizational conditions that affect stress and in this more theoretically based part of the discussion some such possible suggestions will be discussed based on the theories and models described initially.

With the offspring in the requirements / control / support model, with its focus on psychosocial factors in the work environment, the challenges look different depending on how the individual is classified based on the model's categories. According to both Tuomi et al. (2016) and Magnavita and Chiorri (2018) the largest category of low-strain is

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thus constituted. Individuals in this category experienced low demands in combination with high influence. According to these studies, the high-strain category, which is the combination of perceived high demands in combination with low influence, accounted for about 13%. If the goal is that all students who undergo nursing education should be classified as active students, there are several possible ways to approach this goal. Targeted or general efforts at several different levels are possible at the same time.

The high-strain group can possibly be met e.g. through the type of intervention outlined in this dissertation. Experiencing low influence in combination with high demands can entail health risks, which is well established in the research. Helping the student develop the ability and competence to cope with demands and lack of influence, but also strengthen the communicative ability so that one can communicate effectively can be beneficial in terms of health. Training in these respects has therefore been an important element of the intervention.

The low-strain group is located, according to Tuomi et al. (2016, p. 194) in what is called the "comfort zone" in the study. The students in this group are not challenged to any great extent by the education. They are also not very strongly involved. How do we move students from this category to the active category? One possible way could be to increase the level of control to the students in aspects and domains of importance to them. This could, at least from a theoretical perspective, lead to increased (positive) demands and thus according to the model a higher level of engagement.

The essence of Siegriest theory formation, focusing on the social contract aspects, is the central importance it has for individuals to respond in a subjectively acceptable and fair manner based on the relationship between efforts and rewards of various kinds (Siegrist, 2005, 2010). This ranges from strictly material and financial rewards to psychological ones, such as recognition and perceived development. The educational system lacks the opportunity to offer financial incentives. This may mean that the need for other forms of rewards is increasing. An important part of developing the psychosocial work environment in higher education can be to make the implicit more explicit, e.g., regarding requirements, expectations and aspects linked to quality in student work. The importance of communication in these respects is, according to researchers, important (Decker &

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Shellenbarger, 2012; Eddy et al., 2017; Sadler, 2010). The students and faculty are central aspects of each other's physical as well as psychosocial work environment. Everyone has a shared responsibility for the various aspects of the work environment, but how these issues are addressed, researchers say, could reflect the organizational view regarding the main responsibility for work environment-related issues (Kinman & Jones, 2005).

Possible changes can be made by teachers in relation to students working to develop clear goals and role expectations as well as clarity in the feedback systems. For students, they can work with education and active training in group work, leadership and effective communication. All areas are central components in the upcoming professional practice where, in addition to extensive nursing knowledge, it is also included in the task of leading the work in the department (Cummings et al., 2008; Hughes et al., 2016; Murray, Sundin, & Cope, 2017). This places demands on communicative skills and leadership skills in the role models encountered during training both in the academic and in the clinical work environment (Decker & Shellenbarger, 2012; Donaldson & Carter, 2005; Jack et al., 2018). Stress-related ill health needs to be addressed at different levels and in different ways (Jones & Johnston, 2000; Winzer et al., 2018). Small qualitative differences in these respects can be of great importance to the individual student and educators have an important role in these organizational relationships (Byrd & McKinney, 2012; Reeve, Shumaker, Yearwood, Crowell, & Riley, 2013; Zepke & Leach, 2010). Teachers in higher education are, in many key aspects, leaders and thus influence students in different respects. This can lead to both positive and negative consequences (Harland, Harrison, Jones, & Reiter-Palmon, 2005; Padilla, Hogan, & Kaiser, 2007; Theorell, Nyberg, & Romanowska, 2013). By working to develop both teaching and examination forms and curricula, teachers in higher education have relatively much power to develop these areas based on what the research shows. Development of educational aspects and forms, seen from a psychosocial perspective, organizational issues, has a major impact on students (Fernandez et al., 2016; Kember & Leung, 2006). With that comes a responsibility and possibly also a need for training and education in these respects and an insight that it behaves in this way. Anyone who does not consider him/herself responsible will probably not take responsibility either. Training and education of the

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teachers in higher education, as such, could be an example of an intervention, at the primary/structural level, with the potential to positively promote psychosocial working environment conditions (Kelloway & Barling, 2010; Weigand, McKee, & Das, 2013).

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Methodological comments

All studies and dissertations are drawn with different types of methodological problems, and the studies in this dissertation are no exception. Initially, based on the concept of reflexivity, the possible impact and significance of my personal input values on the results of the studies as well as on the method choices made during the course of the project will be we discussed. The problem arises from the fact that I both created, implemented and followed up the intervention. Then it follows that some of the method problems that exist concerning the advantages and disadvantages of using self-assessment scales in psychological studies. Finally, aspects related to selection problems are addressed.

