Citation
Facilitating stress mastery among high-risk professionals

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Title:
Facilitating stress mastery among high-risk professionals
Creator:
Patterson, Nancy Hord, 1943-
Copyright Date:
1984
Language:
English
Physical Description:
ix, 181 leaves : ; 28 cm.

Subjects

Subjects / Keywords:
Control groups ( jstor )
Life events ( jstor )
Locus of control ( jstor )
Nurses ( jstor )
Nursing ( jstor )
Psychological stress ( jstor )
Self concept ( jstor )
Social psychology ( jstor )
Stress management skills ( jstor )
Stress relaxation ( jstor )
Counselor Education thesis Ph. D
Dissertations, Academic -- Counselor Education -- UF
Holism ( lcsh )
Nurses -- Job stress ( lcsh )
Stress (Psychology) ( lcsh )
City of Jacksonville ( local )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1984.
Bibliography:
Bibliography: leaves 165-180.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Nancy Hord Patterson.

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University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
020034136 ( alephbibnum )
12115166 ( oclc )
ACS0338 ( notis )

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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.




Full Text

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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 1984

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;opyright 1984 by Nancy Hord Patterson

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ACKNOWLEDGEMENTS Many people have supported me in many ways throughout this endeavor, and I wish to recognize their contributions to this accompl ishment. 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

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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 Pattersonwho 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.

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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 i i i vi i v i i i 9 9 13 24 42 43 43 44 49 50 54 65 68 70 71

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FOUR RESULTS 73 Conflict 73 Locus of Control . . 75 Social Readjustment 78 Locus of Control in Life Events 80 Conflict in Locus of Control 82 Conflict in Life Events 82 Interaction Between Scales 85 FIVE DISCUSSION 89 Summary 89 Hypotheses Considered 91 Limitations 95 Conclusions 97 Implications for Theory 98 Implications for Practice 99 Implications for Research and Recommendations for Further Study 100 APPENDICES 103 A LETTER TO PARTICIPANTS 103 B SOCIAL READJUSTMENT RATING SCALE 104 C LEVENSON'S INTERNAL/POWERFUL OTHERS/CHANCE .... 105 D FORMAT OF HOLISTIC HEALTH TRAINING SESSIONS FOR STRESS MASTERY 110 E COURSE EVALUATION FORM AND COMPLETE SUMMARY .... 154 F DEMOGRAPHIC DATA SHEET 160 G KNOWLEDGE AND AWARENESS QUESTIONNAIRE 151 H INFORMED CONSENT FOR TREATMENT GROUP 163 I INFORMED CONSENT FOR CONTROL GROUP 164 REFERENCES 165 BIOGRAPHICAL SKETCH 181

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LIST OF TABLES Table Page 1 Demographic Data 46 2 Experimental Group as they were Represented by the MBTI Categories 61 3 Summary of Self Reported Changes in General Knowledge and Awareness from Experimental Group ... 64 4 Summary of Course Evaluations 66 5 Summary of Social Readjustment Scale 69 6 Means and Standard Deviations of the Treatment and Control Groups on the Rotter Incomplete Sentences Blank 74 7 Means and Standard Deviations of the Treatment and Control Group on the Levenson Tridimensional Locus of Control Scale 76 8 Comparisons of Means for Internal, Powerful Others and Chance Between Treatment and Control Groups ... 77 9 Comparison of the Treatment and Control Groups on the Holmes & Rahe Social Readjustment Rating Scale 79 10 Pearson Product Moment Correlations Between the Social Readjustment Scale and the Levenson Tridimensional Locus of Control Scale 81 11 Correlation of Conflict with Locus of Control .... 83 12 Pearson Product Moment Correlations Between Conflict & Life Events 84 13 Summary Table of Two-Way Analysis of Variance Comparisons 85 14 Summary of Instruments 87 15 Summary of Statistical Procedures 88

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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

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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. ix

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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 1 ifestyles. Lifestyle plays a major role in the health of modern America, yet lifestyle is not a freestanding entity. It is the result of the influences 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 demanding 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. 1

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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 useful 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 literature 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, intervention, 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 conflict (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

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study measured and evaluated changes in conflict and locus of control, after statistically equalizing the groups on the basis of prior readjustment 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 awareness—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 learning (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 abstract complexity. To investigate man it has been necessary to destroy this essence of humanity by breaking it into isolated components.

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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 relaxation 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 consultants. 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 relative 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 consultants 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 stressreducing skills.

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Definition of Terms For the purpose of this study, the following definitions of certain 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 positively or negatively perceived; be realistically or unreal istical ly 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 relationship. 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).

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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). Internal ity . 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, nonevaluative, 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 psychological manifestations of arousal resulting from stressors, and (b) mobilizes the individual's internal and external resources and develops new capabilities 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).

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Research Questions Assuming that nurses are representative of a population of professionals 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' perception of locus of control be influenced by training? Is there a relationship in perceptual change due to reported life events and/or measured adjustment? Using an adaptation of the Holmes and Rahe (1967) Social Readjustment 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

PAGE 17

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.

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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 modifiers, 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 manifestations, 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 individual 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

PAGE 19

10 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, communication styles and skills, adjustment and self-concept, habit control and time management, social support systems and autonomy and control. Specific 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 lifelong learning (Jessup, 1969). Hoi ism 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 interwoven and are likewise blended into the social, cultural, and environmental 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).

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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), "holism" 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-spiritpersonality, 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 momentum. The concepts are simple and clear, emphasizing personal responsibility for health care. The integration of mind-body-spirit is positive wellness, and involves vitality, joy, physical fitness, no healthimpairing 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 identified under different rubrics, the recognition of man as a multidimensional 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

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12 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 requiring 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 1 ifestyles--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, psychosocial 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

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13 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 manifestations (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 individual 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 relatively 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.

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14 Pearl in , 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 cardiovascular 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 activity. 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

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15 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 important 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 wery specific response of the body--one that can be elicited at will. Relaxation is merely a normal response of the body used to defend itself against conditions of continuing stress (Benson, 1975). It is the

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16 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 Tal k--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

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17 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 contributed 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

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18 One study found that nurses who had been in their positions for over five years had significantly higher job satisfaction, lower role ambiguity, and a more internal locus of control (Chariff, Duke, Level & Smith, 1980). Communication skills and styles are additional methods of understanding, predicting and influencing change. Whether the approach is Transactional Analysis (Berne, 1972; Harris, 1967; James & Jongeward, 1971, Stein, 1967), Asserti veness (Alberti & Emmons, 1970, 1975; Bloom, Cogburn & Pearlman, 1976; Jakubowski & Lange, 1977), Neurol inguistic 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 verbal or non-verbal--the latter usually more honest and revealing (Satir, 1972). Communication skills and understanding and appreciating individual 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 concept that learning assertive skills can be a tool for developing selfconcept. 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.

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19 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 inventory 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

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20 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; Horney, 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 (Wall is , 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).

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21 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=l,345; Diploma, n=3,171; BSN, n=2,074; MSN, n=566), as well as by specialty.

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22 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 controls 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

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23 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 related. 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 maximum 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

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24 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 relationships 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 adjustments 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

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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 become widely accepted as predisposing factors to illness, and the recognition 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 includes 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,

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26 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 selfconcept 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 clarification," Rahe states

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27 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 environmental 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 cornerstone of existentialism. Frank! (1975) states that "... being human can be described in terms of being responsible . . . the self that

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28 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 independence 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 described 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.

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29 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 influenced 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 control 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 unpredictable 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 contingent 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)

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30 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 connection to the sociological idea of power and its converse, alienation. 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 context of social-learning theory, Rotter states, "The effect of reinforcement 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 internal ity 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 Internal ity/Powerful Others/Chance Scale by Levenson (1972) is selected for use in this study.

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31 Confl ict 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 internalization 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 psychological 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 devastating, making it difficult to assert oneself, intensifying selfconsciousness, and interfering with cognitive processes. Negative selfconcept 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

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32 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 development 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 e\/ery key aspect of his life (Branden, 1971, p. x). A positive selfconcept, 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 unconditional positive regard for self and others as a way to higher living. Gordon All port (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 determining the course of his own psychological development and in strengthening 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

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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 development 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 selfconcept, 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 unconditional 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 determining the course of his own psychological development and in strengthening 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.

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34 In constructing a method for enhancing self-awareness, Krikorian and Paulanka (1982) structured a group learning experience for psychiatric 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

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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 today's society. Classes and programs—whether commercial, educational, or voluntary — emphasize two things: how we can help ourselves, and how

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36 we can help others. We can only help others manage their stress after we have learned to manage our own. He 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 lifestyle 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 (Dil ley, 1 978) . 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 discipline. 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 education. Allen (1977) encourages health care education--as a deliberate

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37 elaboration of psychological education—as a lifelong educational process. This developmental health education would aid in learning more effective ways to cope with stress, with developing positive selfconcepts, 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 satisfier is crucial to any understanding of nursing stress. Changing the nurse's perception, her awareness, and enlarging 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 intervention have been minimal, and \iery few studies have been done using only nurses, Mannino, Maclennan and Shore (1975) found an overall improvement 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 intensive 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

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w 28 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; hile 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 ongoing training series of stress management classes to the drill instructors 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 internal ity (Peter Neidig & Dale Friedman, personal communication, February, 1984). The issue of mandatory vs. voluntary participation in sel f-improveent 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 preand 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. m

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39 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 internal ity, 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 environmental 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 training 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

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40 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, facilitated 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 significant changes at the .001 level. Foulds suggested that other forms

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41 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 expressed 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 preand 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). Menm'nger (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 oursel ves--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.

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42 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 mainstream of both professional and lay literature. Holistic health concepts 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.

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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 professional 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, 1931; Shealy, 1981; 43

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44 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, identified 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 programs 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

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45 professional nurse. Therefore, there were differences in educational levels among registered nurses. Whether or not the nurse was currently actively employed, or employed 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 requirement by the State of Florida for nursing relicensure eyery 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).

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46 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

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47 Specialty Area Intensive Care Medical -Surgical OB/Gyn Geriatrics Pediatrics Psychiatry Public Health Rehabilitation Occupational Health Other 7% 37% 11% 7% 15% 4% 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

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Spouse Salary Average n = 20 n = 12* 36,130 43,958 Range 8,000-120,000 18,000-100,000 Mode 50,000 100,000 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 White 96% 100% Non White 4% 'Does not include 3 spouses with no wages,

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49 The self-selected volunteers for the experimental group were divided into two small groups on the basis of their personal time preference as they individually registered. The results of all experimental 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 consistently 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 tenweek 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 assessment 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.

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50 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 scorable 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. Administration took less than 10 minutes. Forty-three items were in the original 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

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51 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 continued to prove the small but significant reliability of the predictability of later il 1 ness. Internal ity/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 determining 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 (externality) or a perception of a causal relationship between events and one's own behavior or characteristics (internal ity) . Levenson's three dimensions of expectancy, Internal ity (I scale), Powerful Others (P scale), and Chance (C scale), were originally designed as a reconceptualization of Rotter's (1966) I-E scale. The initial unidimensional formulations had since been considered somewhat simplistic, 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

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52 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 = 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 a personalidealogical 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 similiar 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 reliabilities 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).

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53 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 completed 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 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 insignificant 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 reliability 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.

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54 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 preand 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 highrisk 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 holistic health approach, which encompassed individual physical , psychological social, and spiritual needs. The treatment group had pre-test and posttest levels of projected conflict and perception of locus of control, as well as a pretreatment survey of life events. The intervention encompassed 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,

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55 adjustment and self-concept, habit control and time management, social support systems, and control and autonomous thinking. Specific application 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 utilized 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 generalities 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 (Frank!, 1975, p. 111).

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56 The rationale for approaching the psychological and social components of stress was to facilitate the expansion of knowledge, awareness, 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

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57 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 information 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 participants. 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 control 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 RM 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 preand 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.

