A transactional analysis training program on cognitive flexibility and emotion regulation in undergraduate nursing students: an experimental study

Nursing students, as integral members of the healthcare team, engage in direct patient contact, which is crucial for developing the necessary skills and knowledge to assume nursing and caregiving roles. Their student years significantly contribute to their personal and professional growth, as well as the enhancement of their professional competence [1, 2]. However, initial patient and family interactions can lead to stress and anxiety among nursing students, often accompanied by reduced cognitive flexibility and emotion regulation [3]. Students must develop cognitive flexibility and emotion self-regulation to succeed as professionals [4].

Cognitive flexibility is the ability to assess the controllability of a situation and adapt one’s behavior to a changing environment [5]. Individuals with high cognitive flexibility are adept at identifying alternative options and adjusting to changing circumstances [6]. Nurses with high levels of cognitive flexibility play a vital role in mitigating patient and family stress during hospitalization. They exhibit adaptive caregiving behaviors grounded in the three dimensions of cognitive flexibility: awareness, willingness, and self-efficacy [5]. Emotion regulation, another influential factor in mental health, particularly among nursing students and nurses, involves strategies used to modify emotional states [7, 8]. It is a fundamental aspect of psychological well-being, contributing to effective adaptation to stressful life events and positively impacting physical health, academic performance, professional success, and social relationships [9, 10]. Adaptive emotion regulation enables individuals to function effectively in work environments and employ goal-oriented behaviors in the face of emotional challenges [11]. In contrast, maladaptive emotion regulation hinders individuals’ ability to regulate their behaviors in response to challenging situations, impeding goal attainment [9]. Research has demonstrated a positive and significant correlation between adaptive emotion regulation strategies, the quality of life of nurses, and the mental health of medical students [7, 12, 13].

In this regard, transactional analysis (TA), as a group therapy approach, is particularity effective in strengthening cognitive flexibility and emotion regulation. This approach helps individuals identify their cognitive and behavioral patterns and, through group interactions, find strategies to improve group therapy approach, is particularity effective in strengthening cognitive [14, 15]. TA, founded by Eric Berne, is a renowned group therapy approach [16]. TA posits that individuals possess three ego states: “Parent”, “Adult”, and “Child”. By developing awareness of these states, individuals can enhance communication and reduce interpersonal and social conflicts [17]. These ego states interact dynamically, influencing behavior [18]. A primary goal of TA is to empower the “Adult” ego state. An active Adult can critically evaluate information from the “Parent” and “Child” states, integrate it with external information, and make informed decisions based on the current context [19].

Literature reviews have demonstrated the effectiveness of TA in addressing various psychological variables across diverse populations. For instance, researchers have confirmed the positive impact of TA training on the mental and emotional states of alcoholics [20], depression and anxiety in individuals with depressive disorders [21], self-esteem among female inmates [17], overall family functioning and adjustment in couples [22], as well as self-esteem and interpersonal relationships [23]. Additionally, TA has been shown to be effective in resolving internal conflicts and psychological problems among adolescents [24]. In a study of Iranian adolescent girls, TA was found to positively impact emotion regulation [25].

Although cognitive flexibility and emotional regulation play a critical role in the academic success and practical function and mental health of nursing students, little attention has been paid to effective interventions that can enhance these two dimensions simultaneously. TA group therapy, known for improving self-awareness and interpersonal skills, has not been adequately studies in terms of its specific impact on cognitive flexibility and emotional regulation in nursing students. Give the high levels of stress in this population, investigating the effectiveness of TA group therapy is essential for designing interventions that promote their psychological well-being, academic performance, and ability to manage future professional challenge. So, this study aimed to evaluate the effect of TA group training on cognitive flexibility and emotion regulation in nursing students.

This study aimed to examine the impact of TA on the cognitive flexibility and emotion regulation of undergraduate nursing students. Results indicated a significant improvement in cognitive flexibility and its components within the intervention group post-intervention. A comprehensive literature review revealed no previous studies directly investigating the influence of TA on cognitive flexibility in undergraduate nursing students. However, research exploring its effects on other psychological issues provided relevant insights. For instance, Nwosu et al. (2023) demonstrated a decrease in student suicide rates in Nigeria following TA training. The researchers proposed that TA could serve as a primary intervention for both mild and severe depression [31]. One of the reasons for the alignment with the present study is both studies highlight the role of TA in improving individuals’ ability to manage challenging situations. The ability led to a reduction in hopelessness and suicidal thoughts, while in the present research, it resulted in increased cognitive flexibility and enhanced cognitive skills in stressful clinical setting for nursing students. Therefore, it is necessary for TA to be integrated in to nursing education programs.