Reflexivity

Berger (2015) describes the importance and potential impact a researcher's gender, age, ethnic and social background, personal characteristics, theoretical, political and ideological positions preferences and sexual orientation can have on the research process. These factors, Berger believes, can have an impact on who is studied, on what questions are asked, but also on what questions are not asked. Furthermore, it can have a bearing on what data is collected and on what interpretations are made. Based on this, the underlying question is, how has the researcher, based on all these aspects, been influenced and influenced the participants and thus the research?

There is always an ‘I’ involved in research because the researcher is part of the social world being studied. This is especially evident for qualitative studies. The fact that there is an ‘I’ present does not mean that the quality of research automatically becomes low, but it highlights the value of transparently and openly reflecting on the issues surrounding the research subject's involvement and influence in the research process (Mantzoukas, 2005). The majority of those interviewed in the thesis qualitative study were women and they were younger than me. Thus, there is a potential risk that, based on this relationship, I missed important information because I did not perceive signals, messages and word choices as well as nuances based

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on differences related to gender, age or any of the other factors described above. Seen from a social perspective, those interviewed also differed from an educational perspective. I have a number of academic degrees, a long professional life, a relatively rich language and thus potentially a linguistic and powerful advantage that can influence both the participants' will and opportunity to share and formulate their experiences of participation in the intervention.

My academic education can, in various ways, marinate my way of looking at and understanding the world and the people in it and may, possibly, create a communicative barrier with the participants.

Furthermore, in the interview situation there is a power asymmetry that risks affecting the results through so-called double social desirability. There is a risk that the person being interviewed wants me as an interviewer to be satisfied and they themselves want to state that they were satisfied and to justify their own participation (Nederhof, 1985). This validity problem should therefore be considered when discussing the results of the studies. The greatest risk of this phenomenon, researchers believe, is when the matter being investigated is of a sensitive nature (Van de Mortel, 2008). There is no uniform way to determine whether the questions are perceived as sensitive to the interviewees, but the problem is highlighted because it cannot be ruled out that the validity was negatively affected by this relationship. One of the questions that was asked was whether they were affected by the participation. There is a risk that, based on this way of formulating the question, it is difficult for the interviewee to answer in the negative in accordance with the above reasoning on social desirability. One way of dealing with these methodological difficulties would have been to have someone else conduct the interviews and ask the question in a more open way than was the case (Nederhof, 1985).

The strategy used to meet the risks described was regular research guidance, where a key element was to actively look for critical and dissenting opinions, perceptions and perspectives when analyzing data. Collected data were analyzed, coded and discussed by several in the research group to ensure the credibility of the results. The interviews were transcribed by two independent assistants without any formal connection to the project. An interview guide was created and discussed under supervision and then used for everyone who was interviewed. The transcripts were read several times in their entirety

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by the research team with the aim of identifying possible elements of the researcher's interpretation preference vis-à-vis the interviewee.

Self-assessment scales In both study one and three, a variety of scales were used in the data collection. All, with the exception of the VAS-scale developed by the research group themselves, are well known, well used and thus extensively tested psychometrically, for details see Study I and Study III. The advantages of using scales are, among other things, that they enable the collection of relatively large amounts of data in a simple and inexpensive way, are easy to administer and, compared to qualitative studies, have less degree of interpretation and that participants are often accustomed to filling out surveys (McDonald, 2008; Sidani, 2015).

However, there are well-known risks of using self-assessment that should be discussed as it may have an impact on the results. According to McDonald (2008), a basic, but problematic, assumption that the use of self-assessment scales is based on is that individuals who fill them in both have the psychological knowledge that is required and want to share it. There are therefore uncertainties with the use of self-assessment scales, as both the degree of self-knowledge and the willingness to share personal knowledge can influence how one responds, thus affecting the results. Furthermore, there is a risk that individuals respond in a socially expected way or fill out the forms without carefully considering the questions (McDonald, 2008). Some of the potential risks that exist with interviews appear to be, to some extent, also present in self-assessment scales, and are in some form present in all behavioral science research based on self-report measures (Fisher, 1993; Podsakoff, 2003). The design of the questions can in itself also influence the answers and this specific problem has been addressed by using scales that are well established and extensively tested to a large extent. However, the basic problem described above is not avoided regardless of the quality of the scales. One way of dealing with this problem would have been to try to take control of the problem by using scales designed to measure social desirability, e.g. the Crowne-Marlow scale (Franzen & Mader, 2019). To further problematize the findings in the studies, the issue of selection problems should be

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addressed. In Study I, it was investigated whether the participants differed in any systematic way from those who either chose not to participate at all or those who chose to participate five or fewer times. The analyses did not indicate that there were any systematic differences regarding any of the variables examined, but it can nevertheless not be excluded that the group that chose to participate in the intervention differed from those who chose to abstain and that there are differences that may have affected the results, but where data are missing. All the results presented within the framework of the dissertation should therefore be understood and discussed based on these conditions presented. Further, more large-scale and thus more statistically robust, studies are required before the results can be considered representative of the population of nursing students in general.