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58 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 pretests were completed, general questions regarding the nature of the study were answered. Session one . The first session included brief, general introductions. 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:

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59 types of stress; life events; internal-external control; physiology; behaviors; self-concept; time management; exercise, nutrition; relationship:; 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 demonstrating the physiology of breathing and experienced Body Scan relaxation 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 biofeedback. 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 relaxation 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

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60 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 relaxation, 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 usefulness of planning time, delegation of responsibility and authority, and systems for time management were shared. The importance of a nutritionally adequate diet, meeting individual 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.

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61 Table 2 Experimental Group as They Were Represented in the Myers-Briggs Type Indicator Categories n = 27 ISTJ 3

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62 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 subjects 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 identification of a wider spectrum of self concepts. Ideal, real, and

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63 perceived self concepts were discussed. Two exercises in psychosynthesis 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 discussion and suggestions were made for continuing personal development. 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 participants 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.

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64 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

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65 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 professionally 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 general izabil ity (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 results. 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.

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66 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 {]] 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 I more hours (3) group discussion (1) facilities (3) more theories (1) organization (3) purchase tapes (1)

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67 Lifestyle changes I 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 ) intend to 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 ) sel f awareness (5) lose weight (4) seek counsel ing (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

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68 Multiple assessments were possibly affected by pretest sensitization, as well as test-retest reliability. For this reason, at least 10 weeks elapsed between preand 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 understanding, coping with and intervening against stress in a self-help mode. Limitations There were several limitations to both the scope and the generalizability 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 educational stratifications within the profession of "registered nurses." Constraints of the sample size, which were small but statistically adequate, required stronger differences for significance. The motivation

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69 Table 5 Summary of Social Readjustment Rating Scale Treatment Group Control Group n = 27 n = 25 Severe Life Crisis 400 + Moderate Life Crisis 300-400 Mild Life Crisis 200-299 Stable Below 200 n = 6

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70 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 information 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 internal ity 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 hypotheses 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.

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71 3. There will be no difference in life events as measured by Holmes and Rahe's Social Readjustment Rating Scale between the . imbers 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 control 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

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72 Summary statistics were compiled for the demographic data. A correlational 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.

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CHAPTER FOUR RESULTS This study sought to enhance self-awareness and stress mastery skills among registered nurses utilizing a facilitated training format. 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. Confl ict 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 intervention. 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 difference 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 73

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74 Table 6 Means and Standard Deviations of the Treatment and Control Group on the Rotter Incomplete Sentences Blank Group Pretest Posttest Mean M SD M SD Change Treatment (N = 27) Control (N = 25) 136.07 15.00 127.55 16.40 -8.52 117.50 12.33 116.12 15.07 -1.38

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75 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 internal ity, 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 internal ity, 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 internal 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

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76 Table 7 Means and Standard Deviations of the Treatment and Control Group on the Levenson Tridimensional Locus of Control Scale Scale/Group

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77 Table 8 Comparison of Means for Internal, Powerful Others and Chance Between Treatment and Control Groups Pretest Mean Posttest Mean 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 CI 38.88 EI 36.70 EP 19.56 CP 17.56 EC 16.19 CC 15.44 CI 39.04 EI 38.33 CP 18.60 EP 17.63 EC 14.22 CC 14.08 CI Control Internal CP Control Powerful Others CC Control Chance EI Experimental Internal EP Experimental Powerful Others EC Experimental Chance

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78 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 differences 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 &re 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

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79 Table 9 Comparison of the Treatment and Control Groups on the Holmes & Rahe Social Readjustment Rating Scale Group Mean Standard Deviation F F Prob Experimental Control 319.78 190.96 38.00 20.32 8.538 0.0052

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80 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 Readjustment 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 internal ity for either the experimental group, control group, or combined groups on either the pretests 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

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81 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 Internal ity Experimental (n=27) Control (n=25) Total (n=25) Powerful Others Experimental (n=27) Control (n=25) Total (n=25) Chance Experimental (n=27) Control (n=25) Total (n=25) -.014

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82 .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 consistent 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 Correlations 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.

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83 Table 11 Correlation of Conflict with Locus of Control Pre Control X Pre Conflict Internal ity

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84 Table 12 Pearson Product Moment Correlations Between Conflict & Life Events

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85 Interaction Between Scales The seventh question stated that there would be no significant 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 pretestposttest 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 TwoWay 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.

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86 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.

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87 Table 14 Summary of Instruments Instrument Constructs Measured Social Readjustment Rating Life Events weighted according Scale (SRRS) to intensity and length of time necessary to accomodate to a life event regardless of the desirability of the event Levenson's I/P/C Locus of Control Internal Powerful Others Chance Rotter's Incomplete Sentences Projected Conflict/Maladjustment Blank (RISB) Addresses issues of adjustment in family, social, sexual, health, vocational, institutional, educational, interpersonal, and intrapersonal areas. It also deals with past events of control .

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Table 15 Summary of Statistical Procedures Null Hypothesis/Construct Procedure Level of Significance 1 . Conflict 2. Locus of Control 3. Life Events 4. Life Events x LOC Internal ity Powerful Others Chance 5. Conflict X LOC Internal ityPretest Internal ityPosttest Powerful OthersPretest Powerful OthersPosttest Chance-Pretest Chance-Posttest 6. Conflict X Life Events Pretest Posttest 7. Life Events X LOC X Confl ict ANOVA of difference scores Pearson's r to establish interrater reliabil ity 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. Factorial Analysis of Covariance with treatment group and level of life events as variates. 05 .94 .005 n.s. n.s. .03 .008 .012 .027 .001 n.s. n.s. .002 .002 n.s.

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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 learning, 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 experimental 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 lifestyles. 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 maintained that the ongoing skills required to master stress and its attendant 89 '

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90 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 perception 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 perception 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 preto post treatment. However, changes among the control group on the level of conflict were not significant preto post treatment. When these changes were statistically 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.

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91 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 Internal ity/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 difference 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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92 The second hypothesis, which was not rejected, stated that there would be no difference in perceived locus of control, either in the direction of internality, powerful others, or chance following the treatment. Following the study, the treatment group increased the sense of internal locus of control to a degree ten times greater than did the control, although the change was statistically insignificant. Foulds (1977) found differences significant at the .001 level in a pretest/posttest control group design with a group of similar size and length. Chariff, Level, Smith and Duke (1980) found significant relationships between internal locus of control, job satisfaction and role clarity in nurses who had been in their positions for more than five years. The majority of the general duty nurses in this study had been in their present positions for less than one year. The experimental group decreased the sense of control by powerful others following the treatment, while the control increased the sense of control from powerful others. While there were no previous studies found concerning this particular dimension, one should consider that the control group was participating in a wery structured program while the experimental group was involved in a personal, growthoriented program. Both the experimental and control groups decreased the sense of control by chance by similar strengths. Levenson (1972) reports means and standard deviations for a group of 51 females of: 1=35.46 (7.41), P=14.64 (6.87), and 013.38 (9.05). The pooled means for the experimental group were: 1=37.51 (6.95), P=18.59 (8.27) and C=15.20 (8.15). These same scores for the control group were: 1=38.96 (4.27), P=18.08 (8.96) and C=14.76 (8.92). Both

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93 groups of nurses experience a higher sense of internal control than did Levenson's group of females, but they also perceive more control from powerful others and chance. The third hypothesis was that there would be no difference in the life events as measured by the Social Readjustment Rating Scale between members of the treatment and control groups. There were wide differences between the two groups with the members of the treatment group experiencing more, severe life events events that the control group (p=.005). The pilot studies done in preparation for this study found that people enrolling in stress management classes were under moderate to severe life crises as measured by the SRRS which was apparantly true for the treatment group in this study. There were no members of the control group whose scores fell into the severe life crisis range while 23% of the treatment group scored in that range. The middle two ranges (mild and moderate life crisis) were approximately equally shared by both groups, but the stable range had only 26% of the experimental subjects as compared to 56% of the control subjects. The fourth hypothesis dealt with relationships between measured life events and locus of control. Although there were no significant relationships between internal ity or powerful others and life events, it was found that those members of the experimental group that tended to encounter the most life changes also gave the most credit to chance as a controlling force in their lives (p=.03). The study by Sarason & Johnson(1977) specifically identifies an internal locus of control as a buffer against anxiety and adjustment to life events. Those researchers found that life changes have their most adverse effects on those people

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94 perceiving the least amount of control over enviornmental events. The present study would seem to add confirmation to that conclusion. The fifth hypothesis stated that no significant relationships between conflict and locus of control would be found either before or after treatment. Better than chance relationships were found between the internal ity score and the conflict score for the control group and the total sample on both the pretest and posttest comparisons. The total group significance levels were .008 and .012 for the preand post relationships for conflict and internal locus of control, and .027 and .001 for pre and post relationships for conflict and powerful others. The correlations were negative. People with higher internal locus of control tended to have lower conflict scores. The more conflict that was percieved from powerful others tended to be reflected in more projected conflict. There were no significant correlations between chance and conflict. In the study previously cited, Johnson and Sarensen specifically identify an internal locus of control with fewer adjustment problems. The sixth hypothesis predicted no significant relationships between conflict and measured life events before or following the treatment. In general, for the total sample, there was a better than chance relationship between life events and conflict (p=.002 for pretest and posttest). Individuals who had experienced more stressful life events tended to have higher conflict scores. The final hypothesis dealt with the interaction of the variables of conflict, locus of control and life events between the groups, both before and after treatment. No significant interactions were found between the dependent variables tested in this study when analysis of

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95 covariance was computed with the pretest as a covariate or when groups were divided at the median on the pretest life events measurement. Limitations There are several limitations of this sample which might limit the general izability of these results. The female gender exclusivity precludes comparison to males. The occupational exclusivity precludes comparison to any occupation other than nursing. Because the sample was 96% white, the manifestations of stress and the issues of conflict, locus of control, and life events within a minority subculture cannot be adequately related to the findings in this study. The two groups were equal in the distribution of basic nursing preparation, with the majority of both groups having been educated in the two-year associate degree programs. Both groups had small portions with some type of certification, i.e., specialized training in a particular field of nursing. There were differences in the household/ marital status/living arrangements of the two groups. Almost half the members of the control group had no children, and one-third of the control group was unmarried. More of the treatment group was married, and more had children in the 6 to 12 year old range. Members of the treatment group had a total of 67 children as compared to the control group, whose members had 40 children among them. The sample size was small with only 27 in the experimental group and 25 in the control group. Small samples require greater differences in order to be statistically significant. The members had a variety of reasons for volunteering for the study. Most members of the treatment group indicated that stress was a current problem for them and they sought some assistance in dealing

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96 with it. This was confirmed by the distribution of SRRS scores which also indicated high levels of life events in the lives of the treatment group. The range of the SRRS scores for the control group was not as great, although many of them had experienced sufficient changes dueing the past year to place them in the mild and moderate life crisis categories. Only the control group had no members in the highest category of severe life crisis while 28% of the members of the experimental group scored in that category. Regarding the problematic definition of stress, it must be noted that behavior is not a collective perception, but rather behavior is the result of an individuals perception of the enviornment. This study investigated perseptions as reflected by group mean scores, whereas perhaps it would have been more valid to investigate individual perceptions and changes. The two most basic limitations of this study may have been the difficulties of conduction holistic "research" in an uncontrolled setting, and the threat of experimentor bias. It was difficult to obtain a statistical model that was compatible with the conceptual model— a problem that has been consistently encountered in holistic research. This study sought to encompass and schedule many facets of stress--and its ultimate mastery--into the limited number of sessions. It is difficult, at best, to measure something as dynamically multidimensional as holism with such limited tools. In order to avoid the threat of experimentor bias, this study adhered to the teaching guide. Whether using the principal investigator or guest experts, the integrity of the curriculum design was maintained. The results of the course evaluation are offered as evidence that each

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97 participant was allowed to select that information which was most personally meaningful, and the wide range of topics stated as being beneficial indicates that participants were indeed free to select and were not coached. However, experimentor bias may still have been present. Conclusions Within the limitations previously discussed, the following conclusions can be drawn from the results of this study: 1. The nurses who enrolled in the stress management course were significantly more likely to have experienced more stressful life events than nurses who enrolled in courses of advanced study. 2. A facilitated training intervention can significantly decrease perceived conflict among nursing volunteers in a stress management course. 3. The nurses who volunteered for the stress management course had a lower sense of internal control that did the nurses taking the advanced course, but the increase in the sense of internal control was ten times greater for the experimental group as for the control group. 4. The nurses in the stress management course initially had a higher sense of control by powerful others, but this source of perceived control was decreased by the training sessions. The nurses without training sessions may increase the perception of control by powerful others when in highly structured courses of advanced study. 5. Nurses in both types of courses will probably decrease the perception of control by chance. 6. The interactions of these constructs of life events, locus of control and conflict are not statistically significant.

