Introduction:
Every employee in his career experiences a period called retirement. This period is an inevitable stage of working life, through which the employees is supposed to leave the occupational routine and social activities (1, 2). The standard age for retirement and qualification for receiving welfare benefits greatly varies in different countries. Among the Asian countries, the normal retirement age is often less than 60 (3). In Iran, the retirement age ranges from 45 to 66 years based on social security rules and the years of working. Also, the number of the retired nurses and retirement duration are increasing in the recent years (4).
Retirement leads to a change in everyday life of any individual because the person must leave a job identifying with it over his working life, putting an end to his service and transition from one role to another and into a new phase of life (2). From another point of view in adult life, retirement is considered as changes in working, communication and self-image (5, 6) Losing job, friends and colleagues, being separated from patients and the working environment create an emotional bubble, and reduce nurses' social status (7). It could create significant challenges in financial, social and emotional coping. Retirement experience for the nurses is hard &stressful and accompanied with identity threat (8).
Due to its changing impact on the social role, retirement can be one of the critical stages of life accompanied by a certain imbalanced attitude, individual’s lifestyle, and family psychosocial adaptation (9). The ways people deal with retirement vary, but it is associated with several factors, including attitude toward professional activity, senility and physical conditions of tomorrow (10). Retirement is not a simple single-stage transition, but rather it requires adaptation over time (11).
On retirement, the person finds himself under stress, which gives rise to a core problem and additional signs presenting in the form of retirement syndrome. Retirement syndrome is characterized by four criteria including helplessness and failure, feeling old and idle, feeling of effort and new direction and sense of confusion and conflict as the complications of retirement (12). This complex syndrome arises from a period of time before retirement, known as "syndrome on the verge of retirement" with the main symptoms of conflicting attitudes and expectations, feeling of freedom, foresight and imagination, and scattered plans. At the next phase, retirement syndrome progresses into feelings of helplessness and failure, feeling old and idle, feeling of effort and new direction and sense of confusion and conflict (13).
Many descriptive studies have so far been conducted on the psychological effect of retirement, such as restlessness, anxiety, depression, worrying about the future, feeling empty and uselessness (14-17). The association between work and mental health underscores the importance of policies and strategies to encourage and enable people to continue in the workforce after age 55, particularly for men (6, 18). However, it is necessary to conduct interventional studies for curtailing the psychological effect of retirement, including retirement syndrome. While there are a few studies on the nurses’ retirement process, concerns about delayed or insufficient preparation for retirement are available (19-22). Since the retired constitutes a large portion of the society (for example in Iran with 4491000 retiree (23)), whose psychological problems can have a great impact on mental health and quality of life among the families of retired people and ultimately the whole society, psychoeducational intervention aims to adapt them with retirement, thus reducing the complications as well as saving costs of treatment and enhancing the public health. This field trial study aimed to investigate the effect of psychoeducational intervention on retirement syndrome among retired nurses at Shiraz University of Medical Sciences (SUMS).
Materials and Methods
Study Design
This was a field trial assessing the effectiveness of psychoeducational intervention on the retirement syndrome in the control and intervention groups.
Setting
The Association of Pensioners at Shiraz University of Medical Sciences was selected as the research setting. This is a corporate, non-political and non-profit organization, which tries to provide common social benefits and defending the rights of retirees, make the field of reemployment for retired employees using their experience and expertise, offer various services and projects in the field of health support services, cooperative consumption and housing for members and publication of journal.
Study participants
The population consisted of all involuntary retired nurses who worked in the clinical practice affiliated to Shiraz University of Medical Sciences, had completed 30 years of service, passed a maximum of 2 years of retirement without re-employment, and attended at least 6 out of the 8 intervention sessions. On the other hand, the retirees having participated in similar programs, having known history of chronic mental illness, and having experienced severe crises such as crime, addiction and incurable diseases were excluded from the study. The reason for these exclusions was that these complications might affect the results. The intervention was performed by one expert psychiatric mental health nurse.