The scale the research team created themselves, and used in Study III, must be validated in future studies to gain more knowledge of its psychometric properties.

Future research

An essential finding in Study II was the importance of the group for the participants. It is well known from research with clinical samples that patients affect and are affected by each other and that this could potentially affect treatment outcome (Lo Coco et al., 2019). New scales have been developed that measure significant aspects of the interaction between participants and group leaders and between participants that could be used for this purpose, such as the Group Questionnaire (GQ) developed by (Krogel et al., 2013). GQ consists of 30 items and takes between five to 10 minutes to answer and would be interesting to use and validate for Swedish conditions. Another scale that would be interesting to use and validate for Swedish conditions is the Stress Mindset Scale developed by Crum et al. (2013). The scale aims to measure the relationship between how you relate to perceived stress, stress mindset, and stress reactions on the one hand and the extent to which you think stress affects health.

The scale is particularly well suited for CBT-based interventions according to Casper et al. (2017).

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Based on the theoretical perspective and review of the dissertation, one conclusion that can be drawn from the literature is that there are no interventions aimed at the organizational level and thus the factors that cause (unnecessary) stress in the students (Byrd & McKinney, 2012; Galbraith & Brown, 2011). It would therefore be interesting to design, implement and evaluate interventions aimed at the organizational level.

Finally, there is another area where new knowledge would be valuable. There is to our knowledge, no research related to the link between preventative and promotional interventions and learning. Learning constitutes, as Conley et al. (2015) emphasize, all higher education’s primary goals and is therefore of fundamental importance to investigate in various respects. How are students’ study strategies affected by factors in the psychosocial work environment, and how do these factors relate to stress and by extension to learning?

What organizational conditions encourage the surface and deep learning strategies of the students? How can organizational aspects such as the development of teaching, assessment and curriculum promote deep-focused strategies that create student engagement and thus reduce potentially negative stress? Öhrstedt and Lindfors (2018) have shown in their study how there is a link between stress and learning strategies. It would be interesting to investigate whether interventions of the kind described in this dissertation have an impact on the participants’ learning strategies, in clinical as well as in the academic parts of the education.

Conclusions

There is a widespread and growing stress-related problem in higher education and thus also in nursing education. Stress has shown a negative impact on students' learning, social relationships, future professional practice and their own mental health. This dissertation intended to investigate in three separate studies a newly designed stress management intervention that was developed with the intention of meeting this challenge.

Study I showed that the intervention had high acceptability. Regarding feasibility, data showed that care should be devoted to

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creating good conditions for nursing students to participate so that participation does not conflict with regular teaching. This is a problem that is also raised by other researchers (Beanlands et al., 2019). Furthermore, Study I showed that regarding adherence to the intervention, it turned out that the work on homework assignments did not work as originally intended. Based on Study I, it was suggested that this problem be addressed in future studies by suggesting that group leaders be two in number instead of one, as in this study.

In Study II, participants' experiences of participating in the intervention were examined. The survey revealed that most of the participants felt that they had great benefit from participating and that they were affected in various respects. A developed ability to identify and reflect, sort and evaluate thoughts, feelings and behaviors and communicate this was described by participants. Abilities with relevance for both the prospective profession as well as for the clinical aspects of the education and abilities have been sought in research (Eng & Pai, 2014; Timmins et al., 2011). These new abilities affected the participants on several levels, including increased calmness and increased mental presence. Study II also demonstrated, in line with research, the importance of the group itself for participants in terms of normalization and confirmation (Haslam et al., 2019).

Study III examined the psychological impact of the intervention by measuring perceived stress management competence, confidence and self-efficacy. The results showed that for those who participated in the intervention these measures were higher than for the control group. The outcome was for the intervention group and even for several variables at the one-year follow-up.

All in all, this dissertation aims to contribute to research and practice by designing, implementing and evaluating a new well-founded multi-component CBT-based intervention with the aim of promoting nursing students' stress management skills and competencies. Thus, the ambition has been to meet and contribute to parts of what is in demand in the literature (Beanlands et al., 2019; Galbraith & Brown, 2011; Turner & McCarthy, 2017).

