Title: Facilitating stress mastery among high-risk professionals
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Title: Facilitating stress mastery among high-risk professionals
Physical Description: ix, 181 leaves : ; 28 cm.
Language: English
Creator: Patterson, Nancy Hord, 1943-
Copyright Date: 1984
 Subjects
Subject: Stress (Psychology)   ( lcsh )
Nurses -- Job stress   ( lcsh )
Holism   ( lcsh )
Counselor Education thesis Ph. D
Dissertations, Academic -- Counselor Education -- UF
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Statement of Responsibility: by Nancy Hord Patterson.
Thesis: Thesis (Ph. D.)--University of Florida, 1984.
Bibliography: Bibliography: leaves 165-180.
General Note: Typescript.
General Note: Vita.
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Bibliographic ID: UF00099593
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000500705
oclc - 12115166
notis - ACS0338

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FACILITATING STRESS MASTERY
AMONG HIGH-RISK PROFESSIONALS









By

NANCY HORD PATTERSON


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY



UNIVERSITY OF FLORIDA


































Copyright 1984

by
Nancy Hord Patterson









ACKNOWLEDGEMENTS

Many people have supported me in many ways throughout this en-

deavor, and I wish to recognize their contributions to this

accomplishment.

My parents gave me support and encouragement, and demonstrated

a great respect for education by having the foresight to send me to

a school that would profoundly influence my life.

My children were tolerant of my studies and activities, even

when they did not understand what I was doing. They accepted many

years of rigid schedules and long-distance parenting. The rest of my

family clothed, fed, housed and transported me innumerable times.

I sincerely appreciate their care, concern and genuine interest.

There were professors who long ago planted a gleam in my eye,

and motivation in my soul. Dr. Roseann Cacciola, Dr. Pat Bidleman,

Dr. Ann Radwan and Dr. Laura Fairfax, I thank you for your belief in

my potential. Thanks also to Dr. W. G. Scanlon and Dr. J. S. Hasbani

for being my mentors and supporters.

My good friends in the Association of Independent Psychotherapists

helped me to survive. Gaye Scales and Debra Flynn gave long hours to

scoring tests, and extra sanity sessions. Frances Wiggins introduced

me to Stress Management and holism. Jo Brooke calmed me, and Leah

Moss-Ahern was excited for me when I was too tangled up to be excited

on my own.

Special thanks are offered to the library at the University of

North Florida, and the Borland's Medical Library, for the use of their

excellent facilities and resources. David and Michelle Sendler were

my long-distance resource librarians when I was stuck in Jacksonville

and the only copy of what was needed was in Gainesville.

iii









To my committee, my "powerful others" who left nothing to

"chance," thank you for guiding me when I needed it, and thank you

for making me do it on my own when I wanted to lean on you. Thank

you for letting me do it my way.

To the fifth person on my committee--my husband, Bill Patterson--

who encouraged when I was discouraged, who directed when I lost my

way, and who gave more love, patience and support than I deserved

or will ever be able to repay, my thanks are gratefully offered.

Thanks are especially offered to the nurses who participated

in this study, and to all the nurses, and clients, and students

who taught me so much about holistic counseling.













TABLE OF CONTENTS


ACKNOWLEDGEMENTS . . . . . . . . .

LIST OF TABLES . . . . . . . . . . . .

ABSTRACT . . . . . . . . . . .

CHAPTER

ONE STATEMENT OF PURPOSE . . . .


Introduction ...
Statement of the Problems
Purpose of the Study
Theoretical Constructs
Definition of Terms .
Research Questions . .
Overview of the Remainder


of the Study


TWO REVIEW OF THE RELATED LITERATURE ....

Introduction . . . . .
Overview . . . . . .
The Components of Stress and its Management .. ...
Specific Measures and Procedures .....
Summary . . . . . . . . . . . .

THREE METHODOLOGY . . . . . . . . . . .

Overview . . . . . .
Population and Selection of Subjects . . . .
Assessment Procedure and Measurement ....
Assessment Tools .........
Treatments . . . . . .
Threats to Validity . . . . . . . . .
Limitations . . . . . . . . . . .
Research Hypotheses . . . . . . . . .
Statistical Evaluation .......


Page

iii

vii

viii



1









FOUR RESULTS . . . . . . . . . . .

Conflict . . . . .
Locus of Control . . . . .
Social Readjustment ........
Locus of Control in Life Events .. . ......
Conflict in Locus of Control . . . . . .
Conflict in Life Events . . . . . . .
Interaction Between Scales ......

FIVE DISCUSSION . . . . .


Summary . . . . . .
Hypotheses Considered .
Limitations . . . .
Conclusions . . . .
Implications for Theory . .
Implications for Practice .
Implications for Research and
for Further Study . . .


Recommendations


APPENDICES . . . . . . . . . . . .

A LETTER TO PARTICIPANTS ......

B SOCIAL READJUSTMENT RATING SCALE ....

C LEVENSON'S INTERNAL/POWERFUL OTHERS/CHANCE .

D FORMAT OF HOLISTIC HEALTH TRAINING SESSIONS
FOR STRESS MASTERY . . . . . . .

E COURSE EVALUATION FORM AND COMPLETE SUMMARY . .

F DEMOGRAPHIC DATA SHEET . . ..

G KNOWLEDGE AND AWARENESS QUESTIONNAIRE ....

H INFORMED CONSENT FOR TREATMENT GROUP . . . .

I INFORMED CONSENT FOR CONTROL GROUP ...

REFERENCES . . . . . . . . . . . .

BIOGRAPHICAL SKETCH . . . . .













LIST OF TABLES


Table


Page

46


1 Demographic Data . . . . . . . . . .

2 Experimental Group as they were Represented
by the MBTI Categories . . . . . . . .

3 Summary of Self Reported Changes in General
Knowledge and Awareness from Experimental Group .

4 Summary of Course Evaluations ......

5 Summary of Social Readjustment Scale .. ......

6 Means and Standard Deviations of the Treatment and
Control Groups on the Rotter Incomplete Sentences
Blank . . . . . .

7 Means and Standard Deviations of the Treatment and
Control Group on the Levenson Tridimensional Locus
of Control Scale . . . . . . . . . .

8 Comparisons of Means for Internal, Powerful Others
and Chance Between Treatment and Control Groups . .

9 Comparison of the Treatment and Control Groups on
the Holmes & Rahe Social Readjustment Rating
Scale . . . . . .

10 Pearson Product Moment Correlations Between the
Social Readjustment Scale and the Levenson
Tridimensional Locus of Control Scale ....

11 Correlation of Conflict with Locus of Control .

12 Pearson Product Moment Correlations Between
Conflict & Life Events . . . . . . . .

13 Summary Table of Two-Way Analysis of Variance
Comparisons . . . . . .

14 Summary of Instruments . . . . . . . .

15 Summary of Statistical Procedures .....








Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy


FACILITATING STRESS MASTERY
AMONG HIGH RISK PROFESSIONALS


By


Nancy Hord Patterson

April, 1984

Chairman: Janet J. Larsen
Cochairman: P. Joseph Wittmer
Major Department: Counselor Education

This experimental study was concerned with the identification,

intervention and evaluation of stress-related variables among

registered nurses. The study initially identified and assessed the

variables of recent life events, locus of control and the level of

projected conflict utilizing Holmes and Rahe's Social Readjustment

rating scale (SRRS), Levenson's Tridimensional Locus of Control

(I/P/C), and Rotter's Incomplete Sentences Blank (RISB), respectively.

The intervention was facilitated group training based on social

learning. It focused on holistic health concepts, generating self

awareness and individual responsibility for stress mastery. The

study examined perceptions of conflict and locus of control, mediated

by life events. Group mean scores were measured and evaluated

following the training.

Fifty-two female registered nurses comprised the total sample.

The experimental and control groups were comparable in terms of








educational background, nursing experience, and salary, as well as

hospital and nursing specialty representation.

Although the treatment group experienced a significantly higher

degree of life changes (p=.005) than did the control group, these RN's

(n=27) attending a continuing education class on stress mastery had

significantly (p=.05) reduced projected conflict at the conclusion of

the study. At the completion of the intervention the experimental

group had increased perceived internal locus of control and decreased

perceived control by powerful others. The control group (n=25), RN's

attending an advanced course of study in nursing increased the sense

of internal control, but also increased the perceived control by

powerful others. Both groups decreased the perception of control by

chance. Interactively, these changes were statistically non-significant.

Separate ANOVA's indicated significance between chance and life events

(p=.03) and between conflict and internality (p=.008 & .012, pretest

and posttest), as well as conflict and powerful others (p=.027 and

.001, pretest and posttest).

It was concluded that nurses who voluntarily enroll in a stress

mastery intervention significantly decrease perceived conflict. They

experience a significantly high level of life events and these events

lead them to view their lives as being influenced by chance and powerful

others. They are professionals who are at high risk because of a

combination of life events and a perception of external control from

either powerful others or chance. Therefore, an intervention focusing

on a multifacted approach to reducing conflict, self awareness and

self responsibility that stimulates an increase in internal control is

an appropriate treatment.















CHAPTER ONE
STATEMENT OF PURPOSE


Introduction

Facilitation of stress mastery for high risk professionals is

currently being addressed in a number of compartmentalized perspectives.

For example, there is a proliferation of programs addressing meditation,

biofeedback, physical fitness, and positive personal development. The

concept of this proposed intervention is to approach the manifestations,

modifiers, and management of stress from the broader base of total

lifestyles.

Lifestyle plays a major role in the health of modern America, yet

lifestyle is not a freestanding entity. It is the result of the influ-

ences of physiological, psychological, and environmental forces--many

of which can be brought under our control. Well-being depends on the

perception of both the positive and negative results of our lifestyle.

Contemporary society contributes many of our detrimental stressors;

refined foods, unrelenting schedules, and reorientation of family,

occupational and personal responsibilities are but a few of the demand-

ing goals and predictable lifestyle readjustments which may be required

for well-being. It is the pursuit of the new-found goals and their

attendant demands which set the stage for today's acute interpersonal

and intrapersonal conflict. For example, according to the United States

Surgeon General, stress is a contributing factor in 90% of all diseases.









Statement of the Problem

If the problem is the practiced lifestyle which leads to stress

reactions, then there is a need to determine if there are factors use-

ful in identifying high levels of stress, as well as methods useful in

reducing this stress. There is a need to understand the multiple

influences of the process of stress (Pearlin, Lieberman, Menaghan &

Mullen, 1981) and then to intervene and influence the outcome of this

process toward healthier lifestyles, a mastery of stress (Caplan, 1981),

and an increased sense of well-being.

Nurses are representative of high risk professionals needing the

intervention proposed by this study. Psychological and nursing litera-

ture validates the typical syndrome of stress being experienced by

some members of this group. It has an insidious onset, but progresses

to a full disease state--with predictable symptoms affecting all life

dimensions--when left unattended. The extremely stressed victim is one

who is eventually unable to withstand the cumulative pressures of work

and the subsequent lifestyle, and succumbs physically, psychologically,

socially, and/or spiritually to those pressures.


Purpose of the Study

This experimental study was concerned with identification, inter-

vention, and evaluation of changes in stress-related variables among

registered nurses. The study initially identified and assessed the

three variables of recent life events (Holmes & Rahe, 1967), locus of

control (Levenson, 1972; Rotter, 1966), and the level of projected con-

flict (Rotter & Rafferty, 1950). Intervention was in the form of group

training focusing on holistic health, increasing personal awareness, and

promoting stress mastery (Caplan, 1981). Following the training, the









study measured and evaluated changes in conflict and locus of control,

after statistically equalizing the groups on the basis of prior read-

justment to stress.

In this study, a training approach was utilized in which the

facilitator(s) offered information in a non-evaluative format. The

nurses were expected to learn more effective stress mastery skills and

incorporate the information into their personal repertoire of behaviors.

The rationale took an ethological rather than laboratory approach, and

utilized the efficiency and efficacy of group training as a method of

intervention. A basic assumption of this study was that the training

approach for facilitating stress mastery will be the most beneficial to

participants.

The goal of the study is the generation of self-awareness in the

participants which will encourage them to address their own individual

needs in order to master stress. The philosophical thrust of this study

was succinctly expressed by Leah Moss, a baccalaureate nursing student

at the University of North Florida in 1983. The study seeks to promote

a holistic philosophy of personal potential by increasing personal aware-

ness--for it is that awareness that exists beyond our experiences that

represents the potential of the whole person.


Theoretical Constructs

The theoretical approach of this study was based on social learn-

ing (Phares, 1976; Rotter, 1954) and the concepts of holistic health

(Kreiger, 1981; Selye, 1974; Ryan & Travis, 1981). The philosophical

position of this paper was that the nature of man is a harmonious ab-

stract complexity. To investigate man it has been necessary to destroy

this essence of humanity by breaking it into isolated components.









Social learning and the holistic movement seek to integrate this

essence in order to promote realization of man's full potential.

The lifestyles we develop and practice can immensely influence our

ability to deal with stress. The manner in which our time is managed,

occupational satisfaction, social and environmental conditions, the

amount and type of drugs ingested (alcohol, nicotine, caffeine, illicit

and prescribed substances), the amount and type of exercise and relaxa-

tion in which we engage, and the nutritional density of our diets all

interact in our ability to adapt to, and master the stressors in our

environment. Nested within the categories of physical and psychological

concepts are how one thinks of oneself, how one communicates, one's

personality, and the availability of support systems--all of which are

key factors in mastering stress.

It is expected that the information yielded from this study will

be of interest to nurses, counselors, educators, and mental health con-

sultants. Nurses who participated received direct personal benefits of

the study, as well as the novel opportunity to participate in learning

experiences quite different from the traditional didactic methods.

Because they have a responsibility to maintain in-depth knowledge rela-

tive to the patient population served, the participants felt there was

a large pool of potential beneficiaries with whom they would be able to

share this information. Counselors, educators, and mental health con-

sultants might be interested because of recent activity in the holistic

health movement, and generally expanding health horizons. These groups

will be interested because effective, efficient methods of training are

needed for the ever-increasing fund of knowledge that must be promulgated,

as well as the increasing population in need of the specific stress-

reducing skills.






5


Definition of Terms

For the purpose of this study, the following definitions of cer-

tain terms and concepts will be used:

Stress. Stress is the nonspecific response of the body to any

demands made upon it, regardless of the desirability of the stimulus

(Selye, 1974, p. 14).

Stressor. A stressor is considered to be any demand on one's mind

or body. It may exist in environmental and/or social conditions; appear

in interpersonal, intrapersonal, and/or physical situations; be posi-

tively or negatively perceived; be realistically or unrealistically

evaluated. The only element these potential stressors have in common is

their capability to initiate the stress reaction (Shaffer, 1982, p. 7).