In this study, 73 retired nurses (34 female and 39 male) admitted to the Association of Pensioners in Shiraz University of Medical Sciences and achieving scores higher than 80 for the symptoms of the retirement syndrome fulfilled the inclusion criteria. Moreover, the sample size required for the research project was a minimum of 15 subjects in each group (total of 30). According to a previous similar study (24) at a significance level of 5%, power of 0.95, and a= 0.05, d=1, o= 0.75, ß= 0.05, the sample size was estimated. Of course, the sample size was raised to 86 nurses to allow dropping-out. During the study, 13 retirees in the intervention groups withdrew from the study due to the lack of interest to continue (Figure 1). The intervention group received 8 interventional sessions, but the control group did not receive any intervention during the research period.
Data collection
The samples were selected by the co-researchers and cooperation of Association of Pensioners at SUMS providing a list of 176 eligible subjects, who were then contacted. A total of 120 subjects responded to the phone call and completed the retirement syndrome questionnaire in the Association of Pensioners. Then, 86 people were selected who had inclusion criteria and scores higher than 80 in the retirement syndrome questionnaire. At the next stage, a block randomization was used to randomly divide the samples into two groups. After sampling was completed, the subjects were called back. Finally, there were 43 people in the control group and 30 in the intervention group (13 retirees in the intervention group were not interested to be allocated in the intervention group and preferred to be in the control group, so after randomization, they did not participate in the intervention sessions and left the study). Prior to participation, the significance, objective, and methods of this study were explained to all participants, who were also provided with an explanatory leaflet that reiterated this information. At the beginning of the study, all the subjects were asked to complete an informed consent form for participation in the study. They were also assured that their information would remain strictly confidential and that they were free to withdraw from the study at any point. To prevent any possible errors, the questionnaire was completed and coded by the trained co-researcher.
Data collection was also performed at the end of the intervention and also two months later.
Measure
Demographic questionnaire
The demographic information questionnaire was prepared by the researchers according to previous studies. It included several items on age, sex, occupation, experience in management and retirement time, and was filled out by both groups through individual interviews in collaboration with the co-researcher.
Retirement syndrome questionnaire
Another tool used in this study was retirement syndrome questionnaire developed in Iran, This questionnaire is a valid and reliable questionnaire prepared in cultural setting of the study; therefore, it can be more suitable for measuring retirement syndrome in the study setting. This questionnaire which contains 40 items was validated in 2010 by Bozorgmehri Bouzarjomehri; it measures 4 aspects of retirement syndrome, including helplessness and failure (18 items), feeling of effort and new direction (6 items), feeling old and idleness (11 items), and feeling of confusion and conflict(5 items). The items could be responded through a 5-point scale ranging from 1 (never) to 5 (always). The item on feeling of effort and new direction was reverse scored. Thus, the maximum and minimum scores of the questionnaire were 200 and 40, respectively. In this scale, higher scores represented higher levels of retirement syndrome. Cranach's alpha coefficient equaled .71 for the whole questionnaire and .76, .6, .6, and .6, for its four elements, respectively (13).
Intervention group
Psychoeducational intervention was administered by a trained psychiatric mental health nurse under the supervision of an expert university professor so as to ensure coordination between the group meetings in eight sessions at the conference room of Association of Pensioners, SUMS. The program consisted of 8 weekly two hour group sessions on educational and practical program based on cognitive-behavioral approach; some tasks were also presented for them to practice at home and discuss them at the next session. In each group, 6-8 retirees participated.
In the first session, the therapist presented some information about the goals, rules and duration of the intervention. Then, the retirement and its positive and negative consequences were discussed. The second session involved D'Zurilla and Goldfried's approach to problem-solving for people to practice in groups (25). Problem solving was defined as a behavioral process which (a) makes a variety of response alternatives available for dealing with a problematic situation, and (b) increases the probability of selecting the most effective response from among these alternatives (25). The third session included training, performing and practicing through assertiveness based on individual cognitive distortions (such as the idea that there is no solution to this problem and I’ve given up). Sessions 4-6 discussed the cognitive problems of each individual and solutions were proposed. The individual thinks the problem will continue and the situation will not get any better (for example, one of participants kept saying: “My problems are endless; I cannot stand it”). Training and performing the progressive muscle relaxation as an intervention was based on Jacobson’s model and was included in all sessions (26). In progressive muscle relaxation, sixteen muscle groups were engaged. At the end of each session, the participants were asked to give feedback and describe their feelings as they were doing the steps. The assignments and practical exercises were given to the participants after each session. At the beginning of each session, discussion focused on how to exercise and apply the strategies.