In Iran, Zanganeh et al. (2024) demonstrated the positive impact of TA group therapy on the attachment styles of adolescent boys. Another study highlighted the effectiveness of TA in improving the mental health of middle school girls. The researchers advocated for further studies to explore psychotherapy interventions focused on enhancing the mental health of girls [32]. Also, Moradian et al. (2023) stated in a study in Iran that, considering the improvement in the mental health of female students, they suggested that further studies be conducted by providing psychotherapy interventions with an emphasis on improving the mental health of girls [33]. One of the reasons for the consistency of two studies is the same cultural background and the young and adolescent research population in both studies. Also, TA with an emphasis on identifying ineffective cognitive and behavioral patterns and replacing them with more flexible patterns, likely helped the students to approach stressful situations and professional challenges with broader perspective and a more logical approach. Therefore, the need for TA training in students’ educational curricula seems necessary.

Enzejab et al. (2023) proposed that given the impact of menopause on marital adjustment and the need for strengthening marital relationships, nurses, psychiatric nurses, and midwives should utilize this effective method to improve the lives of postmenopausal women in comprehensive health centers [34]. To explain these findings, it can be argued that TA offers a novel perspective, empowering individuals to address problems and correct mental interpretations. Individuals who engage in TA reported a wide range of benefits, including reduced depression, stress, and anger levels, as well as improved relationships, mental clarity, and overall well-being [35]. Consequently, the reduction in stress, anger, depression, and anxiety can lead to enhanced cognitive flexibility [36‐38].

The present study revealed a significant improvement on overall emotion regulation scores and improved the dimensions of adaptability and tolerance of the intervention group post-intervention. But there was no significant improvement in the emotional concealment. However, no significant difference was observed between the intervention and control groups. Pradhan (2024) in India demonstrated that trainees who underwent TA training exhibited higher levels of life satisfaction and psychological well-being. Moreover, senior trainees outperformed younger or novice trainees in these areas. Notably, a sustained impact on life satisfaction scores was observed 30 months post-training. These results suggest that long-term TA training can have enduring effects on psychological well-being [39]. This can explain this result is TA can enhance individuals ability to adapt to challenging situations and tolerate emotional pressure by identifying and modifying ineffective behavioral and emotional patterns [14]. This is particularly important in fields such as critical situations in nursing, where students frequently face stressful situations and critical decision- making scenarios in practice [40].

Williams et al. (2023) in the Philippines found that TA psychotherapy significantly reduced psychological distress and substance cravings among substance abusers. Additionally, the rate of relapse decreased during the sessions. The researchers observed that this approach effectively strengthened the adult ego in individuals with substance abuse disorder. They recommended future studies focus on stress management and parent state in longer follow-up periods [41]. This study is consistent in that it strengthens a person’s mature ego and allows them to have more control over their emotions.

HU et al. (2022) in Malaysia reported that TA psychotherapy training increased emotional intelligence in undergraduate students. The researchers suggested further research to assess the impact of this intervention on interpersonal and social relationships [42]. Iranian researchers found that educational interventions based on choice theory and TA were effective in reducing academic procrastination in female students. However, the choice theory-based training program was more effective due to its positive impact on academic self-confidence and metacognitive skills. Therefore, it is recommended that school counselors utilize a combination of these educational methods to address student procrastination [43]. Therefore, TA by focusing on raising awareness of the “parent”, ”adult” and “child” states and replacing maladaptive patterns with more mature and balanced ones, can play a significant role in strengthening the dimensions of adaptability and tolerance [7].

However, the lack of impact of TA on the emotional concealment dimension may depend on several factors. Emotional concealment, as a complex process, is often deeply rooted in individuals’ beliefs and up brining patterns. Many people, due to cultural or personality factors, tend to suppress or avoid expressing their emotions [44], and TA alone may not be sufficient to influence these longstanding patterns.it may be necessary to incorporate other psychological interventions, such as emotional regulation training, self-compassion or cognitive behavioral therapy (CBT) alongside TA. In this regard, one study demonstrated that group therapy, combining psychodrama and TA, enhanced self-awareness, environmental awareness, and interpersonal awareness in adolescent boys. This approach also facilitated conscious confrontation with problems, leading to reduced anger [45]. A review and meta-analysis study confirmed that TA had moderate to high effects on psychological distress, social functioning, self-efficacy, and psychological well-being, while also strengthening the therapist-client relationship [14]. Consequently, TA group training can be an effective method to enhance emotion regulation in nursing students [46].

The current study demonstrated the effectiveness of the TA program in improving cognitive flexibility and emotion self-regulation in nursing students. These skills are crucial for providing person-centered nursing care. The stressful nursing environments can negatively impact cognitive flexibility and emotion regulation, potentially compromising patient care. Given the extensive patient contact nurses have, developing these skills can foster conscious presence and improve patient relationships. Therefore, strategies such as TA should be incorporated into nursing education to enhance cognitive flexibility and emotion self-regulation. Also, given the lack of improvement in the area of ​​concealing in emotion regulation, other interventions such as mindfulness and emotion regulation need to be included in the nursing program for students. Studies using mixed method, have also been conducted to develop an emotion regulation program for nursing students.