Life event. Measured life events are those commonly occurring

social events which are associated with some adaptive or coping behavior

on the part of the individual involved. The emphasis is on change from

the existing steady state, and not on psychological meaning, emotion,

or desirability (Holmes & Rahe, 1967, p. 217).

Locus of control. Locus of control is the social learning concept

referring to beliefs about the causal relationship between behavior and

the subsequent occurrence of a reinforcement. External control refers

to a belief that fate, luck, chance, or powerful others mediate the re-

lationship. Internal control refers to the belief that occurrences of

reinforcement are contingent upon one's own behavior (Gazda & Corsini,

1980, p. 456).

Powerful others. One measure of external locus of control is that

of powerful others. It is a belief that predictable but powerful others

exercise control in one's life (Levenson, 1972).









Chance. A second measure of externality is that of chance, which

represents a belief that events are not predictable because control

lies in the realm of fate, luck, or chance (Levenson, 1972).

Internality. An internal locus of control represents the extent to

which individuals believe they have control over their own lives (Levenson,

1972).

Conflict. Conflict is a measurable state reflecting maladjustment

related to multiple areas, including self-concept, interpersonal and

intrapersonal relationships, social situations, family, control, and

occupations (Rotter & Rafferty & Schachtitz, 1949; Rotter & Rafferty, 1950;

Rotter & Lah, 1983).

Consultation. One process of sharing information with others is that

of consultation. The consultant has both teaching and counseling skills,

but the purpose is presentation of information in a non-supervisory, non-

evaluative, and non-judgmental manner such that the consultee is free

to accept or reject the information according to individual need. The

goal of consultation is that the information accepted will be integrated,

and will enhance personal and/or professional growth (Caplan, 1970).

Holism. Holism is a concept emphasizing personal responsibility for

health care and recognizing the complexity and interdependence of the

physical, psychological, social, and spiritual dimensions of the individual.

The emphasis of holism is on lifestyle, well-being, and wellness (Yahn, 1979).

Mastery. Mastery is demonstrated in individual behavior that

(a) results in reducing to tolerable limits physiological and psychologi-

cal manifestations of arousal resulting from stressors, and (b) mobilizes

the individual's internal and external resources and develops new capa-

bilities in him that lead to changing the environment or his relation to

it, so that threat is reduced and satisfactory alternatives are found

(Caplan, 1981, p. 413).









Research Questions

Assuming that nurses are representative of a population of pro-

fessionals at high-risk for stress, and that they need to reduce that

stress in order to lead more effective and healthier lives, it becomes

necessary to find effective, efficient, and economical methods of

assisting them to reduce this stress. As the nature of this study is

exploratory, the questions were general (Armstrong, 1974).

Using Rotter and Rafferty's (1950) Incomplete Sentences Blank (RISB)

as a measure of projected adjustment/conflict, do respondents' measured

adjustment scores correlate to training; and is this influence on

measured adjustment predicated on perception of locus of control or

reported life events?

Using Levenson's (1972) tridimensional measure of Internality,

Powerful Others, and Chance Control (I/P/C), can respondents' percep-

tion of locus of control be influenced by training? Is there a rela-

tionship in perceptual change due to reported life events and/or

measured adjustment?

Using an adaptation of the Holmes and Rahe (1967) Social Readjust-

ment Rating Scale (SRRS), are changes in locus of control and/or

measured adjustment biased by residual stress? Are these reported

life events mediated as a function of locus of control?


Overview of Remainder of the Study

The following portions of this study briefly review the concept

of social learning and the philosophy of holistic health. In the

context of lifestyles, an overview of the process of stress, and its

manifestations, mediators, and modifiers is presented. A more detailed

review of the literature related to the measurements considers the





8



rationale for their use. Studies which are similar in nature, focus

or results of this study are reviewed.

The methodology section addressed the selection of subjects,

definition of the population and the treatment, and reviewed the

assessment tools. The limitations of the study and the threats to

validity were discussed. The research hypotheses were proposed and

statistical treatments delineated.















CHAPTER TWO
REVIEW OF THE RELATED LITERATURE


Introduction

The review of the literature dealt with the research related to

the identification, intervention, and evaluation of stress-related

variables, with a focus on nurses as representatives of a high-risk

population. The literature was briefly reviewed in the context of

social learning and the philosophy of holism, followed by an overview

of the process of stress and its manifestations, mediators and modi-

fiers, presented in the context of lifestyles. A more detailed review

of the literature was done on the three measurements, including life

events, locus of control, and conflict. Studies which were similar in

nature, focus or population of this proposal were reviewed.


Overview

This study seeks to facilitate the mastery of stress--its manifes-

tations, modifiers, and management--through increased personal awareness

and lifestyle modification. Significant variables in the management and

perception of the process of stress will be considered. Training modules

have been developed utilizing a holistic health approach and social

learning. Both of the approaches encompass the complexity of each indi-

vidual and emphasize personal responsibility in the establishment of

well-being. These training sessions will be directed at developing

self-awareness through cognitive and affective approaches, and









measurements will be made of changes in locus of control and conflict as

a result of the training process. Measures of existing stress will be

taken pretreatment.

The topics of the training sessions will include measurement and

significance of life events, physiological and behavioral manifestations

and modifiers of stress, personality types and preferences, communica-

tion styles and skills, adjustment and self-concept, habit control and

time management, social support systems and autonomy and control. Speci-

fic application of the training information will be directed at

registered nurses (Berg, 1980; Maslach, 1976), so the principles of adult

learning will be utilized in developing effective, interesting modes of

training and evaluation (Boyles, 1981; Cropley & Dave, 1978; Draves,

1976; Ingram, 1979; Kidd, 1959) compatible with both the concept of

andragogy (Daly, 1980; Knowles, 1950) and horizontal and vertical life-

long learning (Jessup, 1969).


Holism

Sister Callista Roy (1971) noted that any concept of caregiving

begins with the recipient of that care--man.* This study considers man

to be a whole individual, inextricably bound to both his internal and

external physical and phenomenological (Combs & Snygg, 1949) world.

Intrapersonally--intelligence, personality, and physiology are inter-

woven and are likewise blended into the social, cultural, and environ-

mental systems. Few disciplines have the privilege (or the problem) of

isolating any of these factors into a laboratory-controlled situation.


*any human being regardless of sex or age; a member of the human
race; a person (The American Heritage Dictionary of the English
Language, 1976).









The behavioral and medical sciences, in practice, must necessarily take

an ethological approach to man (Oleck & Yoder, 1981; Winstead-Fry, 1980).

From the Greek holos, meaning entire or whole (person), holismm"

was first used by Jan Smuts in 1926, in a theory of relation of parts

to the whole. During the decade of the seventies, the concept was used

for the resurrection of health care of the whole mind-body-spirit-

personality, and departure from the Descartian reductionist view held

since the 17th century (Shealy, 1981). With emphasis on lifestyle,

well-being and wellness, holism is a health care that has gained momen-

tum. The concepts are simple and clear, emphasizing personal responsi-

bility for health care. The integration of mind-body-spirit is positive

wellness, and involves vitality, joy, physical fitness, no health-

impairing habits, meaningful and productive work, quality interpersonal

and intrapersonal relationships, and minimal tension and stress (Yahn,

1979, p. 2202-2203).

Others support the resurgence of holistic health. Although identi-

fied under different rubrics, the recognition of man as a multidimen-

sional being in an increasingly complex environment is returning to the

health care scene (Allen, 1977; Blattner, 1981; Cohen, 1978; Flynn,

1980; Martin & Prange, 1962; Mazzati, 1977; Robinson, 1974: Krieger,

1981; Seiler & Messina, 1979).


Social Learning

Social learning offers a way of looking at the world and viewing

events from many dimensions (Bandura & Walters, 1963). The emphasis on

learning conveys the assumption that most human learning takes place in

meaningful environments and is acquired through social interaction with









others. One's environment is endowed with meaning and significance as

a result of past experiences, but is lived in the present. Rotter

(1954, cited in Gazda & Corsini, 1980) commented:

it is a social learning theory because it stresses the fact
that the major or basic modes of behaving are learned in
social situations and are inextricably fused with needs re-
quiring for their satisfaction the mediation of other
persons. (p. 406)


A Society Under Stress

Dr. Roy Menninger estimated that 80% of the complains seen by

physicians are psychosomatic reactions to problems of living (1978).

Later reports place this number at nearly 90%. As people try to

cope with these problems of living they often end up eating poorly,

smoking, using alcohol or other drugs, and failing to exercise

properly. Stress--problems known to be related to lifestyles--is now

known to be either a direct or indirect major contributor to coronary

heart disease, cancer, lung ailments, accident injuries, cirrhosis

of the liver, and suicide--six of the leading causes of death in

the United States (Brenner, 1973, 1976; Friedman & Rosenmann, 1974).

"In many ways, modern America has become a much less healthful place

to live" (Menninger, 1978, p. 80). "Our mode of life itself, the

way we live, is emerging as today's principal cause of illness"

(Rosch, in Wallis, 1983). "Stress is now a chronic, relentless, psycho-

social situation" (Elkes, in Wallis, 1983), p. 48).

Houghton (1982) reports that the apparent adjustments necessary in

lifestyles and priorities necessary to maintain mental health include

meaningful work, self-discipline, realistic goal setting, good rest and

exercise, supportive family and friends, and social skills. Many of









these same lifestyle adjustments, necessary to successfully adapt in a

stressful society, and to intervene in the syndrome of stress, will be

addressed in the training sessions of this research.


The Components of Stress and its Management

Stress as a Multidimensional Process

"Stress" is a generic term that subsumes a variety of manifesta-

tions (Pearlin, Lieberman, Managham & Mullen, 1981), a phenomenon

involving all aspects of "multidimensional man" (Frain & Valija, 1979),

and rather than a stimulus or response, the interaction of the indi-

vidual to internal and external processes reaching threshold levels

which strain its physiological and psychological integrative capacities

close to, or beyond their limits (adapted from Basowitz, Persky, Korchin,

& Grinker, 1955, in Cleland, 1965, p. 293).

There are several useful ways of conceptualizing stress. Acute

stress is that which occurs quickly, but has the potential for rela-

tively rapid resolution. Chronic stress is more insidious, and is

usually an accumulation of smaller, unresolved stressors (Brenner, 1973,

1976; Dohrenwend & Dohrenwend, 1979; Holmes & Rahe, 1967; Lazarus, 1966,

1981; Pearlin et al., 1981; Selye, 1974). Specific stress is an

individually-defined vulnerability. Sources of stress may be explained

as threats to (a) the physical self, (b) the psychological self,

(c) social relationships, or (3) one's environment (NTL, 1978). Both

sources and types of stress as cited by the above authors are frequently

identified as life events, and are differentiated according to magnitude,

desirability, scheduledness, and controllability.









Pearlin, Lieberman, Menaghan and Mullen further delineate not

only the sources, but also the mediators and manifestations of stress,

which are interconnected to form a process of stress. Mediators are

those behavioral, perceptual, and cognitive methods of coping and

adapting that persons use to alter or mediate the effects of stress,

while the manifestations of stress range from the microbial and covert

to the macro-organismic and overt physical, emotional, and behavioral

reactions (1981, p. 340-342). It is essential to look at the entire

complex interacting process of stress in order to begin understanding

what can be done about it.


Physical Mediators and Modifiers of Stress

Exercise can be a source of mediator of stress. A sound exercise

program can enhance self-esteem, diminish depression, and renew or

replenish energy. It is estimated that only 15% of American adults

practice sufficient aerobic exercise to maintain healthy levels of car-

diovascular sufficiency (Shealy, 1981). Exercise is an important factor

in the treatment of hypertension (Anderson, 1978; Jasmin, Hill & Smith,

1981; Pelletier, 1977; Selye, 1974), has been noted as beneficial for

the treatment of depression (Frain & Valija, 1979), and a replacement

for addictions (Glasser, 1965).

Exercise, abusive exercise may cause joint and muscle damage,

while ineffective exercise does little to enhance cardiovascular acti-

vity. An effective aerobic exercise program facilitates cardiovascular

activity, can help maintain optimal weight, and increases energy level

(Bowerman & Harris, 1967; Cooper, 1970; Cooper & Cooper, 1972; DeVries,

1974).

In King, Cohenour, Corruccini and Schneeman (1978) an in-depth

review of the "Basic Four" food groups found that if this long-standing









nutritional standard was followed as suggested, approximately 30% of

the minimum established daily nutritional requirements were unmet. The

American Dietetic Association has developed the "Modified Basic Four"

which does meet the minimal nutritional requirements and is easy to

teach and integrate (Peterkin, Kerr & Shore, 1978; Sherman, Lewis &

Guthrie, 1978). Nutritional literacy (Sherman et al., 1978) is a

learned skill which is relatively easy to achieve and enhances optimum

stress capacity. Good nutrition consists of eating a wide variety of

non-refined, whole, unaltered foods (Hall, 1981; Cheraskin, Ringsdorf

& Brecker, 1974). Nutritional ignorance results in poor dietary habits

which are linked to many physiological illnesses, including hypertension

and gastrointestinal disturbances. Obesity places excessive burdens on

the heart, muscles, bones and joints; its factors in self-concept and

interpersonal relationships cannot be minimized (Abrahamson & Pezer, 1971;

Airola, 1971; Baggs, 1964; Dufty, 1975; Fredericks, 1969; Lindner, 1973;

Miller, 1980; Schafer, 1979). Nutrition, like exercise, is cited as

primary to the treatment of cardiovascular diseases (Baggs, 1964;

Cheraskin, et. al., 1974; Pritken, 1979; Shealy, 1981; Taylor & Fortmann,

1983), gastrointestinal diseases (Lindner, 1973), as well as chronic

and transitory depression (Abrahamson & Pezet, 1971; Dufty, 1975;

Fredericks, 1969).

Approaches to managing stress (change) are as multiple and varied

as the individual responses and indications. The most basic and impor-

tant skill is developing the ability to relax. It is not possible to be

tense and relaxed at the same time (Wolpe, 1958). Relaxation is a very

specific response of the body--one that can be elicited at will.

Relaxation is merely a normal response of the body used to defend it-

self against conditions of continuing stress (Benson, 1975). It is the









opposite of the alarm state (Donnelly, 1980b; Selye, 1974). Relaxation

lowers blood pressure (Pelletier, 1977, 1978), relieves backache (Kraus,

1965; Shealy, 1981), and decreases muscular tension (Madders, 1979;

Wallis, Galvin & Thompson, 1983). Relaxation is achieved in many ways,

including meditation (Sethi, 1980), various styles of self-hypnosis and

biofeedback (Belar, 1980; Donnelly, 1980a; Hartje, 1976), autogenic

training (Schutz, in Luthe, 1969), progressive muscle relaxation (Jacobsen,

1928, in Donnelly, 1980b; Trygstad, 1980), massage and touch (Krieger,

1981), yoga (Diskin, 1978; Rozman, 1975), and exercise (Cooper, 1970;

Cooper & Cooper, 1972; DeVries, 1974).