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Implications for Theory When examining the constructs of conflict, life events and locus of control, there are several theoretical implications. Life events have a proven place in literature, and in understanding, predicting and directing behavior. This study would seem to confirm that life events are a valid concept, but not useful as a statistical measurement. The primary researchers in life events make this statement and it seem worthy of acknowledgement. Conflict, whether one is discussing anxiety, stress or maladjustment, is a less researched area. The RISB is a useful measure of conflict, and more importantly, seems to be sensitive to the changes in conflict that would indicate that some treatment has been effective in altering that level of conflict. The specific reason for this is likely to be that conflict is so problematic to define. Research validates that "stress" does exist, and that it has far-reaching health implications. There researchers seem obligated to continue to attempt to refine the definition and assessment of it. Locus of control is a construct that has been investigated for more that two decades. The two questions that consistently remain are whether or not it is a dynamic personality preference or a static personality trait. If it is the former, then it can be influenced and altered, and if it is the latter, then theoretically it cannot be altered. Changes that occurred in this and other research would then lead credence to the concept that locus of control is a dynamic personality preference. The devlopments of tools which measure the two dimensions of externality seem to be valid. More research into that area would add to the body of knowledge of control by powerful others and/or control by chance.

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99 Implications for Practice When examining the constructs of life events, locus of control and conflict, there are several implications for counselors in practice. Life events play an important part in the adjustment of most individuals, and at times individuals experiencing a great deal of distress may also be experiencing many life changes. Knowledge of stress theory would enable the counselor to assist the client in reviewing and assessing the life events and in making more appropriate adjustments to them. A key focus of therapy is to assist the client in assuming the responsibility for his/her own actions, i.e., gaining an internal locus of control. An understanding of those areas in a clients' life in which s/he experiences personal control, and those in which s/he feels controlled by powerful others are qualitatively different from those situations when control is attributed to chance. The effective counselor will realize that at times s/he will be in the role of a "powerful other" to the client and will use this position judiciously. Conflict is a constant companion of a client entering therapy and may be one of the most difficult for the therapist to evaluate. Counselors are always in need of useful, reliable, and valid assessment tools. This study suggests that the RISB as a projective test meets that need. The possibilities for counselors to add to their repetoire a test that has the capacity to tap more areas, and that can be objectively scored, takes the projective test away from the mystical realm of the unknown and places it in the arena of practical usefulness for both clients and

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100 counselors. In an era when accountability is an issue, the RISB provides a vehicle for that accountability to occur. The measurement of conflict perceived by a client, and its subsequent reduction following therapy add credibility and measurabil ity to the process of counsel ing. There are some questions as to the advantage or disadvantage of reviewing test data prior to the beginning of a class. If one is seeking to actively engage participants in methods of stress mastery, then knowing the general concerns of the group would enhance facilitation of the group discussions, and subject matter could be deleted or emphasized as dictated by the needs of the group. Implications for Research and Recommendations for Further Study This study of the constructs of life events, conflict and locus of control has given rise to several implications for research and recommendations for further study. Levenson's measure of control (I/P/C) addresses each of the dimensions of control, and is sensitive to changes within these groups. The issue of control of one's life is so central to the focus of counseling that the identification and enhancement of an internal locus of control is justified. Whether these changes can be maintained, and for what lengths of time, needs more investigation. When changing perceptions within oneself, time is essential to process and integrate these changes on a stable basis. Rotter's Incomplete Sentences Blank is a good measure of the dynamic continuum of adjustment-conflict, and is able to reflect overall changes in the state of adjustment in individuals. It worked

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101 well as a pretest/post measurement device. The high interrater reliabilities compared well to those obtained by the raters trained by Rotter and indicate the adequacy of the manual for use in scoring the RISB. The time needed to administer the RISB make it useful to administer to groups, although the necessary hand scoring takes a major amount of time. The use of the Social Readjustment Rating Scale (SRRS) as a teaching tool is advantageous. The authors of this scale point out that it has a small but reliable predictability of future illness, but that is insufficient as the lone predictor and this study confirms that point. The SRRS accounted for very little variability and may have skewed the results of the study. Several recommendations for further study are offered. As must be expected from a group this small, one logical recommendation is replication with larger numbers. If additional nurses are utilized, the resultant data could be pooled with this data. If the subjects represent other professions, new sets of data could be derived and compared with those already available herein. It was frequently mentioned by the participants in this study, and an opinion shared by the principal investigator, that the sessions needed to be closer together in time. Two and a half hour sessions on a weekly basis would encompass the same time frame over ten weeks, but would give more immediate feedback and reinforcement to the newly learned techniques and information. Personality typing is useful in looking at how people differ in the way they cope with change and conflict and would add a valuable

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102 dimension to a study of this type. The Myers-Briggs Type Indicator is a personality measure that yields such information, and fits into a holistic concept. A future study would benefit by building into the analysis a method for statistical evaluation of demographic variables. Valuable information is lost when these are not considered. There are some questions as to the advantage or disadvantage of reviewing the pretest data prior to the beginning of the training sessions. To maintain a true experimental base, data must remain blind. In addition to the usual ethical safeguards when conducting research with human subjects, two ethical principles must additionally be addressed. Participants need to have the nature of the research clarified at the end of the research, when all data &re completed, in a timely manner. Ethical principles note that at times the investigator may discover things about the participants that could be upsetting or damaging to his self esteem if revealed. The question is then raised as to whether full post investigation disclosure is necessary, or even appropriate. The basic conflict is between the obligation to fully inform and the desire to avoid any harm. In order to avoid having to decide between keeping secret from the participant some important, but possibly damaging information or giving disturbing news not bargained for in the spirit of volunteering as a research subject may be avoided by anticipating its development and making suitable arrangements with each participant in advance. The primary consideration in selecting alternate actions is the welfare of the participants. These ethical considerations are strongly recommended for a replication of this study.

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APPENDIX A LETTER TO PARTICIPANTS September 1, 1983 Dear Thank you for volunteering to participate in the Nursing Stress Management Research. This research course uses registered nurses as subjects. The subject is stress management, and will cover aspects of the processes of stress including its management, modifiers and mediators. This study is predicated on the assumption that nurses are representative of professions subjected to high stress levels. It is maintained that the ongoing skills required to master stress can be transmitted using consultation methods. The treatment will be a holistic presentation of the various skills and knowledge necessary to master stress, and includes social, psychological, and biophysical concepts. The consultant/principal investigator is Nancy Patterson, ARNP. The study is being conducted as part of a doctoral study through the Department of Counselor Education at the University of Florida. Any questions may be directed to Ms. Patterson at 904/724-6744. All sessions will be held at the University of North Florida Campus, Building 2, Room 2060. You are in the class indicated below. Dates and times are as follows Morning Class Afternoon Class September 14, 1983

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APPENDIX B. SOCIAL READJUSTMENT RATING SCALE Thomas Holmes and Richard Rahe of the University of Washington School of Medicine developed this scale to measure relative stress induced by various changes in a person's life. It does not matter if any of these events was expected or unexpected, nor if the event was desirable or undesirable. Event Life Change Units Death of a spouse 100 Divorce 73 Marital separation 65 Detention in jail or other institution 63 Death of a close family member 63 Major personal injury or illness 53 Marriage 50 Fired at work 47 Marital reconciliation 45 Retirement 45 Major change in behavior or health of family member 44 Pregnancy 40 Sexual difficulties 39 Gaining new family member (birth/adoption/moving in) 39 Major business readjustment (merger/bankruptcy/reorganization). . 39 Major change in financial state (much better or worse) 38 Death of a close friend 37 Major change in responsibilities at work (promotion/transfer) . . 36 Major change in number of arguments with spouse (more/less) ... 35 Taking on a mortgage greater than $10,000 31 Foreclosure on a mortgage or a loan 30 Change in responsibilities at work 29 Son/daughter leaving home (marriage/attending college) 29 Trouble with in-laws 29 Outstanding personal achievement 28 Wife begins or stops work 26 Beginning or ceasing formal schooling 26 Change in living conditions 25 Revision of personal habits (dress/manner/associations) 24 Trouble with boss 23 Major change in working hours or conditions 20 Major change in living conditions (new home/remodeling) 20 Change in schools 20 Major change in usual type of and/or amount of recreation .... 19 Major change in church activity (more or less) 19 Major change in social activities (clubs/movies/visiting) .... 18 Taking on a mortgage or loan of less than $10,000 17 Major change in sleeping habits (more/less/different) 16 Major change in number of family get-togethers 15 Major change in eating habits 15 Vacation 13 Minor violations of the law 11 Reprinted with permission. 104

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APPENDIX C LEVENSON'S INTERNAL/POWERFUL OTHERS/CHANCE

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106 Name Date On the other side of this sheet is a series of attitude statements. Each represents a commonly held opinion. There are no right or wrong answers. You will probably agree with some items and disagree with others. We are interested in the extent to which you agree or disagree with such matters of opinion. Read each statement carefully. Then indicate the extent to which you agree or disagree by circling the number following each statement. The numbers and their meanings are indicated below: If you agree strongly If you agree somewhat If you agree slightly If you disagree slightly If you disagree somewhat If you disagree strongly circle +2 circle +2 circle +1 circle -1 circle -2 circle -3 First impressions are usually best. Read each statement, decide if you agree or disagree, and the strength of your opinion, and then circle the appropriate number. GIVE YOUR OPINION ON EVERY STATEMENT If you find that the numbers to be used in answering do not adequately reflect your opinion, use the one that is closest to the way you feel . Thank you. (Do not write in this area) I scale: (raw) +24= P scale: (raw) +24=_ C scale: (raw) +24=

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107 >, CD

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i— CD

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109 Scale Items Interpretation Internal Scale (1, 4, 5, 9, High score indicates that the sub18, 19, 21, ject expects to have control over 23) his or her own 1 ife. Low score indicates that the subject does not expect to have control over his or her own life. Powerful Others (3, 8, 11, High score indicates that the subScale 13, 15, 17, ject expects powerful others to 20, 22) have control over his or her life. Low score indicates that the subject expects powerful others do not have control over his or her 1 i f e . Chance Scale (2, 6, 7, High score indicates that the sub10, 12, 14, ject expects chance forces (luck) 16, 24) to have control over his or her 1 i f e . Low score indicates that the subject expects chance forces do not control his or her life. Scoring and Interpretation for the I, P, and C Scales There are three separate scales used to measure one's locus of control Internal Scale, Powerful Others Scale, and Chance Scale. There are eight items on each of the three scales, which are presented to the subject as one unified attitude scale of 24 items. The specific content areas mentioned in the items are counterbalanced so as to appear equally often for all three dimensions. To score each scale add up the points of the circled answers for the items appropriate for that scale. (These items are listed on p. 59.) Add to this sum +24. The possible range on each scale is from to 48. Each subject receives three scores indicative of his or her locus of control on the three dimensions of I, P, and C. Empirically, a person could score high or low on all three dimensions. Reprinted with permission Lefcourt, H. M. (ed.). Research with the locus of control construct . New York: Academic Press, 1 981 .

