Each semester, approximately 100 students begin their education on the nursing program. All were offered to participate in the intervention. This means that approximately 400 individuals were offered to attend the four semesters over which the intervention was conducted. Sixty-seven chose to participate in the intervention, and approximately 330 chose not to participate. This gave a general average participation rate of about 17% for the current period 2015-2016 when the studies and the intervention were carried out as an initial step in examining the conditions for an RCT.
Sample characteristics. First and most important for feasibility, is to answer the question if can we recruit the appropriate participants and to investigate the obstacles to recruitment? Characteristics of the sample that followed the intervention, dropouts, and the control group are provided below (Table 4).
The intervention group and the dropout group did not differ in any background variables measured. This shows that there are no systematic differences between those who chose to participate in the intervention compared to those who chose not to participate in the intervention.
However, when comparing the intervention and the control group, our data shows a difference between how much time the student spent per week on studies and vocational work. The relationship between the number of hours the students spent on average each week on studies or work looks different from semester four. In semester two students on average placed more time on studies in relation to work, and this relationship did not apply to the control group. Whether this is a finding relevant outside our study sample is an open question, but according to studies, this is a phenomenon relatively new to nurse education where the underlying assumption about the student is that he or she is a full or part-time student. This is an assumption with relevance for stress research and under alteration globally (30).
In summary, our analysis of between-group differences revealed no selection bias considering sex, age, social background or educational level of the participants' parents or in time spent on studying and working when comparing the intervention group with the non-participants; thus our sample is representative of the target study population, nursing students.
Obstacles and dropout rates. The reasons for non-participation and for dropout were formally examined by a survey developed by the research team, see additional file 1. On two occasions, the questionnaire was distributed in connection with regular teaching in a full class. The reasons given by individuals present at the time of this questionnaire distribution who participated in the intervention between one to five occasions, but who chose not to complete it are shown below. The reasons given by nursing students offered to participate in the intervention but who chose not to do so are also shown (Table 5).
The table shows that the most common and most prominent reason for not completing the intervention was being busy with other tasks related to regular studies. In addition to this, time for leisure and extra work were mentioned to a lesser extent as reasons for not completing the intervention. Correspondingly, those who chose not to participate in the intervention stated mainly that studies and leisure interests were the reasons for this. In addition to the fixed response options contained in the questionnaire, it was also possible to add comments to a final open question. The qualitative analysis provided additional information. The results of the open-ended questions showed that those who answered (n=26) the open question primarily mentioned long distances as the main reasons for choosing not to participate in the intervention.
CSQ-8. The participants' satisfaction with the intervention was generally high. Most participants (81.7%), had a total score between 27 and 32 points indicating that they were very satisfied with the intervention. 18.3 % scored between 21 and 26 points indicating that they were satisfied. No participants had a total score below 23 points.
The result of CSQ-8 shows that overall, the participants were satisfied with the intervention. Most of the respondents were very satisfied and would highly recommend the intervention to others. The item that received the lowest rating was about how much the intervention responded to the participants' needs. In summary the participants expressed an overall high acceptability of the intervention.
Attendance rates. About half as many from the four groups attended the tenth session compared to the first occasion. No specific occasions differ but overall the number of participants decreased regularly. The last group that participated, however, had a higher attendance throughout all sessions on average (Table 6).
Through all the groups, there were a total of 43 participants who participated in nine or ten sessions and in total 73 participated on five occasions or more.
Adherence. In the second measurement, a question was asked about how the participants worked on the home assignments between each session. This measurement can be considered as one aspect of engagement with the intervention. We found that the participants did not adhere to the homework assigned each session as initially expected. From our data, it appears that a clear majority, 53 out of a total of 61 participants, did not regularly work with the home assignments that form a central part of the intervention. Only six people stated that they regularly worked with home assignments.
Outcome measures and preliminary evaluation
Standardized instruments. For all scales, except the pure procrastination scale as well as the perceived stress scale, there are significant differences between the first and second measurements. When it came to HAD anxiety and CD-RISC, the improved results were also seen in the one-year follow-up. Regarding the Brief cope scale, it was only the sub-scales of self-distraction, self-blame as well as planning where an improvement occurred between the first and the second measurement occasions. Regarding self-distraction and self-blame, the improved results were also seen at the one-year follow-up. The results indicate that the intervention positively influenced the participants regarding central mental health parameters (Table 7 and 8).
In addition, analyzes between groups also compared the intervention group's measurement 3 with the control group's measurement of all the above instruments. Independent t-tests showed that there was a difference for HAD anxiety [t (68.85) = 2.07; p < .05], where the values were higher in the control group 7.95 (3.79) compared to the intervention group 6.53 (2.16). For PSS the values were also significantly [t (58) = 2.41; p < .05] higher in the control group 24.02 (7.99) compared to the intervention group 18.71 (6.93). For COPE active coping, the intervention group showed a significantly [t (76) = 2.42; p < .05] higher value 6.74 (0.99) compared to the control group 6.16 (1.08). Otherwise, no other differences could be observed between the intervention group's measurement 3 and the control group.
Open-ended question. The thematic analysis revealed three themes Focusing on Self and relating deeper to others, Changed life perspective, To know-how.
Focusing on the self and relating deeper to others. In the first theme, the focus is on one's self and is primarily about self-knowledge and self-awareness. The participants describe how, as a result of the intervention, they started to problematize and ask questions to themselves about demands they place on themselves and an increased acceptance of their personality.
”It has taught me to listen to myself, even taken help to rethink / correct in situations where I could influence. I have even gained a greater understanding and knowledge of my feelings.” Ref 2
Through a combination of newly acquired psychological knowledge and reflective ability, several participants describe how they have been positively influenced and gained greater self-knowledge.
Changed life perspective. The participants describe that they have learned to handle stress in a different way, which has contributed to them looking at life in a new way and with a changed life perspective. The participants emphasize that they look at life in a new way, which, among other things, appears through a change as to whether a challenging life situation should be a problem or not.
”I feel that I can handle the stress in a different way, can in some way have control over it and stop stressing for example by prioritizing certain things and accepting that I cannot do everything.” Ref 16
Most of the participants describe how, through a changed attitude, they have been influenced in their way of thinking and relate to the degree of control and influence one has in different situations. The participants expressed this through the question of what is possible to influence and what lies outside of control. This question contributed to the participants experiencing that they could relate differently than before to both large and small issues in life. This was seen, for example, in the view on how both study and work tasks should be handled and prioritized for several participants.
To know-how. The participants describe new behaviors they feel they have learned by participating in the intervention. Relatively many participants describe how they developed new concrete ways to relate to stress and problematic situations based on the theoretical models treated in the intervention. The participants in everyday situations apply ways that work.
” I am much quicker to separate thoughts, feelings, and actions and know that one does not have to influence the other. However, I still work with itJ” Ref 9
In the one-year follow-up, several the participants describe 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 interviews show that the participants were affected by participating in the intervention in several different ways. They became calmer and better at sorting and prioritizing things according to importance and urgency. A developed ability to reflect and improve skills in stress management together with extended theoretical knowledge is described as underlying this perceived change.