The U. S. Department of HEW publishes Plain Talk--The Art of

Relaxation, in which it reminds the public that relaxation takes on

many forms, including activities like education, exercise, creativity,

reading, meditative-mental processes, and an old-fashioned warm bath.

It emphasizes that learning to relax takes commitment and practice,

and that

finding effective techniques for personal relaxation is not
merely a pastime for the idle rich. It is essential for
everyone's physical and mental well-being. (Kopolow &
Fried, 1978, p. 3)


Behavioral Manifestations, Moderators, and Mediators of Stress

Among the self-destructive habits in which Americans engage, the

use of tobacco affects more people than any other. There are no "safe"

cigarettes. The 1964 and 1981 Surgeon General's report indicts all

cigarettes as direct causes of cancer, emphysema, and coronary disease.

Tobacco and its components cause vasoconstriction and are linked with

hypertension, headaches, and sinus condition (Taylor & Fortmann, 1983);

delay healing processes (Lindner, 1973); were linked with approximately









75% of duodenal ulcer surgery over two decades ago (Doll, 1958, in

Lindner, 1973, p. 62) and have been noted as a significant factor in a

ten-year longitudinal study among 90% of post-surgical back pain

sufferers (Shealy, 1981, p. 196-197).

One hundred million Americans drink, and an estimated ten million

are alcoholics. Twenty-four percent of the youth between ages 12 and 17

use alcohol, and one-third of all suicides are alcohol-related (Desmond,

1982, p. 12-13). Sixty-nine percent of the surgical patients treated

for peptic ulcer consume alcohol (Lindner, 1973, p. 62-63).

According to Wallis et al. (1983), it is a sign of the times that

the three best selling drugs in this country are Tagamet, Inderal, and

Valium--treatments for ulcers, high blood pressure, and anxiety. The

number of people using marijuana, cocaine, amphetamines, and a variety

of hallucinogens is not accurately known, but numbers in the high

millions, and encompasses all ages and ethnic groups, socioeconomic

groups, and both sexes.


Psychological and Social Manifestations,
Moderators, and Mediators of Stress

Jobs are frequently a source of life stress. Studies of large

samples--numbering in the thousands--of military and industrial workers

(LaRocca, House & French, 1980), as well as smaller samples of nurses

(Michaels, 1971), post-facto research (Brenner, 1973, 1976; Wallis,

1983), and surveys (Gentry, Foster & Froehling, 1972) all have contri-

buted to the general fund of knowledge of the variables that are related

to job stress. These researchers as well as many others make note of

the interaction of social support systems, self-esteem, and physical and

mental health (Cohen & Orlinsky, 1977; Thoits, 1982; Turner, 1981, Shealy, 1981).









One study found that nurses who had been in their positions for over

five years had significantly higher job satisfaction, lower role ambigu-

ity, and a more internal locus of control (Chariff, Duke, Level & Smith,

1980).

Communication skills and styles are additional methods of under-

standing, predicting and influencing change. Whether the approach is

Transactional Analysis (Berne, 1972; Harris, 1967; James & Jongeward,

1971, Stein, 1967), Assertiveness (Alberti & Emmons, 1970, 1975; Bloom,

Cogburn & Pearlman, 1976; Jakubowski & Lange, 1977), Neurolinguistic

Programming (Bandler, 1978; Piaget, 1980), Rational Emotive Therapy

(Ellis & Harper, 1975), or interpersonal communication and understanding

skills (Patterson, 1974; Rogers, 1942, 1951, 1961; Satir, 1972), the more

we know about ourselves and others, and how and why we communicate, the

greater the chances of minimizing stressful situations.

The ability to communicate may not be taken for granted; it is a

complex system, learned in a cultural setting, and operates on several

levels at one time (Murray & Zentner, 1979). Communication may be ver-

bal or non-verbal--the latter usually more honest and revealing (Satir,

1972). Communication skills and understanding and appreciating indivi-

dual differences are important in job satisfaction, as well as family

and interpersonal relationships (Myers, 1962)--areas strongly affected

when stress is out of control. Ryan and Travis (1981) support the con-

cept that learning assertive skills can be a tool for developing self-

concept. -Communication skills can be taught (Carkhuff & Truax, 1965;

Flynn, 1975; Kegan & Schauble, 1976; Patterson, 1974). Skills that are

particularly useful in communication include self-disclosure, feedback,

listening, assertiveness, transactional analysis, and rational thinking.









That nurses need to learn to communicate more effectively may be

noted in a 1982 study by Johnston, which examined whether other patients

know more about surgical patients' worries than the nursing staff.

Using 20 female patients (24 to 65 years old) and 17 nurses, each patient

was teamed with a nurse and a colleague patient in completing an inven-

tory describing patient worries. Results showed that the other patients

were more accurate than the nurses overall, and confirmed the results of

a previous study in which the nurses over-estimated the number of patient

worries.

The development and use of support systems for mediating stress

are advocated by many (Cobb, 1976; Donnelly, 1980d; Goodwin, 1981;

Michaels, 1971; Murphy, 1981; Norbeck, 1982). The lack of support

systems is frequently noted in the competitive corporate systems (Forbes,

1979; Schwartz, 1980; Scrivner, 1981) and in the helping professions

(Maslach, 1976; Podboy, 1980).

Man is a social being and needs others to fulfill his needs for

belongingness (Maslow, 1954). Although loneliness (not belonging) per

se is unavoidable, levels of loneliness may be dealt with as situational

or transient, rather than chronic (Cox, 1983; Moustakas, 1961). Those

who do belong, i.e., live with others, live significantly longer than

those who live alone (Lynch, 1977).

The most popular method of researching social support is that of

analyzing collected actuarial health data (Kessler, 1979; LaRocca et al.,

1980; Nuckolls, Cassel & Kaplan, 1972; Thoits, 1982; Turner, 1981;

Williams, Ware & Donald, 1981). The volume of research on social

support is extensive, and the most investigated question is whether

support systems are a construct in and of themselves, or whether they









are simply a mediating factor with other things such as life events,

mental illness, and/or self-concept. With sample size in the

thousands (usually from industry and the military), it is acceptable for

this study that social support exists as a concept, and is necessary for

optimum management of stress. Repeatedly, researchers call for more

research and more explicit theories. LaRocca, House & French (1981) state

that it is

our view that it is simply time to stop "proving" that social
support is related to stress and strain, and begin to consider
the mediating factors or mechanisms through which social
support functions. (p. 214)

This is in accord with the thought that strengthening social supports

is more immediately practical than attempting to reduce the occurrence

of the stressor situations (Kaplan, Cassel & Gore, 1977).

Personality has been studied in relation to career choices (Bolles,

1972; Holland, 1966; Keirsey & Bates, 1978; McCaulley, 1977; Super,

1957), family interactions and personal development (Erikson, 1950;

Homey, 1942, 1945, 1950; Jung, 1964), need fulfillment and motivation

(Maslow, 1954), learning styles (Jessup, 1969). Personality factors

such as flexibility and hopefulness have been reported as helpful in

coping with stress (Wallis, et. al., 1983, p. 50). Kobasa (1979, in

Kobasa, Maddi & Courington, 1981) proposed the hardy personality:

Hardy persons have considerable curiosity and tend to find
their experiences interesting and meaningful. Further, they
believe they can be influential in what they imagine, say and
do. At the same time, they expect change to be the norm, and
regard it as an important stimulus to development. (p. 368)

Control (as opposed to powerlessness), challenge (as opposed to threat),

and commitment (as opposed to alienation) are considered to be the

three components of hardiness. Personality factors are considered to

have a time-unlimited effect on stressful events (Kobasa et al., 1981).









Personality patterns in nursing have been studied extensively for

two decades. The results are inconsistent. When using the EPPS, for

instance, the variables that are consistent are that nursing students

are nurturant, deferent, and persistent, but are neither autonomous nor

dominant (Cohen, 1981). The small samples, usually of those who have

remained in a nursing program, must be noted. Levitt (in Cohen, 1981,

p. 93) does suggest that the data indicate a preclinical personality

pattern for nursing students that emphasizes feminine needs, while

assertiveness needs are played down.

The focus of nursing personality research is usually entry-level

motivations or the choice of clinical specialty at the graduate or

post-graduate level. Bernstein, Turrell and Dana (1965) utilized

projective tests in an investigation of the motivation of freshman and

sophomore nurses. Studies of clinical specialization found highly

significant differences between nurses in different practice areas--

psychiatry, medical/surgical, maternal/child, and public health

(Lukens, 1965; Miller, 1965).

More recent studies have been conducted on nurses utilizing the

Myers-Briggs Type Indicator and address issues involving nursing school

dropout, success on licensing examinations, and preventing burnout in

Intensive Care Units (McCaulley, 1967, 1977; Williams, 1975). There

are significant trends within nursing according to personality

preferences which can be demonstrated by educational level (ADN,

n=1,345; Diploma, n=3,171; BSN, n=2,074; MSN, n=566), as well as

by specialty.










Stress Components Summarized

By way of summary, Shealy (1981) states:

Further improvements in American health will more likely come
from changing self-destructive habits--cigarette smoking, being
obese, alcoholism, lack of exercise, highly refined and fiber/
mineral/vitamin deficient diets, and a stressful lifestyle.
(p. 182)

Added to this list can be the manner in which we manage time (Lakein,

1973), occupational dissatisfactions, overcrowding, noise, dangerous

driving habits, the use and abuse of drugs, excessive television, and

industrial and chemical pollution.

Stress Theory

Hans Selye, the "father" of stress, defines it in terms of the

General Adaptation Syndrome (G.A.S.). He states that stress is the

"non-specific response of the body to any demand (change) made upon

it . (and) it is immaterial whether the agent or situation we face

is pleasant or unpleasant" (Selye, 1974, p. 14).

Until quite recently, the major stresses faced by mankind were

primarily physical: food, shelter, and safety. Technology now con-

trols these factors, and the stressors presently faced are more

psychological and social in nature. The human body responds to these

modern stressors in archaic ways. Physiologically, preparation is made

to run or fight--even when the stress is unseen or unrecognized. In

this fight or flight response, bodies enter the automatic patterns that

were formerly protective mechanisms, but now frequently serve only to

disrupt our homeostatic balance. Selye's stages of the G.A.S. include

the alarm, resistance and exhaustion phases, each with predictable,

measurable physiological, individualistic symptomatology (Selye, 1974,

1976). What Selye called "diseases of adaptation" are most likely to









occur in the weakest link of the body. The body's area/organ of least

resistance--vulnerable either by genetic predisposition, prior injury,

or environmental learning--breaks down (Jasmin, Hill & Smith, 1981; Kobasa,

Meddi & Courington, 1981; Selye, 1974).


Individual Reaction to Stress

Many authorities indicate that illness and stress are highly re-

lated. Although stress (change) is universal, responses are highly

individual. The effects of stress on a particular individual are

determined by multiple factors. Personality (Aiken & McQuade, 1978;

Pelletier, 1977; Friedman & Rosenman, 1974), attitudes and anxiety level

(Spielberger, 1979), genetic predisposition (Kobasa, 1981), learning

(Seligmann, 1964), and sense of control (Lefcourt, 1981; Levensen,

1972; Nowicki & Strickland, 1973; Rotter, 1966) are but a few of the

complex interplaying factors.

Moderate stress aids most people to maintain optimum performance

levels (Rosen & Patterson, 1980; Selye, 1974). The key is individually

defining and identifying that optimum level, and further recognizing the

indications of excessive stress (Parrino, 1979; Sharpe & Lewis, 1977;

Yorde & Witmer, 1979).

While each person's ability to effectively deal with his or her

perception of stress is different, each person has an individual maxi-

mum capacity to tolerate stress. However, when chronic stress forces

endocrine and nervous systems into continuous operation, these systems

wear down and provide less effective protection, leaving bodies more

susceptible to disease. Diseases of the cardiovascular, respiratory,

gastrointestinal, genitourinary, nervous, and autoimmune systems have









all been linked to stress (Anderson, 1978; Benson, 1975; Friedman &

Rosenman, 1974; Lindner, 1973; Pelletier, 1977; Selye, 1974).


Specific Measures and Procedures

This study examined the relationship of life events, locus of

control, and conflict among registered nurses. Information based on

behavioral, physical, and psychological manifestations and modifiers

of stress was integrated into a training program and formed the basis

for the intervention.


Life Events

The probable originator of life events work was the Swiss-American

Professor of Psychiatry, Adolph Meyer. His "common sense psychiatry"

popularized the "life chart" approach to recording biographical and

medical information to allow clinicians to investigate temporal rela-

tionships between these categories of events (Rahe, 1978). Two

American researchers standardized and rated the most popular life

events research tool. Previous studies by Holmes and Rahe (1967)

established that

a cluster of social events requiring change in life adjust-
ments is significantly associated with the time of illness
onset . and that these events achieve etiological
significance as a necessary, but not sufficient cause of
illness and accounts in part for the time of onset of
disease. (Holmes & Rahe, 1967, p. 213)

Specifically, in an attempt to correlate the amount of change

(stress) experienced by individuals, Holmes and Rahe developed the

Social Readjustment Rating Scale. It was found that in general, those

people experiencing less than 200 "life-changing units" in a year










adjusted adequately to that amount of change. Increased amounts of

change resulted in statistically significant increased incidents of

physical illness: 200-300 = 37%; 300-400 = 50%; and above 400 = 81%

greater chance of developing a physical illness within the next year,

as directly resulting from the physiological reaction to that amount of

stress. The concepts of the Social Readjustment Rating Scale have be-

come widely accepted as predisposing factors to illness, and the recog-

nition of recent life change is included in the DSM-III. A small but

statistically significant and reliable correlation was found between

the occurrence of major events and problems with physical health within

the next two years. The high degree of consensus suggests a universal

agreement between groups and among individuals about the significance

of those life events under study that transcends differences in age,

sex, marital status, education, social class, generation American,

religion, and race (Holmes & Rahe, 1967, p. 217).

Holmes and Rahe define social readjustment as the amount and

duration of change in one's accustomed pattern of life resulting from

various life events. As defined, social readjustment measures the

intensity and length of time necessary to accommodate to a life event,

regardless of the desirability of this event (1967, p. 312). It in-

cludes social and interpersonal transactions and events in the family

constellation, marriage, occupation, economics, residence, group and

peer relationships, education, religion, recreation, and health.