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APPENDIX D FORMAT OF HOLISTIC HEALTH TRAINING SESSIONS FOR STRESS MASTERY

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Ill FORMAT OF HOLISTIC HEALTH TRAINING SESSIONS FOR STRESS MASTERY Prospectus This course identifies, in a holistic approach to personal and community care, ways people can augment or interfere with wellbeing in areas of nutrition, exercise, relaxation, rational thinking, social support systems and spiritual self-development. It will measure the constructs of life events, conflict and locus of control Textbook Girdano, D. , and Everly, G. Controlling stress and tension: A holistic approach. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1979. Goals and Objectives 1. To increase self-awareness and self responsibility through holistic health consultation. 2. To enhance commitment to a lifestyle that enhances well-being. 3. To apply knowledge of theories taught to one's self through the use of evaluative tools and individual interpretation. 4. To increase awareness of the relationship of the General Adaptation Syndrome and the state of tension; to learn that tension and relaxation cannot exist together; to provide multiple opportunities to practice various relaxation techniques including progressive muscle relaxation, autogenic phrases, guided principles of oxygen consumption and utilization to integrate concepts of relaxation as being aids in returning the body to a state of hemeostasis. 5. To present theories and exercises or skills related to time management, exercise, nutrition, change, social support systems, rational thinking, and communication in such a manner that participants will gain needed skills to master individual stress. Procedures Theories and exercise will be presented in a variety of teaching methods, including lecture, discussion, self-report, small groups, role-playing, demonstrations, group exercises, brainstorming,

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112 journals, and informal sharing. Videotapes, audiotapes, and slidetape presentations will be utilized. Homework Assignments Homework assignments for increasing self-awareness will be given on a voluntary weekly basis. Suggested Readings from Textbook Textbook assignments for increasing knowledge and self-awareness will be given on a voluntary weekly basis. Facilitator Preparation Specific bibliographic references will be given for each session. The faci litator is responsible for reading all the material prior to the training session in order to be fully prepared for the topics to be presented. Theoretical Perspectives The theoretical perspectives for this training session include Assagioli (1965) Psychothesynthesis Berne (1967) Transactional Analysis Combs & Snygg (1949) Phenomenology Ellis (1975) Rational Emotive Thinking Holmes & Rahe (1967) Life Events Horney (1950, 1945) Self Concept and Personality Jacobsen (1938) Relaxation Jung (1964) Personality Typology Kaplan (1977) Social Support Knowles (1950) Andragogy Krieger (1981 ) Holism Lakein (1973) Time Management Levenson (1972) Locus of Control Luthe (1969) Autogenic Therapy Maslow (1954, 1970) Motivation and Human Needs Progoff (1975) Intensive Journal Rogers (1951) Communication Rotter (1950) Conflict Rotter (1954) Social Learning Rotter (1966) Locus of Control Roy (1970) Adaptation Ryan & Travis (1981 ) Holism Satir (1972) Communication Selye (1974) Stress and Adaptation Super (1954) Self Concept Vocational Theory Yura & Walsh (1982, 1983) Human Needs

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113 ORIENTATION SESSION Goals and Objectives 1. To get to know group members. 2. To set trusting, open climate for comfortable sharing of ideas and f-elings. 3. To set limits of confidentiality. 4. To orient participants to the purpose and structure of the training sessions . 5. To collect data. a. Consent forms b. Knowledge and Awareness Questionnaire c. Social Readjustment Rating Scale d. Levenson's I/P/C Scale e. Rotter's Incomplete Sentences Blank f. Myers-Briggs Type Indicator Procedure Introductory presentation (15 minutes). The general purpose of the research is presented, along with a general summary of the topics to be covered. The special nature of research, as opposed to a general class, is defined, especially related to confidentiality and the use of group scores. Begin data collection (30 minutes). Consent forms are signed and witnessed, and Knowledge and Awareness Questionnaires are completed. Exercise: Why we are here and getting acquainted (60 minutes). The group is divided into dyads, with each dyad having 10-15 minutes to get acquainted. Following the dyads, the group reassembles and each person introduces her partner by sharing what they learned about that person. It is important to have the dyads made up of people who do not know each other. Following the introductions the facilitator summarizes the reasons for attending the class, and reminds participants that this sharing format will be part of the training sessions.

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114 4. Orientation to facilities (20 minutes). A walking tour to locate parking facilities, dining areas, phones, library, and restrooms is an opportunity for a physical break and informal discussion. 5. Complete Data Collection (60-90 minutes). Begin with Social Readjustment Rating Scale. It can be scored while participants are continuing to write. Follow with Levenson's I/P/C. It takes only approximately 10 minutes to complete. Directions are read directly from the test sheet. When those are complete distribute Rotter's Incomplete Sentences Blank. This will take longer to complete. Directions are read directly from the test sheet. The final test to be taken is the Myers-Briggs Type Indicator. Directions are printed on the booklet. Members may leave as it is completed. Facilitator Preparation Caplan, G. Mastery of stress : Psychosocial aspects. American Journal of Psychiatry , 1981, 238 (4), 413-420. Claus, K. , & Bailey, J. T. Living with stress and promoting well-being . St. Louis, M0: CV Mosby Company, 1980. Churchill, R. & Crandall, V. J. The reliability and validity of the Rotter Incomplete Sentences test. Journal of Consulting Psych ology , 1955, 1_9 (5), 345-350. Daly, N. Andragogy: Implications for secondary and adult educational programs , 1980, ED 186 627. Flynn, P.A.R. Holistic health--The art and science of care . Bowie: MD, Robert J. Brady Co. , 1980. Frain, M., & Valiga, T. The multiple dimensions of stress. Topics in Clinical Nursing , 1979, T_ (1), 43-53. — Holmes, T. & Rahe, R. H. The social readjustment rating scale. Journal of Psychosomatic Research , 1967, U_, 213-218. Jasmin, S. A., Hill, L., & Smith, N. Keeping your delicate balance-The art of managing stress. Nursing , June, 1981, 53-57. Johnson, J. H. & Sarason, I. G. Life stress, depression and anxiety: Internal-external control as a moderate variable. Journal of Psychosomatic Research , 1977, 22, 205-208. Levenson, H. Distinctions within the concept of internal -external control: Development of a new scale. Proceedings of the 80th Annual Convention of the APA, 1972, 261-262. Menninger, R. W. Coping with life's strains. US News and World Report , May 1, 1978, 80-83.

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115 Pearl i n , L. I., Lieberman, M. A., Menaghan, E. G. & Mullan, J. T. The stress process. Journal of Health and Social Beha vior, 1981, 22, 337-356. Rotter, J. B., Chance, J. E., & Phares, E. J. Appl ications of a social learning theory of personality . NY: Holt, Rinehart & Winston, 1954, 1972. Rotter, J. B. & Rafferty, J. Manual for the RISB college form . NY: The Psychological Corporation, 1950. Sharp, R. & Lewis, D. Thrive on stress . Andersonville, IN: Warner, 1977. Wallis, C, Galvin, R. M. , & Thompson, D. Stress: Can we cope? Time , June 5, 1983, 48-54. SESSION ONE Goals and Objectives 1 . To understand general stress theory. 2. To be able to define homeostasis, alarm, resistance and exhaustion stages of the G.A.S. 3. To identify and assess areas of personal stress; to increase the participants' awareness of sources of change as stress. 4. To assess the degree of individual life changes over the past year; to assess the probable susceptabil ity to illness. 5. To identify personal stressors and responses. 6. To be able to differentiate between stress (change), eustress, and distress. 7. To introduce the general overview approach of the training material, i.e., health oriented; and that attention will be given to a variety of systems and approaches. Procedure 1. Brainstorming Session (45 minutes). Participants list as mamy sources of stress as they can think of on the board. It will be extensive but will probably include: death children finances relationships losses time demands job-related stress weddings, births, etc. The facilitator points out that not all of these stressors are negative, and begins to point out that stress is considered change

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116 in the environment that causes change in our system, and it may be pleasant or unpleasant, planned or uncontrolled. 2. Slide Presentation (30 minutes). A pictorial representation of the holistic approach to stress mastery and well-being. It includes change, control, relaxation, exercise, nutrition, self concept. (Available from Counseling Services, Inc., Jacksonville, FL, 3. Discussion of Selye's General Adaptation Syndrome, and to integrate it into theories of life events (30-45 minutes). 4. Lecture, "Types of Stress" (45 minutes). Lecture covers definitions of "eustress," "stress," and "distress" and how the level of either will increase the intensity of that stressor. Further lecture discusses how stress may be considered a threat either physically, psychologically, socially or environmentally. When these categories are listed across the board, participants are invited to take any event(s) from the brainstorming session and see how they relate. Usually, the stressor falls into all four categories; for example: divorce is both a physical and psychological separation, calls for social changes and sometimes involves moving to a different dwelling. The final portion of this lecture focuses on acute, chronic and specific stressors. Discussion centers on how these affect our lives and what we can (or cannot) do about them. Relaxation Introduction to diaphragmatic breathing; progressive muscle relaxation (30 minutes). Available from Counseling Services, Inc., Jacksonville, FL, Homework Assignment Stress Indicators Cardiac Bingo How long will you live? Suggested Reading from Textbook Chapter Eight Facilitator Preparation Benson, H. The relaxation response . NY: Avon, 1975. Girdano, D. & Everly, G. Controlling stress and tension: A holistic approach. Englewood CI i f f s , N J : Prentice-Hall, Inc., 1979.

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117 RELAXATION RECORD SESSION/TYPE BEGINNING ENDING REACTION PULSE RATE PULSE RATE ONE Progressive Muscle Relaxation TWO Visual Imagery/ Seashore THREE Autogenic Phrases FOUR Fantasy/ Wal k Through a Rainbow FIVE Wise Old Person

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118 INDICATORS OF STRESS Circle all the indicators of stress that you have ever experienced; then go back and highlight the ones that you currently experience. PHYSICAL Allergies Hay fever Asthma Difficult breathing Chest-tightness Muscle tension Trembl ing Tics/Twitching Shaking Colitis Constipation Diarrhea Indigestion Nausea Overeating Loss of appetite Weight changes Ulcers Stomach gas Stomach butterflies Vomiting Dizziness High blood pressure Rapid heartbeat Pounding heart Cold extremities Numb or tingl ing extremities Frequent urination Backaches Dry mouth Flushed face Skin pale Premenstrual syndrome Migraine headaches Tension headaches Low resistance to infection Sweaty palms High cholesterol Dilated pupils BEHAVIORAL Alcohol use Drug use Accident prone Sexual difficulty Sexual disinterest Stuttering Rapid speech Slow speech Voice changes Smoking Competitiveness Gait slowed Hyperactivity Nail biting Hair twisting Grinding teeth Grimacing Frowning Insomnia Nightmares Sleeping too much Slumped posture Sighing Tearfulness Fatigue Non-productive activity Uncoordinated actions SOCIAL Decline in social activities Decline in hobbies Loss of jobs Arguments with others Withdrawal from relationships Fear of groups or crowds Critical of others Difficulty in relationships Blaming others EMOTIONAL Anger Agitation Crying Depression Guilt feelings Hyper-excitabil ity Impul sivity Irritabil ity Jealousy Moodiness Restlessness Sadness Suspiciousness Feelings of worthlessness Anxiety Fearful Critical of sel f Dread Worry Thoughts of death or suicide Loss of initiative Loss of sel f esteem INTELLECTUAL Concentration difficulty Grammar errors Number errors Fantasy increases Fantasy decreases Forgetful ness Inattention Distracted Lack of attention to detail s Loss of creativity Loss of productivity Mental blocking Past Orientation Perfectionism Detail -oriented **These divisions are for convenience, exclusive. They are not necessarily mutually

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119 CARDIAC BINGO Rate Your Risk of Having a Heart Attack Despite a drastic decline in the number of deaths in the 1 970 ' s attributed to disease of the heart and blood vessels, it still remains the nation's No. 1 killer—far ahead of second place cancer. Nonetheless, the decrease in deaths by more than 20% in the last decade is encouraging. To find out how you stack up as a risk for heart attack, we invite you to play along in a game of "cardiac bingo." It was devised originally by the Michigan Heart Association to help individuals measure their risk of suffering a heart attack. Obviously, a high score does not mean you definitely will have a heart attack; nor does a low score make you immune from risk. The scores, however, do indicate a likelihood of what might occur. To play, simply study each of the eight factor rows on the "bingo" chart. When you find the box in each row that best describes your situation, circle the big number. For example, if you are 36 years old, circle the "3" in the box labeled 31-40. After completing the exercise, add up the eight circled numbers for your score. Following are some things to consider as you play "cardiac bingo." Heredity : Count parents, grandparents, brothers and sisters who have had heart attacks or strokes. Smoking : If you inhale deeply and smoke cigarettes down so far they nearly scorch your fingers, increase your risk factor in this row by one. You do not, however, get to subtract one if you think you do not inhale or if you smoke only the first half-inch of each cigarette. Exercise : Lower your score one point if you exercise regularly and frequently. Cholesterol or Fat Intake : A cholesterol blood level taken by your doctor is the most accurate way to determine your risk factor in this category. If you have not had such a test, ignore the boxes containing numbers "1" and "2." Then honestly estimate the percentage of solid fats you eat. These usually are of animal origin (lard, crea, butter, beef and lamb fat). If you eat much of these foods, your cholesterol level is probably high. The U. S. average of 40% is too high for good health, physicians say. Blood Pressure : If you have not had a recent reading, but have passed an examination for insurance or work, you are probably 140 or less. Sex : This category takes into account the fact that men have from six to 10 times more heart attacks than women of childbearing age. Adapted from: Kansas City Life Insurance Company, Kansas City, M0 1982.

