The effects of self-encouragement training on distress tolerance among the mothers of hospitalized children

For nursing students

Study summary

When a child is hospitalized, the parent at the bedside often carries an invisible burden: fear, guilt, exhaustion, and a sense that the crisis is bigger than they can handle. Nurses call the capacity to sit with that discomfort without shutting down or acting out "distress tolerance" (DT). This 2022 study from the Journal of Multidisciplinary Care asked a focused question: can a short, structured self-encouragement training (SET) program raise distress tolerance among mothers whose children are in hospital?

The researchers ran a quasi-experimental study in 2019 at Ghadir subspecialty pediatric hospital in Shiraz, Iran. Sixty mothers whose children had been hospitalized for more than a week in gastrointestinal or respiratory wards took part. Mothers with self-reported serious physical or mental health conditions were excluded, and anyone who withdrew, missed sessions, or whose child was discharged early was dropped from analysis. Using sealed, opaque envelopes marked with a "1" or "2," the researchers randomly split the 60 mothers into two equal groups of 30: an intervention group and a control group. The two groups looked similar going in — comparable age (around 29 vs. 28 years), occupation (mostly housewives), and education (two-thirds with university degrees) — so any later differences would be harder to blame on pre-existing group differences.

The intervention group received SET based on the Schoenaker method, a training approach rooted in Adlerian psychology that focuses on encouraging oneself and others. Delivered as ten one-hour lecture-style sessions over five days, the program moved mothers through a sequence: introducing the concept of self-encouragement, building purposeful thinking and a positive mother-child relationship, examining the mother's role in hard situations, practicing encouraging self-talk, cultivating compassion, accepting imperfection, learning an "empty chair" inner-dialogue technique, confronting obstacles (including spiritual coping), reviewing self-image, and consolidating positive inner thinking. The control group received no such training.

Distress tolerance was measured with the validated 15-item Distress Tolerance Scale (Simons & Gaher, 2005), which scores four dimensions — tolerance, absorption (how much negative emotion crowds out other thoughts), appraisal (how distress is judged), and regulation (effort to relieve distress) — for a total possible score of 15 to 75.

Before the training, both groups had similarly low DT scores, with no statistically significant difference (39.17 vs. 41.55 out of 75; p = 0.33). After the five-day program, the picture changed sharply: the intervention group's average score rose to 51.23, significantly higher than the control group's 41.23 (p < 0.001). Every one of the four DT dimensions improved significantly in the trained group, while the control group's scores barely moved. Within the intervention group itself, the before-and-after difference was highly significant (p < 0.001); the control group showed no significant change over the same period. Looking dimension by dimension, appraisal showed the biggest gain and absorption the smallest — the authors suggest the short, five-day timeline may not have been long enough to meaningfully shift how much mothers got "absorbed" by negative emotion.

The authors' one stated limitation was that the two study groups were matched on only a small number of variables (age, occupation, education); they recommend future studies also account for personality traits, family support, and past experiences that could influence how someone responds to this kind of training. The study did not follow mothers beyond the immediate posttest, so how long these gains last is unknown. It was also a single-site, single-country sample of 60 women, which limits how confidently the results generalize elsewhere.

For nursing students, this study is a concrete example of how a low-cost, nurse-deliverable psychoeducational program might support family members during a pediatric hospitalization crisis — while also illustrating why appraising sample size, follow-up length, and confounding variables matters before applying any single study's findings to practice.

For educators

Teaching and appraisal notes

This quasi-experimental study (Akbarzadeh, Sadeghi, and Radmehr, 2022, Journal of Multidisciplinary Care) examined whether a brief self-encouragement training (SET) program, based on the Schoenaker method rooted in Adlerian psychology, could improve distress tolerance (DT) among mothers of hospitalized children. The setting was Ghadir subspecialty pediatric hospital in Shiraz, Iran, with data collection in 2019.

Sixty mothers whose children had been hospitalized for more than one week in gastrointestinal or respiratory wards were conveniently recruited, then randomly allocated (via sealed, opaque, numbered envelopes) to a 30-person intervention group or a 30-person control group. Inclusion required no self-reported serious physical or mental disorder; exclusion criteria included withdrawal, missed sessions, or early hospital discharge. Sample size (n = 30/group) was calculated a priori for a confidence level of 0.95 and power of 0.85. Groups did not differ significantly at baseline on age, occupation, or education (all p > 0.05), and pretest DT scores were statistically equivalent (39.17 ± 8.39 vs. 41.55 ± 10.28; p = 0.33), supporting comparability.

The intervention comprised ten one-hour sessions over five days, delivered by lecture in a classroom setting, working through Schoenaker-method content: encouragement concepts, purposeful motivation, maternal role reflection, self-encouraging language, compassion, acceptance of imperfection, an "empty chair" inner-dialogue exercise, confronting obstacles (including spiritual/religious coping), reviewing self-image, and consolidating positive inner thinking. Controls received no intervention. Outcome was measured with the 15-item Distress Tolerance Scale (Simons & Gaher, 2005; four subscales — tolerance, absorption, appraisal, regulation; Cronbach's alpha 0.82), analyzed via independent-sample and paired-sample t tests in SPSS v. 22.0 with significance set at p < 0.05.

The posttest total DT score was significantly higher in the intervention group than control (51.23 ± 6.95 vs. 41.23 ± 10.26; p < 0.001), and all four subscales improved significantly within the intervention group (p < 0.001) while the control group showed no significant within-group change on any measure. The appraisal subscale showed the largest gain; absorption showed the smallest, which the authors attribute to the brevity of the five-day intervention window.

For classroom discussion, this paper is a useful, appraisable example of a quasi-experimental (not fully randomized-controlled) design: randomization occurred at the group-allocation stage via sealed envelopes, but recruitment itself was by convenience sampling, and neither participants nor (implicitly) facilitators could be blinded given the nature of a lecture-based psychoeducational intervention. Students should be prompted to distinguish this from a true RCT and to consider how blinding limitations and self-report outcome measures could introduce response bias or expectancy effects. The single explicitly stated author limitation — that groups were matched on only a few demographic variables, leaving personality traits, family support, and prior experience uncontrolled — is worth pairing with methodological questions about single-site sampling (one hospital, one country), the absence of any follow-up beyond immediate posttest, and the modest total sample size (n = 60) relative to the four-dimension outcome being tested. Faculty may also use the paper's discussion section, which situates SET within a wider international literature (e.g., SET's effects on resilience in mothers of children with intellectual disabilities, stress in mothers of children with cancer, and depression in psychiatric inpatients), to model how findings from one small trial are contextualized against — but not proven by — a broader body of related, non-identical studies. The study offers a low-resource, nurse-implementable intervention model worth appraising for feasibility, cultural transferability, and durability before recommending translation into a Canadian pediatric nursing context.