Judging by the volume of research generated, the heuristic value

of life events research is clearly demonstrated. Life event weighting

schemes have been developed and compare extensively. Ross and

Mirowsky (1979) compared 23 methods: additive, multiplicative, tallied,










ranked, rated, and paired. Results indicate that the most predictive

method is adding up undesirable life events, that Holmes and Rahe's

original instrument is as effective as newly developed ones, and that

undesirability is a better predictor than simple change. Dohrenwend

and Dohrenwend (1979) suggest that life events weights are useful

research tools, while Lorimer, Justice, McBee and Weinman (1979) found

high correlations of predictability between counted events, rated

events, and weighted events.

In a five-year study of 5,000 male and female heads of households,

Hagen (1983) reports a study by Cohen (1978) showing that one life

event, loss of job, leads to negative self-concept, and this self-

concept is not necessarily restored when re-employment occurs. This

study was concerned with lengthy unemployment. Brenner (1973, 1976)

found statistically significant relationships between unemployment and

suicide, state mental hospital and prison initial admissions, mortality

from chirrosis of the liver and cardiovascular renal disease, and total

mortality. Other studies correlate the life event of job loss with

homicide, spouse abuse, and child abuse (in Hagen, 1983). First year

post-unemployment has higher incidents of suicides and homicides, while

two and three years post-unemployment increases in cardiovascular disease,

chronic diseases, and mortality are noted. The studies noted by Hagen

further identify the availability and strength of a social support

system to be an important mediator in the effects of unemployment.

Social support will be a topic addressed in the training, although not

measured in the study.

In an editorial statement of "life change measurement clarifica-

tion," Rahe states









Despite the difficulties of simply counting recent life change
events, many studies are currently being conducted trying to
determine if recent life changes are "positive" or "negative,"
"controlled" or "uncontrolled," "anticipated" or "unanticipated,"
"desirable" or "undesirable," and so on. . We've found
these "qualities of life change events to be evaluated quite
differently between individuals, depending on the person's
particular perceptions of the event, their psychological
defenses, coping skills. . For a clean estimate of en-
vironmental stress, vice subjective stress, it is hard to
improve upon a simple counting of recent life changes."
(1978, p. 97)

The conclusion is that the significance of life events is well documented

as a probable cause of stress (Kanner, Coyne, Schaffer & Lazarus, 1981;

Liem & Liem, 1976). There are several mediators of the effect of life

events, including social support systems and locus of control, as well

as the desirability of the event. The Social Readjustment Rating Scale

(SRRS) is a well standardized instrument, recognized among researchers

as among the most reliable and was selected for use in this study for

its additional use as a teaching and research tool.


Locus of Control

Philosophy had uncontested claim to the study of humans for

centuries. That man is ultimately responsible for his own destiny began

as a philosophical abstraction, and later was reaction against the

deterministic stance of Freudian analysis. An internalized locus of

control may be identified as autonomy, a sense of self rule denoting

independent choice regardless of outside control, a sense of having the

right or power to rule oneself.

That man is ultimately responsible for his own actions is a corner-

stone of existentialism. Frankly (1975) states that . being human

can be described in terms of being responsible . the self that









becomes conscious of itself . it meets itself" (p. 24). "No

knowledge can come to know itself, to judge itself, without rising

above itself" (p. 62). It is necessary for one to increase awareness

beyond experience in order to be able to accept, and eventually desire,

self responsibility.

Bakan (1966) notes that the positive duality of human existence

is a sense of internal control with an outward direction for the

common good.

While philosophy and theology have long discoursed the question of

man's responsibility for himself, psychology--specifically sociological

learning theories--have investigated and quantified the various loci

of control. Autonomy is considered as being a state of emotional inde-

pendence in which thoughts and feelings are not merely imitation of what

others require us to think and feel. Acquiring skills for choosing

situations of self expression and in controlling the situation is the

basis for a perceived internal locus of control. Autonomy can be de-

scribed as a growth trend where one's contemporary self structure becomes

the determining influence in the selection of one's choices.

Julian Rotter's Social Learning Theory specifically addresses the

dimension of locus of control. One school of thought notes that locus

of control may be considered as a personality variable taking a

different form in individuals. Other researchers and theorists debate

the existence of locus of control as a dynamic personality variable

vs. a static personality characteristic.









This study was interested in whether or not perception of locus of

control could be altered. The rationale was that many behaviors

depend on the amount of personal control the individual believes he has.

Decaprio (1974) indicates that one's total orientation to life is in-

fluenced by the variable of locus of control, and that one should attempt

to acquire a greater sense of control over his circumstances.

Seligmann (1975) built a strong case for lack of perceived con-

trol as being a major determinant of depression. His construct of

learned helplessness also holds promise that more adaptive attitudes

can be learned. "Powerlessness" was a forerunner of externality in

Rotter's original monograph (Seeman, 1959, in Rotter, 1966). Phares

(1976) states that "to enhance individuals' capacity to cope with the

world successfully one must influence their generalized expectancy of

control" (p. 107).

A substantial body of data regarding the validity of the construct

of locus of control has been accumulated. "Factorial analyses indicate

that there seems to be a general factor which accounts for most of the

variance. Additional analyses have further subdivided the variable

into factors of belief in a difficult world, an unjust world, an unpre-

dictable world, and a politically unresponsive world . comparable

scales have been developed for various groups . [and] from a

psychometric point of view, all the I/E inventories have been carefully

constructed and evaluated" (Anastasi, 1968, p. 556-557). She states

Internal control refers to the individual's perception of an
event as contingent upon his own behavior or his own relative
permanent characteristics. External control . indicates
that a positive or negative reinforcement following some
action of the individual is perceived as not entirely contin-
gent upon his own actions, but the result of chance, fate, or
luck; or it may be perceived as under the control of powerful
others and unpredictable because of the complexity of forces
surrounding the individual. (p. 555-556)









The internal-external concept has led to a veritable flood of

research, making it the most heavily investigated personality variable

in recent years (Phares, in Gazda & Corsini, 1980, p. 440).

What is important about this variable . is in its connec-
tion to the sociological idea of power and its converse, aliena-
tion. Locus of control is one of the few variables in social
science that may be shown to have a consistent relationship
which ties research across levels of analysis. (Rappaport, 1977,
p. 101)

The best known instrument for measuring internal-external locus of

control is that developed by Rotter (1966). Developed within the con-

text of social-learning theory, Rotter states, "The effect of rein-

forcement following some behavior . is not a simple stamping-in

process, but depends upon whether or not the person perceives a causal

relationship between his own behavior and the reward" (1966, p. 1).

Rotter's original scale was the first theoretically based, systematically

studied measurement of the alienation experienced by individuals who

feel unable to control their own destiny. Locus of control measures

have been developed for children and adults and college students

(Nowicki, 1973(b), Nowicki & Duke, 1974; Nowicki & Strickland, 1973).

They have been used in extensive cross-cultural studies (Lindbloom &

Faw, 1982), and in studies with individuals as well as groups (Foulds,

1976). Some researchers have found a skewed distribution, with a trend

toward internality for most subjects (average 8-11) when using the

typical, unidimensional locus of control measures (Drummond, 1983).

Later tests developed the three dimensions of control, internality,

powerful others, and chance (Levenson, 1972).

Because it offers the advantages of a Likert scale, immodifiable

personalization of questions, and three separate factor analytically

sound scales, the Internality/Powerful Others/Chance Scale by

Levenson (1972) is selected for use in this study.









Conflict

For the purpose of this study, conflict represented the individual

psychological manifestations of a stressful lifestyle. Conflict is

present and experienced by both groups and individuals when goals and

methods are incompatible, when engaged in interpersonal or intrapersonal

struggle and disharmony, and when experiencing confusion over roles,

expectations and/or behaviors. Conflict may originate from a variety

of sources, but is usually manifested by some degree of maladjustment.

Conflict has an inverse relationship to self-awareness and a direct

relationship to self-concept. Intra-psychic conflict frequently emerges

in a disturbed concept of self. This distortion may be temporary or

long term. Resolution of disturbed self-concept and conflict may be

approached from several avenues.

The concept of self arises from many sources. It is the inter-

nalization of perceptions of how we are perceived by others. It is the

synthesis (or disintegration) of the real and ideal selves with that

perceived self (Horney, 1942). Social support is related to psychologi-

cal well-being--the feelings of being loved, valued, and able to count

on others gives us a concept of our value to others, and subsequently

our self value (Turner, 1981). Stoddard (1983) discussed the dynamics

of negative self-concept and the processes of building a positive

self-concept. The consequences of a negative self-concept can be de-

vastating, making it difficult to assert oneself, intensifying self-

consciousness, and interfering with cognitive processes. Negative self-

concept is frequently accompanied by feelings of isolation, depression,

loneliness, inadequacy, and failure. If these negative feelings serve

as motivators to overcome obstacles in order to escape that psychological









pain, they are beneficial stimulators. If, however, in order to avoid

that pain one withdraws and becomes less risk taking, the downward

spiral of negative self-concept begins. "Maneuvering to maintain a

belief in yourself is a dynamic process" (Stoddard, 1983). Jourard

encouraged nurses to be aware of themselves in order to be aware of

others (1964).

Branden (1969) states that there is no value judgment more

important to man--no factor more decisive in his psychological develop-

ment and motivation--than the estimate he passes on himself (p. 109).

The degree of his self-esteem (or lack of it) has a profound impact

on every key aspect of his life (Branden, 1971, p. x). A positive self-

concept, the realistic view and acceptance of both positive and negative

aspects of one's personality, enhances positive feelings toward others.

Carl Rogers (1951) and Roberto Assagoli (1965) both urge the uncon-

ditional positive regard for self and others as a way to higher living.

Gordon Allport (1955) sees present awareness of oneself as a major

attribute of maturity. In becoming more self aware (releasing both

buried problems and greatness), the unrealized potential for growth,

achievement, and fulfillment that has been previously undiscovered is

released. "The individual plays a profoundly important role in deter-

mining the course of his own psychological development and in strength-

ening or destroying his self-esteem" (Branden, 1971, p. x).

It is proposed that increased awareness from several sources will

aid in diminishing conflict. Augsburger (1981) indicates that we can

experience awareness through many modes: thoughts, perceptions,

feelings, behaviors, or intentions. The only difference in efficacy

will be determined by the individual's most effective preference









pain, they are beneficial stimulators. If, however, in order to avoid

that pain one withdraws and becomes less risk taking, the downward

spiral of negative self-concept begins. "Maneuvering to maintain a

belief in yourself is a dynamic process" (Stoddard, 1983). Jourard

encouraged nurses to be aware of themselves in order to be aware of

others (1964).

Branden (1969) states that there is no value judgment more

important to man--no factor more decisive in his psychological develop-

ment and motivation--than the estimate he passes on himself (p. 109).

The degree of his self-esteem (or lack of it) has a profound impact

on every key aspect of his life (Branden, 1971, p. x). A positive self-

concept, the realistic view and acceptance of both positive and negative

aspects of one's personality enhances positive feelings toward others.

Carl Rogers (195]) and Roberto Assagiioi (19 7) both urge the uncon-

ditional positive regard for self and others as a way to higher living.

Gordon Allport (195 ) sees present awareness of oneself as a major

attribute of maturity. In becoming more self aware (releasing both

buried problems and greatness), the unrealized potential for growth,

achievement, and fulfillment that has been previously undiscovered is

released. "The individual plays a profoundly important role in deter-

mining the course of his own psychological development and in strength-

ening or destroying his self-esteem" (Branden, 1971, p. x).

It is proposed that increased awareness from several sources will

aid in diminishing conflict. Augsburger (1981) indicates that we can

experience awareness through many modes: thoughts, perceptions,

feelings, behaviors, or intentions. The only difference in efficacy

will be determined by the individual's most effective preference.









In constructing a method for enhancing self-awareness, Krikorian

and Paulanka (1982) structured a group learning experience for psychi-

atric nursing students. The rationale for such a learning experience

was that

since the therapeutic use of self frequently is identified
as the nurse's major tool in the nurse-patient relationship,
it seems important to understand the interrelationship between
self-development and awareness. . (p. 21)

Their findings indicate that behavioral changes do occur when increased

self-awareness is experienced.

A specific measurement of stress-related conflict is difficult to

find. Self-concept tools are too limiting for this study; traditional

projective techniques are too broad and focus on pathology. Projective

tests have been used routinely with nurses (Lukens, 1965; Miller, 1965).

Bernstein, Turrell and Dana (1965) found that with the examiner present,

the expression of strongly emotional material is inhibited, while with

the examiner absent, there is greater involvement on the part of

the subject" (p. 225).

The Rotter Incomplete Sentence Blank (RISB) was originally developed

to obtain an overall score for the degree of conflict being experienced

by an individual. It deals with projected conflict or adjustment in

family, social, sexual, health, vocational, institutional, educational,

interpersonal, and intrapersonal areas. It also deals with past events

and control. The RISB can be administered in groups (examiner absent)

and is a projective instrument that can be objectively scored.

In re-evaluation of the RISB over time, Lah and Rotter (1981) found

that scoring and rescoring reliabilities tested over a 25-year period

substantiate that the RISB manual is still adequate. Means have been









updated to 134.8 (SD = 18.7) for females and 133.8 (SD = 20.0) for males.

Other studies found that scorers could be trained completely from the

manual, and that those reliabilities were in the .90's.

In discussion with Rotter (1983) regarding the appropriateness of

the RISB for use in this study, he suggested that the validity and

reliability studies by Churchill and Crandall (1955) provided adequate

answers to the test-retest questions raised by Cofer and Schofield in

1953, and were especially appropriate for this study. The control group

was educated mothers, ages 35-45. Believed to have relatively stable

lives, the test-retest reliability for the mother group was .70, while

the same reliability for college women ranged from .44 to .54. These

correlations indicate that the RISB measures more than momentary moods,

but less than a stable state. Rotter stated that the use of the RISB

would be appropriate for measuring the dynamic change in conflict in

nurses using a pre-test, post-test design with a control group.

If conflict is influenced by self-awareness and self-concept, and

these can be enhanced by group training, then the measurement of conflict

is an index of progress in stress mastery. Due to the wide range of

areas tapped by the Rotter Incomplete Sentences Blank, and its original

intent to screen for conflict and maladjustment, it is selected for use

as an instrument to measure the transient, reactive state of conflict

caused by the multiple sources of stress.


Similar Approaches and Procedures

The management and prevention of stress is a high priority in to-

day's society. Classes and programs--whether commercial, educational,

or voluntary--emphasize two things: how we can help ourselves, and how









we can help others. We can only help others manage their stress after

we have learned to manage our own. We must recognize the impact of

stress on our health and well-being, and learn to minimize the ill

effects of our own particular stress (Jasmin, Hill & Smith, 1981). The

primary goal of teaching stress management skills then becomes helping

others to discover their own optimal stress level. This is done by

(a) identifying and assessing stressors; (b) identifying and assessing

responses to those stressors; and (c) commitment to a disciplined life-

style that reduces stressors and improves the responses (Jasmin et al.,

1981; Murphy, 1981; Wiggins, 1978).