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122 HOW LONG WILL YOU LIVE? The following life-expectancy quiz is one of the many health questionnaires now used by doctors, medical centers and insurance groups. While quizzes are not precise, they do give a realistic picture of probable longevity. In addition to heredity patterns and medical history, current computations try to measure risk in relation to environment, stress and general behavior, though statisticians and experts do not always agree on how to weigh the components. For example, a high salary may not be as detrimental to longevity—because of competitive stress — as many quizzes suggest. On the other hand, marriage or living together, usually assumed to increase one's chances of living longer, may actually increase stress, especially for notably embattled partners. National average life spans: 70.5 for white males, 65.3 for all other males; 78.1 for white females, 74 for all other females. Start with the number 72 . Personal Facts If you are male, subtract 3. If female, add 4. If you live in an urban area with a population over 2 million, subtract 2. If you live in a town under 10,000 or on a farm, add 2. If any grandparent lived to 85, add 2. If all four grandparents lived to 80, add 6. If either parent died of a stroke or heart attack before the age of 50, subtract 4. If any parent, brother or sister under 50 has (or had) cancer or a heart condition, or has had diabetes since childhood, subtract 3. Do you earn over $50,000 a year? Subtract 2. If you finished college, add 1. If you have a graduate or professional degree, add 2 more. If you are 65 or over and still working, add 3. If you live with a spouse or friend, add 5. If not, subtract 1 for every ten years alone since age 25. Running Total :

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123 Life-Style Status If you work behind a desk, subtract 3. If your work requires regular, heavy physical labor, add 3. If you exercise strenuously (tennis, running, swimming, etc.) five times a week for at least a half-hour, add 4. Two or three times a week, add 2. Do you sleep more than ten hours each night? Subtract 4. Are you intense, aggressive, easily angered? Subtract 3. Are you easygoing and relaxed? Add 3. Are you happy? Add 1. Unhappy? Subtract 2. Have you had a speeding ticket in the past year? Subtract 1. Do you smoke more than two packs a day? Subtract 8. One to two packs? Subtract 6. One-half to one? Subtract 3. Do you drink the equivalent of 1J oz. of liquor a day? Subtract 1. Are you overweight by 50 lbs. or more? Subtract 8. By 30 to 50 lbs.? Subtract 4. By 10 to 30 lbs.? Subtract 2. If you are a man over 40 and have annual checkups, add 2. If you are a woman and see a gynecologist once a year, add 2. Running Total : Age Adjustment If you are between 30 and 40, add 2. If you are between 40 and 50, add 3. If you are between 50 and 70, add 4. If you are over 70, add 5. ADD UP YOUR SCORE TO GET YOUR LIFE EXPECTANCY. Adapted from: Allen, R. F. & Linde, S. Lifegrain . Englewood Cliffs, NJ: Prentice-Hall, Inc., 1983.

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124 Pel 1 etier , K. Mind as healer, mind as slayer . NY: Delta, 1977. Selye, H. Stress without distress . NY: Signet, 1974. Selye, H. The stress of life . NY: McGraw-Hill, 1976. Travis, J. W. & Ryan, R. S. The wel lness workbook . Berkeley, CA: Ten Speed Press, 1981 . SESSION TWO Goals and Objectives 1. To assess factors over which we have no control (age, sex, heredity) and those over which we do have control (weight, habits, blood pressure) . 2. To increase awareness of personality types; to appreciate the differences between individuals; to enhance interpersonal relationships and communication; to define Jung's typology: introversion/extraversion , sensing/perceiving, thinking/feeling, judging/ perception. 3. To increase knowledge of common behavior patterns that relate directly to lifestyle; to define the range of effectiveness and ineffectiveness for Type A/B personalities. 4. To increase awareness and understanding of the difference of between consequences of lifestyle and direct effects of one's behavior (smoking, alcohol and other drugs). 5. To review general indicators of stress, and to identify currently vulnerable systems. Procedures 1. Review CARDIAC BINGO (15 minutes). Note that there are several areas that contribute to vulnerability, specifically age, sex, and heredity. Other factors which contribute to cardiac problems are more directly under our control, and include smoking, weight and blood pressure. 2. Review Stress Indicators (30 minutes). One way to pursue this is to draw the outline of a person, and to illustrate some of the various indicators of stress. Assist the . participants in evaluating which system(s' formerly were activated, and which system(s) are presently activated. If they can recognize the present symptoms, they can begin to recognize the earlier symptoms and deal with them, and/or the circumstances more effectively.

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125 3. Exercise: Discovering Personality (30 minutes). Each participant is to fill out a questionnaire designed to tap the eight preferences measured in the Myers-Briggs Type Indicator. Following individual answers, the group members mix and share answers with one another. The purpose of this exercise is to make participants aware of individual differences, as well as similarities, on a number of dimensions. 4. Looking at Type--Slide presentation (30 minutes). Videotape narrated by a University Counseling Center counselor, with slides prepared from the text by Earl Page. The slides contrast and compare introversion/extraversion, sensing/intuition, thinking/ feeling and judging/perception (available from CAPT, Gainesville, FL' 5. Discussion (15 minutes). Group shares personal examples of instances where MBTI differences enhance or detract from communication. MBTI report forms are explained and each group member is given handouts (available from CAPT) "Effects of Type at Work," "Contributions to Type," and "Understanding the Type Table." 6. Discussion (30 minutes). Group brainstorms all the ways we produce stress through behavior. Examples: Overweight Gambling Alcohol abuse Procrastination Drug abuse Overcommitment Reckless driving Further discussion highlights the various organizations and systems which assist with those behaviors. Examples: Weight Watchers, Overeaters Anonymous, shots, pills, hypnosis, wraps, fad diets, T.O.P.S. and surgical procedures. The alleged purposes of these various treatments, whether or not they give immediate or delayed results, and how much personal and/or collective effort they require is a focus of this discussion. Relaxation Visual imagery—seashore (30 minutes). Available from Counseling Services, Inc., Jacksonville, FL. Homework Assignment Personal Beliefs I Live By Diet Sheets How I Spend my Time How I Would like to Spend my Time Suggested Readings from Textbook Chapter 7 Chapter 9

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126 DISCOVERING DIFFERENCES Those of us participating in this activity have taken the MyersBriggs Type Indicator. Each person has a "type-tag" with the letters of their MBTI-type. We are about to begin a sharing exercise. By asking questions of ourselves, and others, we will try to discover some of the similarities and differences between us. We are going to use an inductive or discovery method to determine the meaning of our profile letters. Sel f Interview Take 5-10 minutes to note your own brief responses to the following questions in the space provided: 1. Do you prefer projects which require you to work alone for long periods of time, or would you rather work on projects with other people? Why? 2. If you were invited to a party where no one knew anyone else, would you go? 3. How do you react to the prospect of a job requiring a regular routine and great patience with, and attention to, facts and details? 4. How do you react to the prospect of a job requiring creative problem solving, imagination, and inspiration? 5. What is the role of impersonal logic and analysis of facts in solving your personal problems? 6. What is the role of feeling and emotion in solving your personal problems? 7. How important is it to be neat and organized in personal habits and to follow a daily plan? 8. Is a deadline a deadline, or a guideline?

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127 Interviewing Others Everyone has a type-tag. Take 1-2 minutes with each person: Find at least two E's and note their response to the following questions (numbers correspond with questions in self interviews): Question #1 : 1 ) 2) Question #2: 1 ) 2) Find at least two I's and note their response to: Question #1 : 1 ) 2) Question #2: 1 ) 2) Find at least two S's and note their response to: Question #3: 1 ) 2) Question #4: 1 ) 2) Find at least two N's and note their response to: Question #3: 1 ) 2) Question #4: 1 ) 2) Find at least two T's and note their response to: Question #5: 1 ) 2) Question #6: 1 ) 2)

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128 Find at least two F's and note their response to: Question #5: 1 ) 2) Question #6: 1 ) 2) Find at least two J's and note their response to: Question #7: 1 ) 2) Question #8: 1 ) 2) Find at least two P's and note their response to: Question #7: 1 ) 2) Question #8: 1 ) 2)

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129 PERSONAL BELIEFS I LIVE BY The following items represent certain beliefs and opinions that we generally hold. If you agree or disagree with an item as it applies to you , indicate the extent of that agreement or disagreement by circl ing the number that best represents your belief. There are no right or wrong answers. Please respond to each item. Disagree Disagree Agree Agree \lery Much Slightly Slightly yery Much 1 2 3 4 5 6 7 1. It is ^jery important to me to be loved by almost everyone I meet. 2. I believe I should be competent at everything I attempt. 3. I believe that there are some people in the world that are bad or wicked. They should be punished for their actions. 4. I become yery upset when things are not the way I want them to be. 5. I bel ieve that most human unhappiness is caused by external factors; that people have little ability to control their own sorrows and disturbances. 6. I am \/ery concerned about things that are dangerous and dwell on the possibil ity of their occurrence. 7. I believe it is better in the long run to avoid some life difficulties and responsibilities than to face them.

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130 Disagree Disagree Agree Agree Very Much Slightly Slightly Very Much 1 2 3 4 5 6 7 8 8. I believe I need another person stronger than mysel f on whom to rely. 9. My past history is an important determinant of my present behavior. Once something strongly affects my 1 ife it will always affect my behavior. 10. I become more upset than I should about other people's problems and disturbances. 11. I believe there is one right solution to any given problem, and if I do not find this solution, I feel I have failed. Adapted from Ellis & Harper, 1975.