Control group
In the control group, there was no intervention administered during the study. Participants in this group only completed the questionnaire for retirement syndrome at the same time as the intervention group. Upon completion of the study, educational CDs were handed to the control group based on ethical rules.
Ethics and consent to participate
The study received ethical approval from the Ethics Committee at SUMS. Prior to participation, the significance, objective, and methods of this study were explained to all participants, who were also provided with an explanatory leaflet that reiterated this information. At the beginning of the study, all the subjects were asked to complete an informed consent form for participation in the study. They were also assured that their information would remain strictly confidential and that they were free to withdraw from the study at any point.
Blinding
In this research, personnel at Association of Pensioners and also the co-researcher were blind to the groups, measurements and intervention. The person who analyzed the data was also not informed about the study aims.
Data analysis
The data were analyzed through SPSS 16. The effect of the intervention on the retirement syndrome was examined by repeated-measures ANOVA. Post hoc and t-test were applied as well as Bonferroni correction when multiple comparisons were made. The significance level in this study was p<0.05.
Results
Demographic characteristics
In this study, the participants’ mean (SD) age in the control and intervention groups were 52.44(24.1) and 52(1.14), respectively. Based on the results of the Chi-square test, the majority of the subjects in the control group were male (55.82%) and in the intervention group the number of male and female participants was equal (50%), but there was no statistical difference between the two groups in this regard (Table 1). Using independent t-test, Chi-square and Fisher exact test, it was found that there was no significant difference between the intervention and control groups in terms of age, retirement time, gender, management experience and marital status (p>0.05).
Table 1. Baseline Characteristics of Participants (N= 73) |
| Variable |
Control (n=43) |
Intervention(n=30) |
P-value |
Age (M, SD) |
52.44(24.1) |
52(1.14) |
a p= .127 |
Retirement time
(month) (M, SD) |
27.8(5.6) |
7(5.88) |
a p= .33 |
Gender n (%) |
Female |
19(44.18%) |
15(50%) |
b p = .24 |
Male |
24 (55.81%) |
15(50%) |
Managerial experience n (%) |
Yes |
4(9.3%) |
7(23.3%) |
b p =2.72 |
No |
39(90.7%) |
23(76.6%) |
Marital status n (%) |
Single |
2(2.7%) |
4(5.5%) |
c p = .14 |
Married |
34(46.6%) |
17(23.3%) |
Divorced |
7(9.6%) |
9(12.3%) |
Note. a=Independent sample t-test, b = Chi-square, c = Fisher exact test. |
Retirement syndrome
The results of t-test showed that there was no difference between the retirement syndrome scores of the two groups before the intervention (p = .066). However, after the intervention, there was a significant difference in scores of the two study groups (p<.001). Moreover, there was a significant difference in the retirement syndrome scores of the intervention group at the follow-up stage as compared with the control group (p<.001) (Table 2).
Table 2. Comparison of Mean Score of Retirement syndrome Before, After and Two Months After the End of the Intervention in Both Groups and Between the Groups Under Testing. |
group |
Pre
M(SD) |
Post
M(SD) |
Follow
M(SD) |
aRM-ANOVA, F,P
Time Group Time/Group |
Intervention |
148.6(12.53) |
93.39(12.96) |
93.2(13.13) |
F=5.4
p=.016 |
F=148.51
p<.001 |
F=544.66
p<.001 |
Control |
143.39(11.38) |
145.26(11.31) |
143.4(10.07) |
|
p = .066 |
p<.001 |
p<.001 |
|
t= 1.86 |
t=-18.05 |
t=-17.71 |
Note. a = RM-ANOVA=Repeated measures analysis of variance |
According to Table 2 and based on the analysis of variance using repeated measures, the scores of retirement syndrome were statistically and significantly different in the three steps of measurement based on time, group and time/group (p< 0. 01). According to Table 3, based on the post hoc test of Bonferroni, there was a significant difference in the score of retirement syndrome between the pre-intervention and post-intervention and also pre-intervention and 2 month follow up in the intervention group (p<0.001). However, there was no significant difference in the retirement syndrome after the intervention compared to 2 months follow up in the intervention group (p=1).