Menninger (1978) notes that psychiatry and medicine have been

concerned only with the seriously ill. He implies that the positive

movement toward health and well-being will be a grassroots, self-help

movement (Dilley, 1978). As do others, Menninger advocates increased

self-awareness and recognition of one's own stress level, which does

not necessitate a psychiatrist. The initial self-awareness should be

learned under some sort of supervision.

Consultation has been shown to be an effective way of training

nurses in stress reduction. Consultation must be done in a timely manner

in crisis, but preventive training gives nurses the skills to handle

future events. The consultant need not necessarily be a nurse, but

will usually be a psychologically trained person from a related disci-

pline. The specific skills, attributes, and attitudes of the consultant

are more important than position, discipline, or clinical background

(Caplan, 1970; Claus & Bailey, 1980; Priesner, 1980).

One purpose of consultation and training is holistic health educa-

tion. Allen (1977) encourages health care education--as a deliberate









elaboration of psychological education--as a lifelong educational pro-

cess. This developmental health education would aid in learning more

effective ways to cope with stress, with developing positive self-

concepts, and dealing with physical and mental fitness. Menninger (1978)

strongly recommends "emotional" education for children and adults (p. 80).

Health education programs would be experiential--using biofeedback,

relaxation, and imagery. Such a program could "systematically attack

the notion that emotions are externally caused, that we are the pawns

of our environment rather than the origins of much of our experience"

(deCharms, 1968, in Allen, 1977, p. 43).

Another purpose of consultation and training is reframing current

perceptions.

The nurse's perception of a situation as a stressor or satis-
fier is crucial to any understanding of nursing stress.
Changing the nurse's perception, her awareness, and enlarg-
ing her behavioral repertoire may be the key in turning
stressful situations into satisfying experiences. With this
enlarged behavioral repertoire from which to draw, the nurse
who previously felt powerless could then actively control
and influence a given situation. (Claus & Bailey, 1980, p. 57)

Although evaluative research on the effects of stress-reduction inter-

vention have been minimal, and very few studies have been done using

only nurses, Mannino, Maclennan and Shore (1975) found an overall improve-

ment of 69% in 35 mental health consultation studies reviewed (in Claus &

Bailey, 1980, p. 98).

There have been a few studies reported which examine nurses and

stress. Gentry, Foster and Froehling (1972) attempted to compare inten-

sive and non-intensive nurses. They found some differences, but all

measures were within normal limits. The number of non-intensive nurses

was only eight, and wider differences are noted between the medical









center nurses and the Veterans' Hospital than the situational stress of

intensiveness.

Another field study involving general duty RN's (n=60) was done

by Cleland in 1965. She found that the need, or lack of need, for social

approval was a motivator, and considered it to be an intrinsic, enduring

individual characteristic. Nurses with an increased need for social

approval performed best under conditions of lowest situational stress;

while those with a low need for approval required moderate stress to

bring motivation up to optimum for maximum performance (p. 297-298).

Behavioral Associates in Beaufort, South Carolina, teaches an on-

going training series of stress management classes to the drill instruc-

tors at the U. S. Marine Training Camp. One of the measurements

routinely used in the evaluation is one of locus of control. Their

findings, in approximately 250 men, who are under mandatory attendance

requirements,are that over a 12-week time period, locus of control takes

a significant turn in the direction of internality (Peter Neidig & Dale

Friedman, personal communication, February, 1984).

The issue of mandatory vs. voluntary participation in self-improve-

ment groups is evidenced in changes in recorded locus of control. In

a group of 55 college-educated social services workers, all of whom were

required to attend a 15-hour, 5-week course on stress management, there

were no significant changes in the pre- and post-test scores of any of

Levenson's I/P/C Scales. The perception of internal control, control

by powerful others, and control by chance was 32.98, 20.36, and 16.76

on the pretest and 35.85, 20.72, and 14.74 on the posttest. It appeared

that the shortened time and mandatory nature both had a limiting effect

on self-awareness and improvement.









The field studies done in preparation for this research showed that

participants in stress management classes (nurses, HRS employees, and

general public) were under moderate to severe stress as measured by the

Social Readjustment Rating Scale. The pilot study found significant

changes in the locus of control of registered nurses in the direction of

internality, following the stress management course (Patterson, 1981).

A study similar to the one proposed (n = 124) investigated life

events as they related to anxiety, support system, and locus of control.

Johnson and Sarason found that life changes have their most adverse

effect on those people perceiving the least amount of control over en-

vironmental events. The results indicate that life events are better

predictors of future illness of those with a higher sense of external

control, as well as those with less effective support systems. There

was not significant relationship between these measures and measures of

state anxiety. "The important determinant is the perception of control

of these stressful life events" (Johnson & Sarason, 1977, p. 207).

The responsibility for oneself and the holistic approach to train-

ing are repeatedly emphasized. Claus and Bailey (1980) have prepared

and taught an entire curriculum around Living with stress and promoting

well-being for intensive care nurses. These goals of responsibility and

holism (Pincus, 1980) are likewise presented from independently developed

programs in Canada (Murphy, 1981) and Appalachia (Porter, Peters &

Heady, 1982). Generally, the goals are quite similar: identify and

assess personal vulnerability, stressors, and responses; examine general

attitudes, skills, and preferences; and a commitment to a lifestyle that

enhances well-being (Claus & Bailey, 1980; Jasmin, Hill & Smith, 1981;

Johnson & Sarason, 1977; Murphy, 1981). These goals of personal









identification, examination, and commitment become the stated objectives

for consultation and training. Shealy (1981) notes that although

processes may be initially reparative, as they stabilize over time they

also have the potential for prevention. Other intervention projects

report continued stabilization up to three years later.

Chariff, Duke, Level and Smith (1980) studied locus of control in

a population of general duty registered nurses as it related to role

ambiguity and job satisfaction. They found a significant relationship

between internal locus of control, job satisfaction, and role clarity

in nurses who had been in their positions for five years or more.

Connolly (1980) proposes a counseling model based on locus of

control. He proposes that the "transfer of beliefs from one life area

to another and the experiences in each are key variables in formulating

internal versus external expectancies of control" (p. 178). Drawing

from many humanistic psychology approaches, the model takes traditional

experiential approaches and integrates those with the phenomenological

aspects of social learning theory to aid in behavior change. It is

offered as a useful tool in both individual and group settings.

Foulds (1976) used an experiential-gestalt growth group, facili-

tated by the experimentor, in a study which found that "increased

self-awareness and authentic interaction may be one effective method

for altering generalized expectancies in the direction of internality"

(p. 299). Groups were conducted 3-1/2 hours weekly for 8 weeks. Using

pooled results of two groups with 15 subjects each, and matched control

groups (n = 60), the pre-test, post-test control group design found sig-

nificant changes at the .001 level. Foulds suggested that other forms









of treatment, as well as follow-up studies, be used to determine the

factors reliably associated with constructive personality and behavior

change.

A recent study by English (1983) investigated a sample of 18

women, divided into three groups (treatment, support, and control).

The treatment consisted of sixteen hours of training over an eight-week

time frame. The stress reduction program was designed to address as

many facets of stress as possible, and included some, but not all, of

the dimensions addressed in this study. All the subjects had ex-

pressed a desire for assistance in dealing with stress. In addition

to a self-developed questionnaire, this study used the Life Events

Survey by Johnson and Sarason, which is similar to the SSRS as both a

pre- and post-test. The results were non-significant, with improvement

occurring in the treatment, support, and control groups. There was

twice as much improvement in the treatment group, however.

Frain and Valija (1979) report that "individuals whose systems

successfully adapt to modern stress express improvement in their energy

and capabilities as well as their emotional states." "I feel ready

to . I feel less afraid. My spirits are back to normal." These

comments often confirm a health professional's estimation of their

current health status (p. 47).

Menninger (1978, p. 83) claims that

people are already demanding "psychological competence" skills
. Although he had another context in mind, H. G. Wells'
comment aptly describes the problem of prevention . "Human
history becomes more and more a race between education and
catastrophe." Learning about ourselves--the ability for men
and women to establish greater individual control; a sense of
mastery of their own destinies, their own difficulties, their
own problems--is the essence of developing better mental health.









Summary

The review of the literature supports the need to determine factors

which are useful in identifying high stress levels, understanding those

influences on the process of stress, and influencing the outcome of

those stress factors. The topic of stress proliferates in the main-

stream of both professional and lay literature. Holistic health con-

cepts best address the pervasive nature of stress, in that holism deals

with the integration of the psychological, physiological, social, and

spiritual nature of man. The measurement of life events has been known

as a reliable way of measuring social readjustments and predicting

future illness. Social learning theory addresses both conflict and

locus of control, indicating that both are related to a wide range of

life activities, and may be investigated in many spheres. Studies

similar in nature to this proposal have dealt with stress reduction

programs, identifying locus of control and/or life events as mediators

of stress.















CHAPTER THREE
METHODOLOGY


Overview

There is a need to investigate those factors which are useful in

identifying high stress levels, understanding those influences on the

process of stress, and influencing the outcome of those stress factors.

This experimental study was concerned with the identification,

intervention, and evaluation of stress-related variables. Registered

nurses comprised a population of high-risk professionals. The study

initially identified and assessed the variables of recent life events,

locus of control, and the level of projected conflict. Intervention was

in the form of a training group focusing on holistic health concepts to

increase personal awareness and promote stress mastery. Following the

intervention, the study measured and evaluated changes in conflict and

control, after statistically equalizing the group on the basis of the

amount of prior readjustment to stress.

The topic of stress proliferates in the mainstream of both pro-

fessional and lay literature (Benson, 1975; Frain & Valija, 1979;

Lindner, 1973; Pearlin, Lieberman, Managhan & Mullen, 1981; Pellitier,

1977; Selye, 1974, 1976; Ryan & Travis, 1981). The holistic health

concept best addresses the pervasive nature of stress, in that holism

deals with the integration of psychological, physiological, social, and

spiritual nature of man (Blattner, 1981; Krieger, 1981; Shealy, 1981;









Seiler & Messina, 1979; Yahn, 1979). Life events are known as a

reliable way of measuring social readjustment and predicting future

illness (Brenner, 1973; Dohrenwend & Dohrenwend, 1979; Holmes & Rahe,

1967; Lazarus, 1966, 1979; Rahe, 1978). Social learning theory addressed

both conflict and locus of control, and identified both variables as

related to a wide range of life spheres (Girdano & Everly, 1979;

Lah & Rotter, 1981; Lefcourt, 1981; Levenson, 1972; Rotter, 1966;

Rotter & Rafferty, 1950; Seligmann, 1975). Studies similar in nature

and results of this proposal dealt with stress reduction programs, identi-

fied locus of control and/or life events as mediators of stress, and

utilized either nurses or group interventions in the process (Chariff,

Duke, Level & Smith, 1980; Claus & Bailey, 1980; Connolly, 1980; Foulds,

1976; Gentry, Foster & Froehling, 1972; Jasmin, Smith & Hill, 1981;

Krikorian & Paulanka, 1982; Murphy, 1981; Johnson & Sarason, 1977).


Population and Selection of Subjects

The total of 52 participants was drawn from a large population of

registered nurses that was asked for volunteers, and the potential

existed for any race, age, or sex to participate. All participants

were female, and all were white except one. All participants had a high

school education, and had received their nursing education from one of

the three types of nursing programs. The three types of education pro-

grams leading to licensure as a registered nurse include the Associate

Degree (ADN) in nursing, which is a two-year junior college technical

degree; the Diploma program, which is a three-year, hospital-based

training program; and the Bachelor of Science in Nursing (BSN), which

is a four-year, university-based program for the education of the









professional nurse. Therefore, there were differences in educational

levels among registered nurses.

Whether or not the nurse was currently actively employed, or em-

ployed on a part-time basis did not preclude participation in this

study. Neither did the actual place of employment affect eligibility

to participate. Places of employment included, but were not limited

to, hospitals, nursing homes, home health agencies, public health,

and physicians' offices. Demographic information is summarized in

Table 1. The nurses who participated in this course received 24 hours

of continuing education credit, which fulfilled the mandatory require-

ment by the State of Florida for nursing relicensure every two years.

The study was publicized in a newsletter mailed monthly to the

6000-plus licensed nurses in a five-county nursing district of

Northeast Florida. The JHEP Nursing News is a publication of the

Jacksonville Health Education Program, a division of the University

of Florida, and distributed to all active and inactive RN's and LPN's

in Baker, Clay, Duval, Nassau, and St. Johns counties. The JHEP

Nursing News was the primary mode of publicity to individual nurses.

Announcements were approved by both the Editorial Board and the

State Board of Nursing Division of Continuing Education. Directors

of all area hospitals were personally contacted by the principal

investigator and their aid enlisted. Twenty-seven registered nurses

volunteered to participate in the study, as part of the experimental

group. Those volunteers were mailed an introductory letter prior to

the beginning of the study (Appendix A).









Table 1

Demographic Data


Variable Treatment Group Control Group
n=27 n=25

Licensure
Active License 96% 96%
Inactive License 4% 4%

Employment Status
Working full time 77% 52%
Working part time 25% 32%
Unemployed 15% 12%
Not working in nursing 4% 8%
Full time student -- 8%
Seeking work 7% 4%
Working full and part time 11% --

Shift
Days 33% 60%
Evenings 15% 4%
Nights 19% 4%
Rotate Shifts 15% 4%
Baylor Plan 4% 20%

Location
Hospital 59% 68%
Nursing Home 7% --
Doctor's Office 4% 8%
Home Health Agency 7% 4%
Community Health 4% 4%
Industrial 4% --
Other 11% 4%

Position
Staff 37% 44%
Supervision 19% 12%
Administration 4% 8%
Educator 4% --
Other 7% 4%
Specialist 11% 12%

Years in Nursing
Average 13.29 10.76
Range 1-40 1.5-32









Specialty Area
Intensive Care
Medical-Surgical
OB/Gyn
Geriatrics
Pediatrics
Psychiatry
Public Health
Rehabilitation
Occupational Health
Other


4%
25%
Chemotherapy
Dialysis
IV Therapy
Emergency Room
Dental
Records Review


32%
24%
4%


4%
4%
4%

24%
Oncology
Administration
Dialysis
Dermatology


Years in Present Position
Average 3.5 3.2
Range .1-18 .1-10
Mode 1 (14 = 1 yr 1 (19 = 1 yr
or less) 51% or less) 36%

Salary
Average n = 20 n = 19
22,358 21,417
Range 12,000-33,280 10,000-31,000

Basic Nursing Education
ADN 52% 60%
Diploma 33% 36%
BSN 15% 2%

Advanced Degrees 15% --
Certification 15% 12%

Children
None 15% 40%
Ages 0-6 6% 7%
Ages 6-12 21% 10%
Ages 12-18 22% 25%
Ages 18+ 51% 58%

Total Children 67 40

Financial Structure
Sole Wage Earner 30% 40%
Joint Wage Earner 63% 56%
Earn No Wages 7% 4%









Spouse Salary
Average

Range
Mode


n = 20
36,130
8,000-120,000
50,000


n = 12*
43,958
18,000-100,000
100,000


Marital Status
Married 66% 64%
Single -- 12%
Separated 3% --
Divorced 22% 12%
Widowed 3% 8%
Remarried 7% 4%

Age
Average 42.5 36
Range 25-61 21-54

Sex 100% female 100% female

Race
White 96% 100%
Non White 4% --


*Does not include 3 spouses with no wages.