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FOOD DIARY 131 (Reduced'

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132 HOW I REALLY SPEND MY TIME >
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133 HOW I WOULD LIKE TO SPEND MY TIME

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134 Facilitator Preparation Anderson, R. A. Stress power . NY: Human Sciences Press, 1978. Friedman, M. & Rosenman, R. H. Type A behavior and your heart . NY: Knopf, 1974. Keirsey, D. & Bates, M. Please understand me . DelMar, CA: Prometheus Nemesis Books, 1978. Kobasa, S. C, Maddi , S. R., & Courington, S. Personality and constitution as mediators in the stress-illness relationship. Journal of Health and Social Behavior, 1981, 22, 368-378. SESSION THREE Goals and Objectives 1. To be introduced to the myths of hypnosis, as well as the actual process and possible uses of hypnosis. 2. To identify irrational ideas held by individuals, and provide an opportunity to restate ideas in a rational manner. 3. To increase effective use of time; to define goal setting, objectives, delegating, prioritizing; short term, intermediate and long term goals; to identify cycles of activity/inactivity. 4. To increase awareness of the relationship between nutrition and stress; to identify individual eating patterns. Procedure 1. Videotape—Hypnosis (60 minutes). Clinical hypnotist lectures on the myths of hypnosis, as well as the uses and benefits of hypnosis. Several case examples are given, and a group demonstration is utilized. Available from Counseling Services, Inc., Jacksonville, FL. 2. Videotape—Nutrition (60 minutes). Registered dietician speaks on the necessity of being personally responsible for recognizing nutritional quackery. The tape and following discussion attempts to promote the consumption of a nutritionally dense diet and to decrease non-nutritious (i.e., junk food) consumption. The group discussion lists ready sources of nutritious foods, from the actual eating patterns recorded during the previous two weeks. Special attention is given to the negative aspects of salt, sugar, fats and refined flour. Available from Counseling Services, Inc., Jacksonville, FL.

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135 One technique is to list on the board columns, (a) Dairy products, (b) Protein, (c) Grains, (d) Fruits and Vegetables, (e) "AUJ-Absolutely Useless Junk. Foods that were recorded on the diet sheets are listed in the appropriate column. Another technique is to "cook" a "healthy" apple pie (it may have a whole wheat crust, extra spices for flavor, fresh apples, deep dish, lattice crust, extra fruit, e.g., raisins, cheese on top). 3. Time Management Discussion (30 minutes). Participants are encouraged to examine the balance of time in their lives. Approximately 1/3 should be devoted to work, 1/3 devoted to home responsibilities, and 1/3 to self development. Participants take a 5 minute exercise in goal setting. Two minutes are spent in writing down all the things one wishes to do in a lifetime (plus one more minute). During the next minute, the three most important of those goals is selected, and then the first (or next) step towards achieving these goals is defined. For example: Travel to Europe (long-term goal) is selected for an intermediate goal, and calling the travel agent or opening a savings account would be a short-term goal. 4. Videotape — Rational Emotive Thinking (60 minutes). In this videotape, participants examine the eleven irrational ideas of R.E.T., and compare it to the results of the Personal Belief Inventory. They will have an opportunity to restate ideas in a rational manner. The lecture provides an opportunity to understand how emotions (Consequences) are controlled by Beliefs about Activating events, and can therefore be changed. The emphasis is on the realization that life is not always fair, we may not be loved by everyone, and that perfection is unattainable. Available from Counseling Services, Inc. , Jacksonville, FL. Relaxation Autogenic Phrases (30 minutes). Available from Counseling Services, Inc., Jacksonville, FL. Homework Assignment My Perfect Day Suggested Readings from Textbook Chapter Three Facilitator Preparation Blanchard, K. & Johnson, S. The one minute manager . NY: William Morrow & Company, Inc., 1 982.

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136 MY PERFECT DAY Describe a perfect day in your life five years in the future.

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137 Ellis, A. & Harper, R. A. A new guide to rational living . North Hollywood, CA: Wilshire Book Co., 1975. Hall, R. H. Whither nutrition. Journal of Holistic Medicine , 1981, 3 (1), 23-29. King, J. C, Cohenour, S. H., Corruccini, C. G. & Schneeman, P. Evaluation and modification of the basic four food guide. Journal of Nutritional Education , 1978, ]_0 (1), 27-29. Kopolow, L. E., & Fried, H. Plain talk—The art of relaxation . Publication No., (ADM) 78-632 Rockville, MD: U. S. Department of HEW, January 1978. Lakin, A. How to get control of your time and your life . NY: Signet, 1973. Peterkin, B. P., Kerr, R. L., & Shore, C. J. Diets that meet the dietary goals. Journal of Nutritional Education , 1978, 1_0 (1), 15-18. Shuman, A. R., Levies, K. J. & Guthrie, H. A. Learner objectives for a nutrition education curriculum. Journal of Nutritional Education , 1978, 1_0 (2), 63-65. Winston, S. Getting organized . NY: Warner Books, 1978. SESSION FOUR Goals and Objectives 1. To increase awareness of a variety of communication theories and techniques. 2. To be able to identify and differentiate between Parent, Adult and Child ego states, and to understand the effectiveness of parallel, adult transactions, and the ineffectiveness of crossed transactions. 3. To differentiate between assertive, non-assertive and aggressive. 4. To increase awareness of the importance of available others in the management of stress; to identify and evaluate the availability of one's present support system; to discuss means of enhancing currentsupport system. 5. To increase knowledge of the relationship between oxygen consumption and oxygen utilization via increased cardio-vascular sufficiency; to increase awareness of one's already-present exercise skills, and to increase awareness of the importance of aerobic exercise. 6. To review life planning homework.

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138 Procedure 1. My Perfect Day (30 minutes). Participants were given a blank sheet titled, "My Perfect Day," and were instructed to write about a realistic, ideal day, projected five years into the future. They are placed in dyads, and encouraged to share, either in part or in full, their ideal day. After 10 minutes, the group reunites, and the facilitator lists on the board the highlighted qualities of the ideal day. The lists usually include: purposeful activity intellectual stimulation adequate rest peace and contentment physically fit freedom quality family time lack of pressure relaxation happiness job satisfaction financial security meaningful relationships with family personally rewarding and creative activities The group then discusses how most of these things are attained, primarily through their own efforts over time. 2. Lecture--Transactional Analysis (30 minutes). A chalk-talk illustrates the ego states of Berne's (1967) Transactional Analysis and is followed by sharing illustrative examples from individual situations. 3. Assertiveness Awareness Exercise (15 minutes). The group is divided into triads, and each person is given at least one chance to communicate in each of the three ways: passively, aggressively and assertively. The facilitator gives a brief situational description, and then person #1 responds assertively, #2 responds aggressively, and #3 responds passively. For the next situation, response positions are rotated. Suggested situations: a. Your supervisor has asked you to stay late, and your son is in Little League Playoffs tonight. b. You are in a restaurant, and it has been 20 minutes since your order was taken, but no food has been served. c. You are in a crowded meeting room and someone nearby is smoking, and the smoke is drifting in your face. 4. Exercise--a great way to go (45 minutes). Participants are asked for the various reasons they exercise, and these are listed on the board. To lose weight To look good in clothes To work off tension To help heart and lungs The facilitator points out that most of these are visible and have rather immediate results, but that the long-term benefits of regular exercise are increased cardio-vascular sufficiency.

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skate

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140 d. any on the list who does not live in (city) e. anyone on the list not seen or talked to in a year; six months; three months. What remains on the list is their support system. The number will vary from to 12-15. It is useful to discuss the fact that everyone has had support systems in the past, and to evaluate the sources (friends, family, work, school, church, special interest groups) in order to renourish support in the present. Relaxation Exercise Fantasy/Walk Through a Rainbow (30 minutes) Available from Counseling Services, Inc., Jacksonville, FL. Homework Assignment The Smiling Dragon Self Descriptors Checklist Suggested Readings from Textbook Chapter 10 Chapter 11 Facilitator Preparation Alberti, R. E. & Emmons, M. I. Your perfect right . San Luis, CA: Impact Publishers, 1970. ~ Bowerman, W. J. & Harris, W. E. Jogging . NY: Grossett & Dunlap, 1967. Cooper, K. H. The new aerobics . NY: Bantam Books, Inc., 1970. Cooper, M. & Cooper, K. H. Aerobics for Women . NY: Bantam, 1972. Di skin, E. Yoga for your leisure years . NY: Wagner, 1978. Harris, T. A., I'm OK— You're OK . NY: Harper Books, 1967. Norbeck, J. S. The use of social support in clinical practice. Journal of Psychosocial Nursing and Mental Health Services , 1982, 20 , (12), 22-29. Satir, V. Peoplemaking . Palo Alto, CA: Science and Behavior Books, Inc., 137Z Stein, L. I. The doctor-nurse game. Archives of General Psychiatry , 1967, 16, 699-703. '

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141 SUPPORT SYSTEMS A support system can be defined as a lifelong need for intimate, trustworthy others to enhance growth and coping; given and received in a relatively stable network of basically healthy relationships; the type and amount of support needed and given is reciprocal, and is individually determined. It is available, adult individuals who sustain and uphold a person, who can then bear the weight of the stress, and take the necessary actions. This is done by people who care, listen, affirm and challenge, both personally and professionally. List below (and on the back if necessary) all the people in your life who have been part of your support system. Go back as far as you can remember, and include friends, family, relatives, teachers, etc.

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142 THE SMILING DRAGON Please keep me smiling! In each of my spots, write in one of your most positive qual ities.

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143 SELF DESCRIPTORS CHECKLIST Circle any of the adjectives below which describe you as you are now. Circle as many or as few as you wish. Attractive

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144 SESSION FIVE Goals and Objectives 1. To increase self awareness of factors involved in job satisfaction/burnout; to identify the inter-dependent needs that jobs meet. 2. To increase self-awareness and understanding of all the aspects of one's personality; to focus on areas that need enhancement for more effective mastery of stress; to introduce the concepts of psychosynthesis and unconditional positive regard as tools for more positive self-concept. 3. To introduce Journal-Keeping as a method of continued personal awareness. Procedures The Smiling Dragon (45 minutes). Each group member will have completed filling in the "spots" on the dragon with his/her good qualities. Some people will find this difficult to do, as they are more accustomed to finding things "wrong" than finding things "right." The group will divide into groups of four, and share their dragons with each other. If there are any members having difficulty in completing their forms, the other group members will be able to help them. This exercise gives participants an opportunity to give feedback to one another, in a trusting, safe environment. When the group returns, feelings are shared about the difficulty that may have been experienced in sharing these good aspects of themselves, and how it felt to have others give them positive feedback. Discussion on Job Satisfaction (45 minutes). The group will list the various things that make a job satisfying. This list will include, among other things, adequate pay professional respect flexible hours social rewards praise friendship challenging opportunity for growth personality fit More discussion will focus on the trade-offs of working, which may include: time spent with family quality of housework time for social activities quantity of housework quality of family activities physically draining work emotionally draining work The discussion will point out that there are both positive and negative aspects to working, and that these are considerations when selecting a career.

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145 3. Self-Concept Exercise (45 minutes). Participants completed the Self Descriptors Checklist as homework, marking as many of the adjectives as applied to themselves. At this point, the facilitator introduces the concepts of IDEAL, REAL and PERCEIVED self and explores the various sources of self concept (peers, family, institutions). The members write down which of those descriptors fit into which category, and how they might wish to change those self concepts. For example, "gullible" might be both part of their real and perceived self concepts, yet not their ideal self concept. Another example is that "peaceful" is part of their ideal and perceived concept, but they do not truly perceive themselves as peaceful. 4. Psychosynthesis Exercise (35 minutes). Each member is given a blank sheet of paper with an "I" encircled in the middle. She is then told that now she will look at a total picture of herself. The sections of this picture may include roles, personality preferences, habits, and any qualities that she possesses. The pictures tend to become somewhat like a kaliedoscope or mosaic, but may be flower petals, lists or mandalas. This is one of the most peaceful tools in this course. Following this exercise, a discussion is led into the value of writing, or keeping a journal. Participants are reminded that they have been keeping various types of journals throughout this course, and are encouraged to keep all these materials in a notebook, with dated entries, and to continue to work on the areas of most interest to them. Relaxation Exercise Wise Old Person/Meditation Tape (30 minutes). Available from Counseling Services, Inc., Jacksonville, FL. Homework Assignment None Suggested Readings from the Textbook None. Participants are given a lengthy bibliography for future use. Facilitator Preparation Assagioli, R. Psychosynthesis--A collection of basic writings . New York: Penguin Books, 1965. Hagan, D. Q. The relationship between job loss and physical and mental illness. Hospital and Community Psychiatry, 1983, 34_ (5), 438-441 .