Table 3. Pair Wise Comparison of Retirement Syndrome Scores in the Intervention and Control groups Before, Immediately After, and Two Months After the Intervention. |
| Group |
Stages |
Mean differences |
SE |
Bonferroni
(p-value) |
| Intervention group |
Step 1 and 2 |
55.26 |
2.33 |
p<.001 |
| Step 1 and 3 |
55.42 |
2.35 |
p<.001 |
Step 2 and 3 |
2 |
0.31 |
p=1 |
Control group |
Step 1 and 2 |
2.04 |
1.05 |
p<0.17 |
| Step 1 and 3 |
0.19 |
0.63 |
p=1 |
Step 2 and 3 |
1.85
|
0.88 |
p=0.12 |
Note. Step 1: Baseline, step 2: Immediately after the intervention, step 3: Two months after the intervention. |
Based on Table 4 and analysis of variance with repeated measures, the scores of 4 subscales of retirement syndrome scale were statistically and significantly different in the three measurement times based on time, group and time/group in the intervention and control groups.(p<0.001). Based on the post hoc test of Bonferroni, there was a significant difference in the scores of 4 subscales of retirement syndrome between the pre intervention and after the intervention and also pre-intervention and 2 months follow up in the intervention group (p<0.001). However, there was no significant difference in the scores of 4 subscales of retirement syndrome after the intervention compared to 2 months follow up (p>0.05). There was no significant difference between the three measurement times of the control group in 4 subscales of retirement syndrome (Table. 5).
Table 4. Comparison of the Mean (SD) Scores of Retirement Syndrome Subscales Before, Immediately After, and Two Months After the Intervention. |
Sub scale |
Group |
Pre Mean(SD) |
Post Mean(SD) |
Follow Mean(SD) |
aRM-ANOVA, F,P Time Group Time/group |
FH |
G1 |
71.06(6.09) |
38.6(7.24) |
38.1(6.8) |
F=706.62 p<.001 |
F=184.35
p<.001 |
F=720.68 p<.001 |
G2 |
67.44(6.03) |
67.67(5.41) |
67.53(5.70) |
FED |
G1 |
19.5(3.01) |
16.6(2.4) |
16.83(2.93) |
F=39.82p<.001 |
F=18.92
p<.001 |
F=46.42
p<.001 |
G2 |
20.19(2.53) |
20.47(5.53) |
20.07(2.5) |
FOI |
G1 |
40.56(3.97) |
27.56(3.9) |
23.73(3.88) |
F=120.38
p<.001 |
F=97.6
p<.001 |
F=155.25
p<.001 |
G2 |
39(3.22) |
40.44(5.16) |
39.18(2.88) |
FCC |
G1 |
17.53(2.51) |
10.63(2.93) |
10.53(3.09) |
F=157.87
p<.001 |
F=54.81
p<.001 |
F=58.91
p<.001 |
G2 |
16.76(2) |
16.79(2.42) |
16.76(2.15) |
Note. G1=Intervention group, G2=control group, HF: helplessness and failure, FED: Feeling of effort and new direction, FOI: Feeling old and idleness, FCC: Feeling confusion and conflict. |
Table 5: Pair Wise Comparison of Retirement Syndrome subscales Scores in the Intervention and Control groups Before, Immediately After, and Two Months After the Intervention |
Variable |
Group |
Stages |
Mean differences |
Standard error |
Bonferroni (p-value) |
| HF |
G1
|
Step 1 and 2 |
32.46 |
1.23 |
P<.001 |
Step 1 and 3 |
32.96 |
1.25 |
P<.001 |
Step 2 and 3 |
5 |
0.29 |
P=.31 |
G2 |
Step 1 and 2 |
0.23 |
0.51 |
P=1 |
Step 1 and 3 |
0.09 |
0.49 |
P=1 |
Step 2 and 3 |
0.14 |
0.21 |
p=1 |
| FED |
G1 |
Step 1 and 2 |
2.9 |
0.34 |
P<.001 |
Step 1 and 3 |
2.66 |
0.32 |
P<.001 |
Step 2 and 3 |
0.21 |
0.21 |
P=.88 |
G2 |
Step 1 and 2 |
0.23 |
0.51 |
p =1 |
Step 1 and 3 |
0.09 |
0.49 |
p=1 |
Step 2 and 3 |
0.14 |
0.21 |
p=1 |
| FOI |
G1 |
Step 1 and 2 |
13 |
0.78 |
P<.001 |
Step 1 and 3 |
12.83 |
0.74 |
P<.001 |
Step 2 and 3 |
0.16 |
0.16 |
P=.97 |
G2 |
Step 1 and 2 |
1.44 |
0.74 |
P=.17 |
Step 1 and 3 |
0.18 |
0.21 |
P=1 |
Step 2 and 3 |
1.25 |
0.72 |
P=.27 |
| FCC |
G1 |
Step 1 and 2 |
6.9 |
0.59 |
P<.001 |
Step 1 and 3 |
7 |
0.6 |
P<.001 |
Step 2 and 3 |
0.1 |
0.11 |
P=1 |
G2 |
Step 1 and 2 |
0.02 |
0.19 |
P=1 |
Step 1 and 3 |
0.00 |
0.16 |
P=1 |
Step 2 and 3 |
0.02 |
0.08 |
P=1 |
Note. G1=Intervention group, G2=control group, HF: helplessness and failure, FED: Feeling of effort and new direction, FOI: Feeling old and idleness, FCC: Feeling confusion and conflict.Step 1: Baseline, step 2: Immediately after intervention, step 3: 2 months after intervention. |