The self-selected volunteers for the experimental group were

divided into two small groups on the basis of their personal time pre-

ference as they individually registered. The results of all experi-

mental participants were pooled. There was one (pooled) treatment group

with 27 participants and one control group with 25 subjects, for a total

of 52 participants. The treatment group met for five four-hour sessions,

twice a month for two and a half months. Meeting conditions were con-

sistently uniform throughout the study. A single room was provided by

the University of North Florida for use during the entire study.

The control group consisted of volunteers from the same population

as the treatment group (i.e., the 6,185 active and inactive RN's in the

five-county area). Members of the control group were enrolled in the

University of North Florida's Department of Nursing. All these women

were registered nurses who had graduated from either ADN or Diploma

nursing programs who were seeking to become BSN's. The participation of

these controls was approved by the University faculty. During the ten-

week period of the experiment, the control group attended a course in

Professional Issues in Nursing.


Assessment Procedure and Measurement

Three standardized instruments were used in the data analysis for

assessing participants and measuring change. One of these was an assess-

ment of the amount of social change and readjustment that has occurred

in the participant's life over the past year, and was administered only

at the beginning of the study. The other two assessment tools measured

conflict and locus of control, and were administered both before and

after the treatments.









The Social Readjustment Rating Scale (SRRS, Appendix B) was used as

an indication of the amount of life changes experienced and perceived by

the participants over the past year (Holmes & Rahe, 1967). The life

events measured will not decrease over the ten-week period and will be

used as a pre-treatment measure only.

The Incomplete Sentences Blank-Adult Form (available from the

Psychological Corporation) is influenced by temporary moods and reactive

states, making it a useful screening tool for assessing and measuring

change in conflict states. The RISB was used as an objectively scor-

able projective measure of personal conflict reflected in several

areas (Rotter & Rafferty, 1950).

Levenson's Tridimensional measure of locus of control--Internality,

Powerful Others, and Chance (Appendix C)--was used to assess the perceived

locus of control of each participant in each of these three dimensions

(Levenson, 1972).


Assessment Tools

Social Readjustment Rating Scale (SRRS)

The SRRS was used in self-administered, self-scored assessment of

"life change units" that occurred during the previous year. Adminis-

tration took less than 10 minutes. Forty-three items were in the ori-

ginal scale, and 42 items remained on the final form, with 100 "points"

given for the highest ranking event--death of a spouse. Other events

had lesser values. The adapted form allowed for changes such as economic

inflation--mortgages $10,000 have been changed to $50,000--and

includes death of child or a parent, as well as spouse. Holmes and Rahe

(1967) indicated that individuals can successfully physiologically cope

with the adjustments required for 200 life change units during a one-year









period. Changes totaling greater than 200 increase the possibility of

a stress-related illness as follows: 200-300 = 37%; 300-400 = 50%; and

changes above 400 = 81% greater chance of developing an illness due to

stress. The amount of adjustment required for these mild, moderate, and

severe life crises is considered to be sufficient but not necessary

cause for illness, and the extensive research on life events has contin-

ued to prove the small but significant reliability of the predictability

of later illness.


Internality/Powerful Others/Chance (I/P/C)

Levenson's (1972) tridimensional measure of locus of control--

internality, powerful others, and chance (I/P/C)--was utilized as a

measure and differentiation between one's dependence upon (a) internal

choices, (b) powerful others, and/or (c) chance, fate or luck in deter-

mining life events. These perceived loci of control may either result

in an unpredictability of life events due to the great complexity of

forces in the environment externalityy) or a perception of a causal

relationship between events and one's own behavior or characteristics

internalityy).

Levenson's three dimensions of expectancy, Internality (I scale),

Powerful Others (P scale), and Chance (C scale), were originally de-

signed as a reconceptualization of Rotter's (1966) I-E scale. The initial

unidimensional formulations had since been considered somewhat simplis-

tic, and the subsequent factor analytic studies underscored the need for

a multidimensional view of the construct of control. Rotter's scale was

the first theoretically based, systematically studied measurement of

locus of control, and is the instrument against which all other measures









are compared. Rotter's test yields a single raw score, while Levenson's

yields three scores.

The I scale measures personal control--the extent to which people

believe they have control over their own lives; the P scale deals with

powerful others, who control predictable events; and the C scale deals

with unpredictable chance or fate. Each scale on the test is composed

of eight items on a Likert format (possible range on each scale = 0 to

48), which are presented to the subject as a unified attitude scale of

24 items. The Likert scale makes the dimensions more statistically

independent of one another; the I, P, and C scales make apersonal-

idealogical distinction by phrasing all statements so as to pertain only

to the person answering; and specific issues are worded so as to be

immodifiable.

The I/P/C scales are factor analytically sound. The validity of

the scales has been demonstrated through covergent and discriminate

methods. Internal consistencies similar to, or slightly higher than

Rotter's are found: I scale = .64 to .73; P scale = .78 to .82; C scale =

.78 and .79 (the range for Rotter is .69 to .73). Split half reliabili-

ties are .62, .66, and .64 for the I, P, and C scales. Test-retest

reliabilities are approximately .60-.73 for two-month intervals.

A word of caution about interpretation is necessary. High scores

on each sub-scale are interpreted as indicating high expectancies from

that source. Low scores reflect tendencies not to believe in that locus

of control (Lefcourt, 1981, p. 18).









Rotter's Incomplete Sentence Blank (RISB)

The RISB-Adult Form is a 45-item test, consisting of beginnings or

"stems" of sentences which are to be completed by the subject. The com-

pleted sentences may then be scored according to a standardized system,

with male and female examples. The original validation studies stated

that the purpose of the test was to obtain an overall score for the

degree of conflict. Areas of conflict which were considered included

family, social, sexual, health, vocational, and educational (Rotter,

Rafferty & Schachtitz, 1949). Responses are independently scored on a

scale of 0 to 6, with higher numbers indicating greater conflict. The

total score is an index of adjustment/maladjustment. The instrument

is useful for screening purposes. The test yields a continuous score,

and the study evaluated changes in the scores.

The test was standardized on 299 college freshmen at Ohio State

University. The changes between the college form and the adult form are

only slight, and it is believed that the stem modifications are insignifi-

cant enough to allow the scoring principles and manuals to be applicable

when used by competent clinical workers.

The correlated split-half reliability for the RISB is reported as

.84 and .83 for males and females, respectively. Inter-scorer relia-

bility is reported as .91 and .96 for males and females. Only two

scorers, trained by the author, were used in the standardization study.

In a test of this kind, where the possibility of subjectivity in scoring

exists, inter-scorer reliability is of the greatest importance.

In order to meet the demand for interrater reliability, a training

session was held to prepare six independent raters. The trainer was a

clinician well-versed in the teaching and administration of the RISB.









All raters were either licensed psychologists or licensed mental health

counselors, and at least two were also Advanced Registered Nurse

Practitioners in Psychiatric Mental Health Nursing. All raters received

the same training simultaneously. At least two independent raters

scored each test, and the same raters blindly scored both the pre- and

post-tests for each participant.

Approximately 20 to 40 minutes are needed to administer the test,

and it can be administered equally well either individually or in groups.

It must be hand-scored. Available from the Psychological Corporation,

New York 17, New York, the cost is $3.00 for a package of 50 blanks.

The manual is available for a cost of $7.00.


Treatment

The treatment in this study was a training intervention for the

recognition and mastery of stress among a representative group of high-

risk professionals, registered nurses. The 27 treatment subjects

attended five four-hour training sessions over a two and a half month

period. The training content included theory and assessment of stress,

and intervention to aid in stress mastery. The emphasis was on a holis-

tic health approach, which encompassed individual physical, psychological,

social, and spiritual needs. The treatment group had pre-test and post-

test levels of projected conflict and perception of locus of control, as

well as a pretreatment survey of life events. The intervention encom-

passed the entire 10 weeks of the training period, and the sessions were

composed of the following: measurement and significance of life events,

physiological and behavioral manifestations and modifiers of stress,

personality types and preferences, communication styles and skills,










adjustment and self-concept, habit control and time management, social

support systems, and control and autonomous thinking. Specific applica-

tion of the training information was directed at registered nurses as a

representative population of high-risk professionals. The principles of

adult learning were an integral consideration for the structure of the

training sessions. The training sessions were directed at developing

self-awareness and responsible lifestyles. The training modules uti-

lized holistic health approach and social learning, as both of these

approaches encompass the complexity of each individual and emphasize

personal responsibility in the establishment of well-being.

The control group participated in all pre-tests and post-tests,

but did not participate in the intervention process.


Treatment Rationale

The rationale for approaching the components of stress theory was

to establish within the participants an expansion of knowledge and

awareness, leading to acceptance. This was accomplished in the least

threatening and most effective manner by beginning with group generali-

ties and progressing to specific personal implications.

The rationale for focusing on self-awareness is more positive, as

opposed to a possibly detrimental approach of externally "fixing a

patient," which might debilitate one's awareness of himself as a free

and responsible agent (Frankl, 1975, p. 111).









The rationale for approaching the psychological and social com-

ponents of stress was to facilitate the expansion of knowledge, aware-

ness, and acceptance. Beginning with self-awareness and promotion of

self-concept, the awareness and acceptance of others was enhanced, and

formed the basis for further generalization to interpersonal and larger

social relationships.


Treatment Content. The content for the training session was

developed in several ways. Texts focusing on stress management were

reviewed for order and content, experts already practicing in the field

were consulted, and a field study was conducted to develop the training

modules. The focus of all modules was the presentation of the subject

matter in such a way as to meet the specific needs of the adult learner,

and to enhance the adoption and integration of the concepts by the

participants. The participant's ability to eventually share with

others (eng., with their patients) the various methods of identifying

and managing stress in everyday life were considered in the subject

matter presentation. Overlapping and interrelating of the concepts is

planned.

In a few cases, outside presenters were used for special topics.

In all cases, they were briefed on the philosophy and purpose of the

content and treatment. The presenters on the individual topics were

recognized experts in the area of that subject. For example, those

speaking on relaxation and self-hypnosis were practicing members of the

American Society of Clinical Hypnosis; the speaker on nutrition was a

registered dietician; the speaker on the Myers-Briggs was a counselor

in the University Counseling Center. All presentations by outside









speakers were videotaped in their entirety. The purpose of outside

speakers was to make the training more varied and interesting, as well

as credible, and to avoid trainer effect. The role and function of the

speakers was to reinforce the context and concepts as planned for this

experimental study.


Treatment group. The treatment group was presented with informa-

tion focusing on a holistic approach to stress. The presentational

format was that of group training, and there was maximal opportunity for

dialogue and interaction between both the facilitator and the parti-

cipants. The principal investigator was the primary facilitator, and is

experienced in teaching stress management from a holistic framework, and

experienced in teaching nurses as adult learners. Expert speakers were

utilized periodically, to augment the presentation of subjects and con-

trol for experimentor bias. Theories were presented in an informal

survey, as opposed to detailed didactic information.


Control group. The control group was a class of RN to BSN

students attending the University of North Florida in Jacksonville.

These women were all registered nurses who had graduated from either ADN

or Diploma programs who were seeking to upgrade their education to BSN

level. They studied professional issues in nursing, and should not have

any influencing factors along the lines of the treatment group. The

control group took all pre- and post-tests in the same time frame as

the experimental group (i.e., ten weeks apart). Arrangements have been

made to mail the results and interpretations of the study to both the

experimental and control groups when all the data are evaluated.









Briefly, an overview of the holistic health sessions follow.

A complete course guide is detailed in Appendix D.


Orientation. Prior to the beginning of the experiment the

participants met at the selected site and completed all evaluational

instruments. Rotter's Incomplete Sentences Blank (RISB) and Levenson's

I/P/C were completed by all participants. Each was filed under the code

number that was randomly assigned to each participant and saved for

scoring at the conclusion of the experiment. For teaching purposes

the Social Readjustment Rating Scale (SRRS) was completed and scored

prior to the first class. The results were not known by the investigator

until completion of the study. Consent forms, demographic data sheets,

and the Myers Briggs Type Indicator (MBTI) were completed at the

orientation meeting. Consent forms were recorded and demographic

information was filed for later evaluation. The MBTI was scored for

distribution at a subsequent class meeting.

After protests were completed, general questions regarding the

nature of the study were answered.


Session one. The first session included brief, general introduc-

tions. Most participants were attending because they hoped to benefit

from the course, as well as to receive continuing education credit. The

concepts of the SRRS were shared and the relative importance of the

resultant scores were discussed. A lecture and a slide show of Selye's

(1974) General Adaptation Syndrome were presented to introduce stress

and lifestyle management. General stress and adaptation theories

were taught. These included, but were not limited to the following:









types of stress; life events; internal-external control; physiology;

behaviors; self-concept; time management; exercise, nutrition; rela-

tionships; support systems; and job satisfaction. The purpose was

a general overview of the multi-dimensional process of stress and

to introduce holistic attitudes in addressing lifestyles. Disclosure

of teaching events and techniques to be employed for the entire course

was presented to the participants.

Participants were introduced to relaxation techniques by demon-

strating the physiology of breathing and experienced Body Scan relaxa-

tion and progressive muscle relaxation techniques. These relaxation

exercises were presented in the form of audiotapes. Participants

were informed that audiotapes would be further presented in a variety

of types employing both male and female voices, progressing from

simple to more abstract formats as the participants' ability to relax

increased. The group members were encouraged to record their pulse

rates before and after each relaxation exercise as a form of biofeed-

back. Additionally, they were to record their personal reactions so

as to later identify those personally effective relaxation techniques.

All sessions were concluded with the same format, i.e., a relaxa-

tion exercise, homework assignments and suggested readings.