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146 3. Self-Concept Exercise (45 minutes). Participants completed the Self Descriptors Checklist as homework, marking as many of the adjectives as applied to themselves. At this point, the facilitator introduces the concepts of IDEAL, REAL and PERCEIVED self and explores the various sources of self concept (peers, family, institutions). The members write down which of those descriptors fit into which category, and how they might wish to change those self concepts. For example, "gullible" might be both part of their real and perceived self concepts, yet not their ideal self concept. Another example is that "peaceful" is part of their ideal and perceived concept, but they do not truly perceive themselves as peaceful. 4. Psychosynthesis Exercise (35 minutes). Each member is given a blank sheet of paper with an "I" encircled in the middle. She is then told that now she will look at a total picture of herself. The sections of this picture may include roles, personality preferences, habits, and any qualities that she possesses. The pictures tend to become somewhat like a kaliedoscope or mosaic, but may be flower petals, lists or mandalas. This is one of the most powerful tools in this course. Following this exercise, a discussion is led into the value of writing, or keeping a journal. Participants are reminded that they have been keeping various types of journals throughout this course, and are encouraged to keep all these materials in a notebook, with dated entries, and to continue to work on the areas of most interest to them. Relaxation Exercise Wise Old Person/Meditation Tape (30 minutes) Homework Assignment None Suggested Readings from the Textbook None Facilitator Preparation Assagioli, R., & Van de Riet, V. Introduction to psychosynthesis . New Frontiers in Counseling: Accountability through Credibility, workshop presented at Gainesville, Florida, February 10-12, 1977. Hagan, D. Q. The relationship between job loss and physical and mental illness. Hospital and Community Psychiatry , 1983, 34_ (5). 438-441 . "' " ~

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147 Horney, K. Our inner confl icts . NY: W. W. Norton and Co., 1945. Horney, K. Self analysis . NY: W. W. Norton and Co., 1942. LaRocco, J. M. , House, J. S., & French, J. R. P. Social support, occupational stress and health. Journal of Health and Social Behavior , 1980, 2]_ (9), 202-218. Maslow, A. H. Motivation and personality , NY: Harper and Row, 1954, 1970. Progoff, I. At a journal workshop . NY: Dialogue House, 1975. Super, D. The psychology of careers: An introduction to vocational development. NYl Harper, 1957.

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148 NUTRITION BIBLIOGRAPHY Abrahamson, E. M. , & Pezet, A. W. Body, mind and sugar . New York: Pyramid, 1975. Airola, P. Are you confused? Phoenix, Arizona: Health Plus, 1971. Baggs, A. E. Cooking without a grain of salt . New York: Bantam, 1954. Baggs, A. E. Calories and Carbohydrates . New York: Grosset & Dunlap, 1979. Chera.sk/ih., E. , Ringsdorf, W. , & Brecher, E. Psychodietetics . New York: Bantam, 1974. Davis, A. Let's eat right & keep fit . New York: Harcourt Brace Javonvich, 1970. Davis, A. Let's stay healthy . New York: Harcourt Brace Jovonvich, 1981. Dufty, W. Sugar blues . New York: Warner, 1975. Ford, F. The Simpler life cookbook . Ft. Worth, TX: Harvest Press, Inc., 1 974 , 1981. Frederiks, C. Low blood sugar and you . New York: Grosset & Dunlop, 1959. Hall, H. Whither nutrition. Journal of Holistic Medicine , 1981. Lappe, F. M. Diet for a small planet . New York: Ballentine, 1975. McGill, M. & Pye, 0. The no-nonsense guide to food and nutrition . New York: Butterick, 1978. Williams, R. J. Nutrition in a nutshell . New York: Doubleday, 1962.

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149 EXERCISE BIBLIOGRAPHY Bailey, C. Fit or Fat? Boston: Houghton Mifflin Co., 1978. Cooper, K. H. The new aerobics . New York: Bantam, 1970. Copper, M. , & Cooper, H. Aerobics for women . New York: Bantam, 1972. Dechanet, J. Yoga in ten lessons . New York: Coverstone Library/ Simon & Schusta, Inc. , 1973. Diskin, E. Yoga for your leisure years . New York: Warner, 1978. Friedman, B. J., & Knight, K. American Journal of Nursing , April 1978. Morehouse, L. E. , & Gross, L. Total fitness in 30 minutes a week . New York: Simon & Schusta, 1 971T! Ullyot, J. Women's running . Mountainview, CA: World Publications, 1976.

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150 PERSONAL AWARENESS AND COMMUNICATION BIBLIOGRAPHY Berne, E. Games people play . New York: Grove, 1964. Berne, E. What do you say after you say hello? New York: Bantam, 1972. Bloom, L. , Coburn, K. , & Pearlman, J. The new assertive woman . New York: Delacorte Press, 1975. Casewit, C. The diary: A complete guide to journal writing . Allen, TX: Argus Communications, 1982. Col grove, M. , Bloomfield, H., & McWilliams, P. How to survive the loss of love . New York: Bantam Books, 1976. Dowling, C. The Cinderella complex . New York: Pocket Books, 1981. Dyer, W. Pulling your own strings . New York: Avon Books, 1978. Ellis, A. & Harper, R. A new guide to rational living . North Hollywood, CA: Wil shire Book Company, 1975. Harris, T. A. I'm 0K--You're OK . New York: Harper, 1967. Jakubowski , P., & Lange, A. The assertive option . Champaign, Illinois: Research Press, 1978. James, M. , & Jongward, D. Born to win . Reading, MA: Addison Wesley, 1971. James, M. Breaking free . Reading, MA: Addison Wesley, 1981. James, M. Marriage is for loving . Reading, MA: Addison Wesley, 1981. Leshan, L. How to meditate . New York: Bantam Books, 1974. Peck, S. The road less traveled . New York: Simon & Schuster, 1978. Progoff, I. At a journal workshop . New York: Dialogue House Library, 1975. Rainer, T. The new diary . Los Angeles: JP Tarcher, Inc., 1978. Satir, V. Peoplemaking . Palo Alto, CA: Science & Behavior, 1972. Sheeny, G. Passages . New York: Bantam Books, 1978. Sheehy, G. Pathfinders . New York: Bantam Books, 1978. Shostrom, E. Between man and woman. New York: Bantam, 1972.

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151 Shostrom, E. Freedom to be . New York: Bantam Books, 1972. Simons, G. Keeping your personal journal . New York: Paulist Press, 1978. Smith, M. When I say no I feel guilty . New York: Bantam Books, 1972. Smith, M. Kicking the fear habit . New York: Bantam Books, 1977. Stearns, A. K. Living through personal crisis . Chicago: Thomas More Press, 1978. Viscott, D. How to live with another person . New York: Arbor House, 1974. Viscott, D. Risking . New York: Simon & Schuster, 1979. Viscott, D. The language of feelings . New York: Pocket Books, 1977. Watts, A. The book on the taboo against knowing who you are . New York: Co 1 1 i er Books, 1966. Wood, J. How do you feel: A guide to your emotions . Engelwood Cliffs. NJ: Prentice-Hall , Inc. , 1974.

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152 STRESS BIBLIOGRAPHY Anderson, R. A. Stress power . New York: Human Sciences Press, 1978. Benson, H. The relaxation response . New York: Avon, 1975. Brown, B. New mind, new body . New York: Bantam Books, 1974. Cox, T. Stress . Baltimore: University Park Press, 1978. Dudlely, D. , & Welke, E. How to survive being alive . New York: Doubleday, 1977. Friedman, M. , & Rosemann, R. Type A behavior and your heart . New York: Knopf, 1974. Girdano, D., & Everly, G. Controlling stress and tension—a holistic approach . Englewood Cliffs., NJ: Prentice-Hall , 1979. Kraus, H. Backache, stress and tension . New York: Simon & Schuster, Madders, J. Stress and relaxation . Scarborough, Ontario, Canada: Prentice Hall of Canada, Ltd., 1979. McQuade, W. , & Aikman, A. Stress . New York: Bantam Books, 1974. 01 sen, K. How to hang loose in an uptight world . Parrino, J. J. From panic to power, the positive use of stress . New York: John Wiley & Sons, 1979. Pelletier, K. R. Mind as healer, mind as slayer . New York: Delta, 1977. Selye, H. Stress without distress . New York: Signet, 1974. Selye, H. The stress of life , revised edition. New York: McGraw-Hill, 1976. Sharpe, R., & Lewis, D. Thrive on stress . Andersonvil le, IN: Warner, 1977. Snider, A. J., & Oparil, S. A doctor discusses hypertension . Chicago: Budlong Press, 1976. Wool folk, R. L., & Richardson, F. C. Stress, sanity and survival . New York: New American Library, 1978.

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153 TIME MANAGEMENT BIBLIOGRAPHY Blanchard, K. & Johnson, S. The one minute manager . New York: William Morrow & Company, Inc. , 1 982. Davidson, J. Effective time management . New York: Human Sciences Press, 1973": Douglas, M. E., & Douglas, D. N. Manage your time, manage your work, manage yourself . 1980. Lakin, A. How to get control of your time and your life . New York: Si gnet, 1973. Winston, S. Getting organized. New York: Warner Books, 1978.

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APPENDIX E COURSE EVALUATION FORM AND COMPLETE SUMMARY

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155 COURSE EVALUATION 1. This course was personally relevant: of 1 ittle quite relevance relevant 12 3 4 5 6 2. This course was professionally relevant: of little quite relevance relevant 12 3 4 5 6 3. I would recommend this course to others: would not without recommend reservation 12 3 4 5 6 4. The most important thing I (re)learned was: 5. Other important things I (re)learned were: 6. We could have spent less time on: 7. I would like to have spent more time on: 8. To improve the course next time: 9. Changes I intend to make in my lifestyle are:

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156 EVALUATION SUMMARY 1. This course was personally relevant: 5.6 2. This course was professionally relevant: 5.5 3. I would recommend this course to others: 5.8 4. The most important thing I (re)learned was: time management skills; self-awareness; the relaxation techniques; the need to take care of myself; the most important thing I learned was how to relax and the importance of breaking the stress cycle daily (using General Adaptation Syndrome as a guage or chart in my thought patterns); to stress the positive, but keep working on the negative; how to relax; that I control me, my life, my circumstance; that I create much of my own stress; relaxation techniques, put them back into practice; I am a unique, important person, with a lot to offer this life; that you are not "bad" if you refuse to take on more than you can reasonably handle; how to be assertive; I cannot change others--that only increases stress; my personality profile—I'm basically an efficient, positive person— I thought I was lazy— I'm more of a perfectionist than I realized; personality type and relaxation techniques; I must live with my job— think of myself first (for a change); get my health on an even line by more exercise and diet for my medical problems; how to relax; how badly I'm ruining my health; others can't make me do things — feel things; how difficult it is for me to identify my feelings — I tend to be (n)either high or low (up or down) most of the time; how to cope; my own stressors. 5. Other important things I (re)learned were: personality categories — body relaxation; ways to control my emotions; how to say "no" when I feel over-extended — how to fix goals for my remaining lifetime— how to feel more positive about me; the need to write my feelings and deal with them; importance of exercise— realized the importance of putting my needs first some of the time— so I can be more to others— importance of goalsetting— not to worry about what we cannot change— seeing myself, with all my facets, and that some of what I considered negative has a purpose— ex. bitchy self for car problems; the use of different focal points for concentration to relax— how to effectively assess your progress-time management; time management— assertiveness ; to increase my awareness of my attitude— knowing I can change only me— to take care of me first and that I don't depend on anyone else for happiness or sadness— just me; I can enhance my physical and emotional well-being with good coping (stress management); management of stress-the ways to effectively decrease stress; I have learned to recognize my stressors and how to deal with them— how to manage my time more effectively— and relaxation techniques;