The intervention corresponds to, and is at the same time and ultimately an example of, the type of intervention that is sought in the literature that is student-centered, contains real life applications, strengthens the participant's reflective ability, is easily accessible, cheap and broad and

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emphasizes the importance of active training of new behaviors, see e.g. (Bernhardsdóttir & Vilhjálmsson, 2013; Conley et al., 2015). In conclusion, however, it is important to emphasize, and at the same time agree with what has already been argued by other researchers, that interventions of the kind presented in this dissertation should only be a complement and not a substitute for organizational efforts (Frögéli et al., 2016). Our combined findings show that the current intervention has the potential to constitute such a supplement and further research in the form of impact studies is recommended. This would simultaneously address some of the methodological limitations described for each study and for the results presented in this dissertation.

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Acknowledgements

After just over four years, it is time to look back and thank everyone who in one way or another contributed in different ways along the way. I would therefore first like to thank Värmland County Council (now Region Värmland) that contributed with funds and thus made it possible to carry out this postgraduate education. I am also most grateful to all nursing students who participated in the intervention, without whom it would not have been possible to deepen my knowledge in this area.

I would also like to thank Ulla-Britt Beyron. You helped me a lot with all the administrative details I needed in the beginning of the project and for that, I am very grateful.

Two people who have been particularly important along the way are, of course, my supervisors, Fredrik Hjärthag and Birgitta Bisholt. Much of what I have learnt during the education, I have learned by watching you as role models of how I want to be if one day I become a supervisor. Fredrik's ability to drive processes forward with warm and friendly care has influenced me deeply. Birgitta's incalculable energy and focus mixed with a pathos of the kind seldom seen, likewise.

I would also like to thank the professionals at the University library in general, but Ann Dyrman, Eva Backström, Annelie Ekberg-Andersson and Berith Hjort in particular. For unknown reasons, I have had recurrent problems with Endnote. Every single time you intervened and helped me get it back on track. You have really taught me a lot about the ABC of references. No detail is too small because it matters to the whole. I have learned so much from you. You are amazing and do incredibly important work.

I would also like to address large and heartfelt thanks to Professor Petter Gustavsson from Karolinska Institute and Professor Petra Lindfors from Stockholm University who have both contributed their deep and broad Knowledge by reviewing my work along the way. Petter Gustavsson was reviewer at the mid seminar in October 2018 and Petra Lindfors examined both the dissertation and different texts when the work was in the final stages. Through your wise and well-formulated remarks, reflections and critical objections, I was given the opportunity

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to develop lines of thought I had not previously thought (enough) about and for this, I am grateful.

Postgraduate education has in different ways been a lonely hike. This has meant that colleagues and friends have been of importance. Among my PhD colleagues, the Writing Boot Camp Gang has been of great significance to me. So, thanks Åsa Melin, Anna Hulling, Helena Draxler, Tomas Gustavsson, Carin Lindskog and Håkan Eilard for all the sittings at Gunnerud and Minerva. I would also like to thank Jenny Höglund, Karin Lundkvist, Anna Willman and Sture Nöjd for all the major and important conversations we have had in recent years. Special thanks to Sture for the help with NVivo, I am looking forward to working with you again in the future (so stay on track).

It has also been good to be a part of the lovely gang who ”live" in the 5C corridor at work. There has been a lot of laughter so a big thank you for being such a lovely bunch.

Among my good friends, I would particularly like to thank Thomas Ringsby. Having the opportunity to, as regularly as has been the case, go from work to a sweaty workout with you has been of very great importance to me. Watching you turn into the Hulk is just a fun bonus.

To my friend Pär Löfstrand, I would also like to say a big thank you. Over the years, we have always twisted and turned on everything that it is possible to twist and turn on. It has, in addition to being nice and stimulating, also been helpful for my work.

My family have been most important of all and I would like to give you all a gigantic thank you for being who you are. My children Anton and Theo and my wife Anna-Lena. I love you most in the whole world (no post-hoc test needed).

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Ulrik Terp



The thesis includes three studies. The aim in the first study was to investigate the feasibility and acceptability of the stress management intervention. The analysis suggested that the feasibility of conducting a full-scale evaluation was confirmed for recruitment, acceptability, data collection, and adherence to the intervention. However, difficulties were also identified. In the second study the aim was to investigate the participants’ experiences from participating in the intervention. The findings indicate that participants developed new and more adaptive coping strategies. Findings emphasize the importance of both theoretical and structural aspects when planning a stress management training intervention. The third study aimed at investigating preliminary psychological effects regarding self-esteem, self-efficacy and stress management competence. Perceived stress management competency was improved and had withstanding effects one year later when compared to a control group. Self-esteem and self-efficacy, both psychological resources, also increased over time after the training program. In summary, this thesis provides insight and knowledge into the challenges and the complexities of developing and implementing a stress management intervention in a nurse education context.


Faculty of Arts and Social Sciences

Psychology


ISSN 1403-8099

ISBN 978-91-7867-066-6 (pdf)

ISBN 978-91-7867-056-7 (print)

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