Session two. An experiential exercise useful in becoming aware of

personality differences was used to introduce the Myers Briggs Type

Indicator, a self report inventory based on Carl Jung's personality

theory. Looking at Types, a slide show by Earl Page, was narrated

by a counselor from the University Counseling and Testing Center.

Interpretation and discussion of individual MBTI profiles continued









and focused on how personality preferences and differences are useful

and manifested in multiple areas of life, including among other things

relationships, occupations, and communication. The MBTI profiles

are summarized in Table 2.

Theories and research on coronary prone lifestyles, Type A/B

behavior (Friedman & Rosenman, 1974), and indications of stress were

presented and discussed. Stressful habits, particularly smoking,

alcohol abuse, and overeating were examined. Ways to consider bringing

them under control concluded this particular discussion.

The session ended with a relaxation exercise that included visual

imagery of a seashore.


Session three. Much of the focus of the third session was relaxa-

tion, biofeedback, and self-hypnosis. A licensed hypnotist and

clinical psychologist lectured on the various applications of hypnosis

and gave a group demonstration.

There was a presentation of time management theories, along with

multiple techniques for managing time. Participants had been using a

daily Day-Timer notebook since the beginning of the class and the use-

fulness of planning time, delegation of responsibility and authority,

and systems for time management were shared.

The importance of a nutritionally adequate diet, meeting indivi-

dual needs, took up the remainder of this session. Participants

reviewed their dietary habits which were reflected by the nutrition

sheets kept for the prior two weeks. Fiber, cholesterol, fats,

carbohydrates, proteins, salt and sugar were the primary components

covered in discussion. The session concluded with a relaxation

exercise of autogenic phrases.









Table 2

Experimental Group as They Were Represented in
the Myers-Briggs Type Indicator Categories


n =27



ISTJ ISFJ INFJ INTJ
3 6 2 2


ISTP ISFP INFP INTP
2 1


ESTP ESFP ENFP ENTP
2


ESTJ ESFJ ENFJ ENTJ
3 4 1 1


59% were Introverted
66% were Sensing
66% were Feeling
88% were Judging


Most participants work best in the here and now, rather than future-
oriented, and most make feeling, personal decisions after careful
consideration.









Session four. The focus of session four was communication theories

and processes, rational thinking, exercise and social support systems.

Communication theories and techniques presented and discussed included

assertiveness and transactional analysis. As in previous sessions,

discussion was directed at how these theories interrelated with

previously presented concepts and how they applied both to general

populations and individuals.

In the area of exercise, discussion centered around the importance

of aerobic exercise. Participants found that they knew how to do many

types of exercises and activities but that their current lifestyles

generally precluded time for exercise, and virtually none of the sub-

jects participated in any type of aerobic exercise.

The final topic of discussion was the identification and assessment

of each person's support system. The importance of developing and

maintaining an adequate support system as a buffer against stress was

emphasized.

The relaxation exercise was a guided imagery utilizing the colors

of the rainbow and music.


Session five. The final session was the most personal. It dealt

with job satisfaction, self-concept, psychosynthesis, and continued

self-help and evaluation.

The reasons for work, its rewards and responsibilities, comprised

the discussion of jobs, with varying degrees of job satisfaction being

shared.

Participants reviewed two homework assignments. One was directed

at identifying positive traits, and the other at a fuller identifi-

cation of a wider spectrum of self concepts. Ideal, real, and









perceived self concepts were discussed. Two exercises in psycho-

synthesis helped to clarify various self analyses and made the first

attempt at a transpersonal view of each lifestyle.

The value of continued self-awareness formed the concluding dis-

cussion and suggestions were made for continuing personal develop-

ment. An extensive bibliography was distributed and a variety of

journal techniques were demonstrated. Most participants expressed a

desire to continue their awareness experience in some manner.

Time was allowed for participants to express some concluding

remarks, to define for themselves where they desired to go from this

point, and to assess what had been accomplished. This was done both

verbally and in writing.


Posttesting session. Participants returned the following week for

posttesting with the Rotter Incomplete Sentences Blank and the I/P/C.

Knowledge and awareness were assessed and written course evaluations

were completed. These were all completed without discussion. Most

participants chose to remain after the posttests were completed and

visit with each other, generally socializing before final separation

occurred.

Procedurally, all Rotter Incomplete Sentences Blanks were blindly

rated by two of the trained raters and interrater reliabilities for

the pretest and for the posttest were obtained. Each of the 52 parti-

cipants completed two RISB's which were scored by each of the two

raters for a total of 208 separate scores. All I/P/C tests were

hand-scored by the principal investigator for a total of 104 tests.

Twenty-seven knowledge and awareness questionnaires were recorded.

The results are included in Table 2.









Table 3

Summary of Self Reported Changes in General Knowledge
and Awareness from Experimental Group


Percent
Category Of Increase


n = 22

1. Knowledge of stress theory 40%
2. Understanding of personal stressors 34%
3. Knowledge of physical indications of stress 38%
4. Ability to identify individual stress indicators 31%
5. Knowledge of behavioral indications of stress 35%
6. Control of stressful behaviors 31%
7. Knowledge of relaxation/meditation techniques 39%
8. Efficacy of relaxation skills 34%
9. Knowledge of relationship of job satisfaction and
stress 37%
10. Stressfulness of job 7%
11. Satisfaction with present job **12%
12. Knowledge of relationship of personal control of
stress 38%
13. Amount of perceived personal control 30%
14. Knowledge of time management theories 31%
15. Efficacy of time management skills 23%
16. Time spent in self nurturing 20%
17. Knowledge of theories of support systems 36%
18. Efficacy of own support system 23%
19. Understanding of personality preferences of others 24%
20. Understanding of our personality preferences 25%
21. Personality as a stressor ***11%
22. Knowledge of components of self concept 31%
23. Personal self concept 24%
24. Knowledge of communication concepts and theories 17%
25. Efficacy of communication skills 16%
26. Knowledge of relationship between nutrition and
stress 20%
27. Adequacy of personal nutritional habits 9%
28. Knowledge of relationship between exercise and
stress 20%
29. Adequacy of personal exercise habits 19%


It was expected that perceived job stress would decrease
** It was expected that perceived job satisfaction would increase
*** It was expected that perception of own personality as being
stress producing would decrease









Generally, participants increased their knowledge and awareness

of the concepts and theories by approximately 30%.

A summary of the evaluation of the course is presented in Table

4. Most participants found the course both personally and profes-

sionally relevant and indicated they would recommend the course to

others. Detailed evaluations are presented in Appendix E.


Threats to Validity

There were several threats to the validity of this study, both

procedural (internal validity) and generalizability (external validity).

Participants may have reacted to being assessed--either attempting to

appear in a more positive sense, or experiencing their lives in an

exaggerated negative sense. In order to minimize these reactions to

assessment, participants were as fully informed as possible of the

purpose of the study without giving them cues as to the expected re-

sults. Participants were encouraged to be as open and honest as

possible and were reminded that the final analysis would be using

group, not individual, data. Confidentiality was observed at all

times. The fact that participants would receive direct feedback in

the form of the results of their tests, as well as the study, gave

them an incentive to respond accurately.








Table 4

Summary of Course Evaluation


1. I found this course to be personally relevant: 5.6

2. I found this course to be professionally relevant: 5.5

3. I wound recommend this course to others: 5.8

4. The most important thing I (re)learned was:
category (number)
relaxation (6) GAS (1)
self-awareness (8) R.E.T. (1)
control (5) personal stressors (1)
assertiveness (2) health (1)
personality (2) exercise & nutrition (1)
time management (1)

5. Other important things I (re)learned were:
category (number)
self-awareness (8) exercise (2)
relaxation (7) assertiveness (3)
control (6) awareness of others (1)
time management (6) mutual experiences (1)
personality (4) support systems (1)
self-management (3) moderation (1)
psychosynthesis (2) nutrition (2)

6. We could have spent less time on:
category (number)
nothing (9) relaxing (1)
diet/nutrition (8) testing/paperwork (2)
meditation tape (1) exercise (1)
"problems" (1) MBTI (1)

7. I would like to have spent more time on:
category (number)
time management (6) exercise (1)
relaxation (5) personality types (1)
nutrition (4) individual problems (1)
hypnosis (4) behavior mod (1)
class discussions (2) stress theories (1)
biofeedback (1)

8. To improve the class next time:
category (number)
every week (6) biofeedback (1)
relaxation (5) decision-making skills (1)
more hours (3) group discussion (1)
facilities (3) more theories (1)
organization (3) purchase tapes (1)









9. Lifestyle changes I intend to
include:
category (number)
school (1)
relaxation (9)
assertiveness (5)
family (5)
nutrition (4)
control (5)
work (1)
health (1)
R.E.T. (1)
spiritual (2)
exercise (13)
psychosynthesis (1)
moderate (1)


make as a result of this course

anticipate stressful situations (6)
personality types (4)
time management (3)
time for self (10)
quit smoking (2)
deal with past (1)
self awareness (5)
lose weight (4)
seek counseling (1)
not to feel guilty (1)
increase involvement with others (3)
grow old gracefully (1)
run 1-2 marathons in 1984 (1)
pray to God this all works (1)


26 participants listed at least three lifestyle changes.









Multiple assessments were possibly affected by pretest sensiti-

zation, as well as test-retest reliability. For this reason, at

least 10 weeks elapsed between pre- and posttests, to allow adequate

time for genuine behavior change or attitude change to occur. The

control group was tested in an identical manner to the treatment

groups.

Both maturation and contemporary history figure greatly in studies

of this type. It was expected that the type of person volunteering

for participation in this type of study would be undergoing some type

of stressful situation, and might be actively engaged in behaviors to

cope with those situations. This expectation of increased life events

was borne out in the Social Readjustment Rating Scale and summarized

in Table 4. Those activities might also effect positive change.

Treatment was expected to expedite the therapeutic process of under-

standing, coping with and intervening against stress in a self-help

mode.


Limitations

There were several limitations to both the scope and the general-

izability of the results of this study. Women dominate the population

and profession studied, and the sample was completely female, so there

was gender domination and occupational exclusivity. There were educa-

tional stratifications within the profession of "registered nurses."

Constraints of the sample size, which were small but statistically ade-

quate, required stronger differences for significance. The motivation









Table 5

Summary of Social Readjustment Rating Scale


Treatment Group Control Group
n = 27 n = 25

Severe Life Crisis n = 6 n = 0

400 + 22%


Moderate Life Crisis n = 5 n = 5

300-400 13% 20%


Mild Life Crisis n = 8 n = 6

200-299 30% 24%


Stable n = 8 n = 14

Below 200 30% 56%


100% 100%









for volunteering for such a study varied among participants. The

dimensions of learning that delineate those who learn more effectively

through their auditory, visual, or kinesthetic senses were not addressed

by this study. There were a number of other, different ways this in-

formation could be arranged and taught. These factors limited the

strength and number of inferences that could be made beyond a population

represented by this sample to the general population.


Research Hypotheses

The major thrusts of this study were the modification of personal

stress and conflict, and the development of internality of control, as

well as investigation of the mediating effects of prior life events.

All hypotheses considered changes among the treatment groups, as well

as changes between the treatment and control groups. The research hypo-

theses of this study were stated in the null form, as follows:

1. There will be no difference in conflict among the participants

as measured by Rotter's Incomplete Sentence Blank due to the treatment.

2. There will be no differences in perceived locus of control of

the participants as measured by Levenson's Tridimensional Locus of

Control due to the treatment.

a. There will be no difference in perceived internal

control among the participants.

b. There will be no difference in perceived control by

powerful others among the participants.

c. There will be no difference in perceived control by

chance among the participants.









3. There will be no difference in life events as measured by Holmes

and Rahe's Social Readjustment Rating Scale between the emberss of the

groups.

4. There will be no significant relationships between measured

life events and locus of control of the participants before or after

treatment.

5. There will be no significant relationships between conflict and

locus of control of the participants before or after treatment.

6. There will be no significant relationship between conflict and

measured life events of the participants before or after treatment.

7. There will be no significant difference between groups on

measured conflict, locus of control, and measured life events before

or after treatment.


Statistical Evaluation

This was a pretest-posttest nested analysis of variance design.

Subjects were nested in two groups: an experimental group and a con-

trol group, with 27 and 25 subjects, respectively. The dependent

variables were the measure of conflict by the Rotter's Incomplete

Sentence Blank and the tridimensions of locus of control as measured

by Levenson's I/P/C. Separate ANOVA's were performed on the related

questions.

To adjust for the inequality in levels of life events between the

groups, the above ANCOVA design was incorporated into an analysis of

covariance using the level of life events as the covariate.

A Pearson's Product Moment Correlation was used to determine the

reliabilities of the ratings and raters of the Incomplete Sentence Blanks.






72


Summary statistics were compiled for the demographic data. A correla-

tional matrix of all variables was compiled.

The data file was built by the principal investigator. Upon

completion of the data file, the Computer Center at the University of

North Florida made a setup according to the Statistical Analysis Systems

(SAS, Box 8000, Cary, NC, 27511) and the analysis was run according to

the proper procedure as delineated by the statistical consultant and

SAS. Computational services were purchased through Northeast Regional

Data Center (NERDC) at Gainesville, Florida, and are acknowledged and

documented in the final results.














CHAPTER FOUR
RESULTS


This study sought to enhance self-awareness and stress mastery

skills among registered nurses utilizing a facilitated training for-

mat. There were 27 experimental subjects and 25 control subjects

participating in the 10-week, pretest-posttest experimental design.

The constructs of conflict, life events, and locus of control, as well

as their possible interactions were investigated. In this chapter,

the findings of the study are presented. Each research question is

restated and the appropriate data reported.


Conflict

The first research question addressed in this study was whether

the perceptions and/or amelioration of conflict measured among the

participants of this study could be influenced by the proposed inter-

vention. The Incomplete Sentences Blank (Rotter, 1950) was given

prior to and following the training sessions to the experimental group

and twice to the control group during the same time frame. The tests

were scored by two trained raters and pooled ratings were used for

the analysis. The means and standard deviations for both groups are

presented in Table 5. The mean change was -8.52 for the treatment

group and -1.38 for the control group. There was a significant differ-

ence between the pretest and posttest change scores (F=4.927, df

1,50 at the .05 level of significance). The null hypothesis that

there would be no difference in conflict as measured by the RISB, was





74



Table 6

Means and Standard Deviations of the Treatment and
Control Group on the Rotter Incomplete Sentences Blank


Pretest Posttest Mean
Group M SD M SD Change


Treatment 136.07 15.00 127.55 16.40 -8.52

(N = 27)

Control 117.50 12.33 116.12 15.07 -1.38

(N = 25)









not accepted. Participants showed a significant change in that the

level of conflict decreased between pretest and posttest while the

control group showed no significant change in level of conflict. The

treatment group had a pretest mean of 136.07 as compared to 117.50 for

the control group, and showed a decrease of 8.52 points, with a mean

of 127.55 on the posttest. The control group decreased 1.38 points

to a mean of 116.12 on the posttest.