Discussion
This field trial study aimed to investigate the effect of psychoeducational intervention on retirement syndrome among retired nurses at SUMS. Statistical results showed that the intervention was effective in the intervention groups' retirement syndrome score compared to the control group and the intervention had a lasting impact on the intervention group.
The findings were consistent with certain results of previous research, while slightly contrasting with other results of relevant studies. In the study, Taghvayee and Mansour (2008) examined the effect of cognitive therapy on depression in 20 elderly women suffering from depression in one of the nursing homes. The former participated in ten 90-minute sessions of cognitive therapy, while the control group did not receive any treatment. At the end of the course, there was a significant difference found in the mean depression scores. In other words, group cognitive therapy reduced depression in older women (p<0.001) (24).
Several studies have indicated the effectiveness of psychoeducational intervention on improving mental health status and quality of life among individuals (27-33). However, studies focusing on the impact of psychoeducational intervention on retirement syndrome were limited.
In explaining why therapeutic outcomes persisted in the follow-up phase, it can be argued that the frequent use of stress management techniques such as relaxation, diaphragmatic breathing, identifying and correcting dysfunctional thoughts, etc. after the sessions reduced retirement syndrome in the subjects. In general, it can be stated that the relative reliability of the results during the follow-up period is associated with the use of active therapeutic techniques.
The results demonstrated that the assumption held true, suggesting that psychoeducational intervention could reduce the retirement syndrome in the intervention group as compared to the control group. As an explanation, it can be argued that psychological problems (such as anxiety, depression, etc.) could potentially reduce the level of mental health. As a result, any factor weakening the above items might lead to lower incidence of retirement syndrome. In this study, effort was made to employ various techniques of psychological training so as to treat retirement syndrome.
Conclusion
The findings of the present study are an important contribution to the body of the results of previous studies on retirement, provide information about psychoeducational intervention on retirement syndrome, and improve the psychological health of retired nurses.
In Iran, nurses make up a significant portion of the employees in the health care system. The results of the study stress the need for educating retired nurses on retirement syndrome management. Since retired nurses all over the world are prone to retirement syndrome, it is recommended that such cognitive-behavioral interventions be used to lower the retirement syndrome in retired nurses in other countries as well. It is necessary to supervise the nurses’ work in collaboration with higher levels of management and health policy makers so as to take measures in relation to providing psychoeducational intervention prior to retirement as well as during and after retirement, thus curtailing the psychological complications. This study adds to the limited number of research available on the topic and provides an appropriate and effective education for retirees. Similar studies with larger sample size and longer follow-up are recommended to be conducted on the issue. Also, using theories that improve personal control are recommended to be used for retiree (34)
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the authorship and/ or publication of this article.
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