Locus of Control

The second series of research questions focused on the influence

of the experimental treatment on locus of control. The subjects were

given Levenson's Tridimensional Locus of Control Scale which

measured the dimensions of internality, powerful others, and chance.

The test was administered to both the treatment group and the control

group prior to and following the training sessions. The means and

standard deviations for the three dimensions of internality, powerful

others and chance are all summarized in Table 7, and illustrated in

Table 8.

The first related hypothesis stated that there would be no

difference in perceived internal control. The statistical decision

was to fail to reject the null hypothesis (F=1.254, df 1.50, p=.05).

The pretest mean for the experimental group was 36.70 as compared to

38.88 for the control group. The posttest means showed a similar

pattern: 38.33 for the experimental group and 39.04 for the control

group. Although both groups increased their perceived sense of in-

ternal locus of control, the increase was not significant.

The second related hypothesis stated that there would be no

differences in perceived control by powerful others. The statistical









Table 7

Means and Standard Deviations of the Treatment and Control
Group on the Levenson Tridimensional Locus of Control Scale


Pretest Posttest Mean
Scale/Group M SD M SD Change


Internality

Experimental 36.70 5.86 38.33 6.23 +1.63

Control 38.88 3.99 39.04 4.54 + .16

Powerful Others

Experimental 19.56 7.45 17.63 9.09 -1.93

Control 17.56 8.64 18.60 9.27 +1.04

Chance

Experimental 16.19 7.81 14.22 8.48 -1.97

Control 15.44 8.92 14.08 8.93 -1.36









Table 8

Comparison of Means for Internal, Powerful Others and
Chance Between Treatment and Control Groups


Pretest Mean


Posttest Mean


CI 38.88 -.

El 36.70


19.56

17.56
16.19
15.44


CI 39.04
El 38.33














CP 18.60


17.63
14.22
14.08


- Control Internal
- Control Powerful Others
- Control Chance


El Experimental Internal
EP Experimental Powerful Others
EC Experimental Chance









decision was to fail to reject the null hypothesis (F=0.139, df 1.50,

p=.05). The pretest mean of the experimental group was 19.56 as

compared to 17.56 for the control group. The posttest mean for the

experimental group was 17.56 as compared to 18.60 for the control

group. The experimental group decreased in their perceived control

by powerful others, while the control group gained in that direction,

but the changes were not statistically significant.

The third related hypothesis stated that there would be no dif-

ferences in perceived control by chance. The statistical decision

was to fail to reject the null hypothesis (F=0.791, df 1.50, p=.05).

The pretest mean for the experimental group was 16.19 as compared to

15.44 for the control group. The posttest means were lower for both

groups: 14.22 for the experimental group and 14.08 for the control

group. Both groups decreased their perception of a locus of control

from chance, although not significantly.


Social Readjustment

The third research question was whether there would be differences

in the life events of the experimental group and the control group as

measured by the Holmes and Rahe (1967) Social Readjustment Rating

Scale (SRRS). The means and standard deviations are reported in Table

9. The F of 8.538 was found to be significant beyond the .01 level,

and thus the null hypothesis of no difference was not accepted. There

were significant differences between the means of the two groups as

well as the variances. The treatment group had the highest mean

score, 319.78. This placed them in the moderate life crisis category

according to Holmes & Rahe. The mean 190.96 for the control group

placed them in the stable life category. The variance was approximately


~





79



Table 9

Comparison of the Treatment and Control Groups on the
Holmes & Rahe Social Readjustment Rating Scale


Standard
Group Mean Deviation F F Prob


Experimental 319.78 38.00 8.538 0.0052

Control 190.96 20.32









twice as large for the experimental group as for the control

group. The scores for the treatment group ranged from 50 to 850,

whereas the scores for the control group ranged from 61 to 356.

The two groups differed on the dimension of social readjustment, with

the experimental group experiencing significantly more life events

over the past year than did the control group


Locus of Control and Life Events

The fourth research question asked if there was any relationship

between life events as measured by the Holmes and Rahe Social Read-

justment Rating Scale (SRRS) and locus of control measured by the

Levenson Tridimensional Locus of Control Scale. Pearson Product

Moment Correlations were computed among the three scales, for both

pretest and posttest measures, and for the SRRS. The results are

summarized in Table 10. There were no significant correlations between

the Social Readjustment Scale and Locus of Control on the dimensions

of internality for either the experimental group, control group, or

combined groups on either the protests or posttests.

The same pattern held true for the dimension of powerful others.

There were no significant pretest or posttest correlations between

Powerful Others and Social Readjustment for either the experimental

group, control group, or the combined groups.

There was a significant correlation between Chance and Social

Readjustment on the posttest for the treatment group. A correlation

of .473 was computed and was significant at the .006 level. There

were no significant differences for the control group but when the two

groups were combined, the correlation of .254 was significant at the









Table 10

Pearson Product Moment Correlations Between the Social Readjustment
Scale and the Levenson Tridimensional Locus of Control Scale


Testing
Scale Groups (n) Pre Post

Internality Experimental (n=27) -.014 -.189

Control (n=25) -.269 -.288

Total (n=25) 211 -.221

Powerful Others Experimental (n=27) .076 .319

Control (n=25) .203 .202

Total (n=25) .151 .226

Chance Experimental (n=27) .203 .473 p .006

Control (n=25) .227 -.084

Total (n=25) .199 .254 p .03









.03 level, with increases in life events correlating with increased

perceptions of control by chance.


Conflict and Locus of Control

The fifth hypothesis stated, in general, that there would be no

significant relationships between conflict and locus of control before

or after the treatment. The Conflict scores were the pooled ratings

from the RISB and locus of control was measured by the I/P/C. Overall

there appears to be a better than chance relationship between internality

and conflict for the participants of this study. The correlations are

negative, indicating that internally oriented individuals tend to have

less conflict. There was a significant better than chance relationship

between powerful others and conflict. The pattern was not as consis-

tent between Conflict and Chance across raters and test periods.

These results are summarized in Table 11.


Conflict and Life Events

The sixth hypothesis stated, in general, that there would be no

significant relationship between conflict and measured life events

prior to and following treatment. The Pearson Product Moment Correla-

tions are presented in Table 12. There was a consistent pattern

across the total group indicating a better than chance relationship

between conflict as measured by the RISB and life events as measured

by the SRRS. The individuals with more conflict tended to have more

experience with stressful life events. The decision was to fail to

accept the null hypothesis.









Table 11

Correlation of Conflict with Locus of Control


Pre Control X Pre Conflict


Internality

Experimental (n=27)
Control (n= 25)
Total (n=52)

Powerful Others

Experimental (n=27)
Control (n=25)
Total (n=52)


-.221
-.354 (p=.042)
-.335 (p=.008)



.393 (p=.051)
.078
.269 (p=.027)


Chance


Experimental (n=27)
Control (n=25)
Total (n=52)


Control

Internality

Experimental (n=27)
Control (n=25)
Total (n=52)


Post X Post Conflict


-.315
-.367
-.315


(p=.012)
(p=.03)
(p=.012)


Powerful Others


Experimental (n=27)
Control (n=25)
Total (n=52)


.429 (p=.001)
.482 (p=.005)
.429 (p=.001)


Chance


Experimental (n=27) .195
Control (n=25) .149
Total (n=52) .195





84


Table 12

Pearson Product Moment Correlations
Between Conflict & Life Events


Pre Post
Group Rater 1 Rater 2 Rater 1 Rater 2


Experimental .228 .333 (.045) .124 .156

Control .314 .451 (.012) .548 (.002) .623 (.000)

Total .391 (.002) .493 (.002) .323 (.010) .396 (.002)









Interaction Between Scales

The seventh question stated that there would be no signifi-

cant differences between the groups prior to and following the

treatment on measured conflict, locus of control, and measured life

events. A two-way analysis of variance was computed on the pretest-

posttest difference scales with life events as one variate and

treatment group as the second variate. On the variate of life events,

the samples were divided into two groups: above and below the median.

The results of the ANOVA are summarized in Table 13.


Table 13

Summary Table of Two-Way Analysis
of Variance Comparisons


F Ratio
Variable Group Level of Adjustment Interaction


Two-Way Analysis

Conflict 3.905 0.013 3.813

Internality 1.248 0.091 0.127

Powerful Others 3.825 0.032 0.089

Chance 0.133 2.439 2.076


Analysis of Covariance

Internality 0.853

Powerful Others 3.671 (.06)

Chance 0.443


No significant differences were found on any of the dependent

variables when treatment group or level of social adjustment were

utilized as variates.









Analysis of Covariance was also computed on each of the dependent

variables with life events utilized as one of the covariates and the

pretest utilized as the other covariate. The results of this analysis

are also reported in Table 13. No significant differences were found

on any of the dependent variables when treatment group or level of

social adjustment were utilized as variates.

Analysis of Covariance was also computed on each of the dependent

variables with Life Events utilized as one of the covariates and the

pretest utilized as the other covariate. The results of this analysis

are also reported in Table 13.


Summary

The constructs of conflict, life events and locus of control were

statistically evaluated, both independently and interactively. The

procedures and results are summarized in Tables 14 and 15.









Table 14

Summary of Instruments


Instrument


Social Readjustment Rating
Scale (SRRS)




Levenson's I/P/C




Rotter's Incomplete Sentences
Blank (RISB)


Constructs Measured


Life Events weighted according
to intensity and length of time
necessary to accommodate to a
life event regardless of the
desirability of the event

Locus of Control
Internal
Powerful Others
Chance

Projected Conflict/Maladjustment
Addresses issues of adjustment
in family, social, sexual,
health, vocational, institu-
tional, educational, inter-
personal, and intrapersonal
areas. It also deals with
past events of control.









Table 15

Summary of Statistical Procedures


Level of
Null Hypothesis/Construct Procedure Significance


1. Conflict





2. Locus of Control


3. Life Events
4. Life Events x LOC

Internality
Powerful Others
Chance
5. Conflict X LOC
Internality-Pretest
Internality-Posttest
Powerful Others-
Pretest
Powerful Others-
Posttest
Chance-Pretest
Chance-Posttest
6. Conflict X Life Events
Pretest
Posttest
7. Life Events X LOC X
Conflict


ANOVA of difference
scores
Pearson's r to estab-
lish interrater
reliability
ANOVA of difference
scores
Paired t-tests
ANOVA
Pearson's Product
Moment Correlation
Pearson's r
Pearson's r
Pearson's r


Pearson's r
Pearson's r
Pearson's r

Pearson's r


Pearson's r
Pearson's r


Pearson's r
Pearson's r
ANCOVA with the pretest
as a covariate. Fac-
torial Analysis of
Covariance with treat-
ment group and level of
life events as variates.


.05





.94


.005


n.s.
n.s.
.03


n.s.
n.s.


.002
.002
n.s.













CHAPTER FIVE
DISCUSSION


Summary

This experimental study addressed the identification, intervention,

and evaluation of stress-related variables among registered nurses.

Initially this investigator identified and assessed the variables of

recent life events, locus of control, and the level of projected conflict

utilizing the Holmes & Rahe (1967) Social Readjustment Rating Scale

(SRRS), Levenson's (1972) Tridimensional Locus of Control scale (I/P/C),

and Rotter's (1950) Incomplete Sentences Blank (RISB), respectively.

Intervention was in the form of a training group based on social learn-

ing, focusing on holistic health concepts directed at self awareness

and individual responsibility for stress mastery among the experimental

subjects. After statistically equalizing the groups on the basis of

the amount of prior stress, the investigator measured and evaluated

changes in conflict and locus of control.

The training approach used was one in which the facilitator(s)

offered information in a flexible, non-evaluative format. The experi-

mental group benefited from the training by assimilation of more

effective stress mastery skills. Additionally, this group selected

skills which had the greatest applicability to their respective life-

styles. The goal of the study was to generate self awareness among

the participants, and encourage them to address and be responsible for

their own individual needs in order to master stress. It was main-

tained that the ongoing skills required to master stress and its attendant









conflict could be transmitted using training methods and active

group participation.

Fifty two nurses from a five-county area comprised the total

sample. The experimental and control groups were comparable in

terms of educational background, number of years in nursing, sex,

salary, and hospital as well as nursing specialty representation.

There were significant differences found in the degree of life

changes experienced between the treatment group and the control group

in this study. The nurses in the experimental group (n=27), RN's

attending a continuing education class on stress mastery, experienced

higher levels of stress as measured by the life events survey, (p=.005) and

more conflict as measured by the projective Incomplete Sentences Blank.

At the completion of the intervention, the experimental group increased

the perception of an internal locus of control and decreased the per-

ception of control by powerful others. Conversely, the control group

(n=25), RN's attending a class on professional issues in nursing, also

raised the sense of internal control, but increased the perception of

control by powerful others (p=.06). Both groups decreased the percept-

ion of control by chance. Although strong trends were evident, these

changes were not statistically significant.

The treatment group experienced a significant (p=.05) decrease in

the projected level of conflict from pre- to post treatment. However,

changes among the control group on the level of conflict were not

significant pre- to post treatment. When these changes were statis-

tically evaluated using life events as a covariate in an attempt to

equalize the groups, the changes were non-significant. Statistically,

the SRRS accounted for less than one percent of the total variance.









Methodologically this presented a problem and indicated that the use

of the Social Readjustment Rating Scale as a statistical variate might

be inappropriate for a study of this type. The Rotter Incomplete

Sentences Blank and Levenson's Internality/Powerful Others/Chance

were considered useful tools for identifying and evaluating stress

and its mastery.


Hypotheses Considered

The first hypothesis postulated was that there would be no differ-

ence in the degree of conflict experienced by members of the treatment

group and members of the control group prior to or following the

treatment. This hypothesis was not accepted. It was found that

there was a significantly higher degree of conflict experienced by

members of the treatment group, and further that the degree of this

conflict was significantly (p=.05) reduced following the treatment

for the experimental group.

The means and standard deviations for the normative group (Rotter

and Rafferty, 1950) are listed as 127.4 (14.4) for females. In 1981,

Rotter and Lah updated these means to 134.8 (18.7). Rotter suggests

a general cutting score of 135 for separation between adjusted and

maladjusted individuals and a cutting score of 110 for "pure" research.

Scores ranging from 110 to 150 are considered most common. The scores

in this study ranged from 103 to 169 for the experimental group and

from 81 to 148 for the control group.

An interrater reliability of .94 was obtained for this study,

using trained raters as well as utilizing the RISB manual for reference.

Rotter obtained an interrater reliability of .96 for females in the

validation studies.




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