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157 beginning steps to relaxation (hopefully will increase ability) — how I irritate others unknowingly--to look at a problem and decide whether it's my problem or belongs to the other party involved— other people feel as miserable as I; how to be relaxed; I need to take time to relax--my husband cannot be my only support system— I need others--my diet is inadequate; order of priorities and "dividing self"; I'm more important than anyone or anything—do not let my worries take me over; no response; not to get so upset over various things — not to worry so much—say "no" more often— should "moderate" more; what personality type I am— how to relaxhow to budget time; that I could teach this course and would enjoy doing so; that I'm not so bad after all — I understand better why I think the way I do; how to deal with stress through diet and exercise. 6. We could have spent less time on: I can't think of anything; relaxing; I wouldn't have wanted to spend less time on anything; diet— Rational Emotive Thinking; testing; I didn't feel like we spent too much time on anything; diet; listening to some boring repetitions of others' problems; the last tape (meditation) which I found irritating; ? diet (was boring); nothing; nutrition; no response; diet; I felt all was relevant; nutrition and exercise; paperwork ?; nutrition; no response; nothing; Myers-Briggs ; nutrition— only because it is boring to me, even though I know it probably is vitally important to me— it probably is one of the next subjects I need to explore; I feel that all my time was well spent. 7. I would like to have spent more time on: time management— body relaxation— follow-up of our class or an advanced— Part II would be great; understanding people and class discussions; I think time budgeting could have been discussed a little more; relaxation techniques— class discussions; specific nutritional information— 1 ike how sugar interferes with vitamin absorption; hypnosis; hypnosis; pretty much the whole class--I enjoyed all of the instruction and the instructor— time management; relaxation techniques — explain more about hypnosis— time management; time management; personality types; I would like to have spent more time on diets; theories of stress and response; planning my meals and being more efficient in time management; behavior modification; relaxing—learning the techniques; no response; no response; hypnosis (would like to know more about this and biofeedback); exercise and nutrition — loved the homework and lots of handouts; can't think of anything; individual problems. 8. To improve the course next time: weekly for a shorter period of time—every two weeks was too hard to anticipate and too easy to forget and put off homework; better facilities; I think the next course should be held every week;

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158 better relaxation facilities—more organization; I would like to see biofeedback demonstrated in class, and more decision-making skills incorporated; more relaxation techniques and better facilities to use to relax in; more hours/classes together; to improve the next course—longer with more relaxation time; more feedback on tests--maybe a price increase to include individual counseling session on results; different and more relaxation techniques; be a little more organized—have weekly; make tapes available for purchase so that participants can obtain a copy of the one they found most effective; I would suggest to put in more time-instead of every two weeks, make it one day a week; relaxation response — learning how to; more practical theories and education; outline of course to start— more group discussion of problems we have— I think sharing is important to all of us; no response; no response; cut down tape on nutrition from girl at St. Vincent's— was a little too long; more time for follow-up on homework and more general class sharing; I will probably attend; I would come to an early morning class. 9. Changes I intend to make in my lifestyle are: try to anticipate stress situations in advance and be prepared to handle them better— be more tolerant of other personality types and be aware that they can't help their weaker traits — plan and schedule ahead so as not to have panic baking, shopping, etc.— practice saying NO; go back to school— have more fun--relax morelove each day; take more time out for me— try to be more understanding—patient—helpful—loving with Ericka and Bill — be a better wife and mother in looking for more ways to help or fill the needs of my family; live one day at a time—get out of the pastlose weight— quit smoking; more exercise (regular)--eat less sugar and fats— relax daily— distinguish between what I can change and can't change; more exercise— more time in evaluating my life and its direction— more time using hypnosis tapes for relaxation; lose weight — more exercise—more assertive; decrease stress to my most manageable level — increase my running distance and speed — run 1-2 marathons in 1984— depend on me for my own happiness and learn to enjoy those around me—be less affected by material possessions— stay outside as much as possible and enjoy all outside; making more time for myself—exercise routine—not allowing others to be a constant source of misery to me— seeking some counseling in dealing with family problems — relaxation; keep up exercise programs— improve nutrition (lose 6 more pounds for goal) — plan more time out for "me"; I am going to become my own person again — not who I think others want me to be— I am going to take time out for myself and for enjoying the time I have left with my children— I am going to take time for relaxation daily to increase my effectiveness and enjoyment in all aspects of my life-I am going to learn to accept my husband for the wonderful person he is, rather than unforgiving of things that annoy me; try to say "no" — try not to feel guilty— put me on my priority list— get more exercise; ;stop smoking or at least stop feeling guilty about it; set short-term goals — try to enjoy

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159 myself more--try to grow old gracefully; try to increase exercise-try not to overreact in situations over which I have no control; notice when I'm reacting to stress and learn to head it off— spend more time nurturing my relationship with my husband--keep exercises as a routine part of my life; exercise — nutrition — self control; I'm No. l--don't let my job rule me--work on my health problems— learn to re!ax --pray to God this all works; no response; not to get as upset over piddling, inconsequential thingsexercise more—spend more time on myself— say "no"— moderate (not to try to do it "all"); increase exercise— relax more often— recognize stress factors and NOT eat stress off 1 '.--hoi ler at kids less— not take stress out on them; continue with feelings sheets— re-start diet sheets— actually sensible eating sheetsgreater involvement with others in my leisure time; mix— have a tendency to stay at home now— make some new friends — start doing ceramics again— lose weight— walk; more relaxation.

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APPENDIX F DEMOGRAPHIC DATA Name: +J

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APPENDIX G KNOWLEDGE AND AWARENESS QUESTIONNAIRE NAME For the pretest, please circle the number which represents your assessment of how much you know and/or are aware of the concepts enumerated. For the posttest, please indicate your choice with an "X." 1 . How much do you know about the theories of stress? 2. How much do you understand about how stressors affect you? 3. How much do you know about the various physiological indications of stress? 4. How well can you identify your specific physical responses to stress? 5. How much do you know about the various behavioral indications of stress? 6. How well do you control your stressful behaviors? 7. How much do you know about relaxation and meditation? 8. How effectively can you relax your body? 9. How much do you know about the relationship of job satisfaction and stress? 10. How stressful do you consider your job? 11. How well satisfied are you with your job? 12. How much do you know about the relationship between personal control and stress? 13. How much control do you have in your own circumstances? Least Most 2 3 4 5 6 7 8 9 10 23456789 10 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 23456789 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 10 161

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162 14. How much do you know about time management? 15. How effective are your time management skills? 16. How much available time is spent in sel f-nuturing? 17. How much do you know about support systems? 18. How effective is your support system? 19. How much do you understand about various personality preferences in others? 20. How well do you understand your own personality preferences? 21. How stress producing is your own personality? 22. How much do you know about the components of self-concept? 23. How adequate is your selfconcept? 24. How much do you know about the various ways we communicate? 25. How effective are your communication skills? 26. How much do you know about the relationship between diet and nutrition and stress? 27. How nutritionally adequate is your diet? 28. How much do you know about the relationship between exercise and stress? 29. How adequate is your exercise program? Least Most 23456789 10 2 3 4 5 6 7 8 9 10 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 23456789 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 23456789 10

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APPENDIX H INFORMED CONSENT University of Florida Committee for the Protection of Human Subjects I understand that this study is seeking to improve stress mastery skills. I agree to be a member of the treatment group for a period of ten weeks. I further understand that I will be taking some paper-and-pencil tests which will be used in the evaluation of this study. The results of these tests will be treated as confidential material, and will be available to no one other than the principal investigator and myself. At all times confidentiality will be maintained. Results will be anonymous during analysis. I will receive no monetary compensation (payment) for participating in this study, and my participation is purely voluntary. If I should decide to drop out of the study for any reason, at any time, I may do so without penalty. If I have questions about the study or the procedures, the principal investigator will answer them. If I complete the course, I will receive approved continuing education credit hours, which may be applied toward renewal requirements for my Florida nursing license. I have read and I understand the procedure described above. I agree to participate in the procedure and I have received a copy of this description. Signatures: Subject ~" ~~ Date Witness Date Principal Investigator: Nancy H. Patterson 7555 Beach Boulevard, #231 Jacksonville, FL 32215 Phone: 904/724-6744 153

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APPENDIX I INFORMED CONSENT University of Florida Committee for the Protection of Human Subjects I understand this study is using registered nurses in the treatment group. I agree to be a member of the control group for a period of ten weeks. I further understand that I will be taking some paper-and-pencil tests which will be used in the evaluation of this study. The results of these tests will be treated as confidential material, and will be available to no one other than the principal investigator and myself. At all times confidentiality will be maintained. Results will be anonymous during analysis. I will receive no monetary compensation (payment) for participating in this study, and my participating is purely voluntary. If I should decide to drop out of the study for any reason, at any time, I may do so without penalty. If I have questions about the study or the procedures, the principal investigator will answer them. I have read and I understand the procedure described above. I agree to participate in the procedure and I have received a copy of this description. Signatures : Subject '" Date Witness "" " " Date Principal Investigator: Nancy H. Patterson 7555 Beach Boulevard, #231 Jacksonville, FL 32216 Phone: 904/724-6744 164

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REFERENCES Abrahamson, E. M. , & Pezet, A. W. Body, mind and sugar . New York: Rinehart, 1971. ' '"" " Aiken, L. M. (Ed.). Nursing in the 1 980's--Crisis--opportunitieschallenges . Philadelphia: J. B. Lippincott Co., 1982. Airola, P. Are you confused? Phoenix, Arizona: Health Plus, 1971. Alberti , R. , & Emmons, M. I. Your perfect right. San Luis, CA: Impact Publishers, 1970. Alberti, R. E. , & Emmons, M. I. Stand up, speak out, talk back: The key to assertive behavior . New York: Pocket Books, 1975. Allen, T. W. Physical health: An expanding horizon for counselors. Personnel and Guidance Journal , 1977, 56 (1), 40-43. Allport, G. Becoming: Basic considerations for a psychology of personality . New Haven: Yale University Press, 1955. Anastasi, A. Psychological testing , 3rd Edition. New York: Macmillan Company, 1 968. Anderson, R. A. Stress power . New York: Human Sciences Press, 1978. American Pharmacy . Exercise, one way to cope with stress, 1979, 19 (9), 17. Armstrong, R. L. Hypotheses: Why? when? how? Phi Delta Kappan , 1974, 56, 213-214. Assagioli, R. Psychosynthesis--A collection of basic writings . New York: Penguin Books, 1965. Augsberger, C. Caring enough to forgive, caring enough to not forgive . Scottdale, PA~! Herald Press, 1981. 165

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166 Baggs, E. W. Cooking without a grain of sal t. New York: Bantam, 1964. Bakan, D. The duality of human existence. Boston: Beacon Press, 1966. ~~ Bandler, L. C. They lived happily ever after . Cupertino, CA: Meta Publications, 1978. Bandura, A., & Walters, R. H. Social learning and personality development . New York: Holt, Rinehart and Winston, 1963. Belar, C. D. Stress management of chronic pain. Journal of the Florida Medical Association , 1980, 67_ (5), 487^WL Benson, H. The relaxation response . New York: Avon, 1975. Berg, M. J. Tune in, turn on, drop out? A look at burnout. Imprint, 1980, 27_ (4), 11-24. Berne, E. What do you say after you say hello? New York: Bantam, 1972. " Bernstein, L., Turrell, E. S., & Dana, R. H. Motivation for nursing. Nursing Research , 1965, 1_4 (3), 222-226. Blanchard, K. , & Johnson, S. The one-minute manager . New York: William Morrow and Company, Inc. , 1982. Blattner, B. Holistic nursing . Englewood Cliffs, NJ: PrenticeHall, Inc., 1981. Blocher, D. H. Developmental counseling . New York: The Ronald Press Company, 1966. Bloom, L., Cogburn, K. , & Pearlman, J. The new assertive woman . New York: Delacorte Press, 1976. Bolles, R. N. What color is your parachute ? Berkeley, CA: Ten Speed Press, 1 977" ~ Bowerman, W. J., & Harris, W. E. Jogging . New York: Grossett & Dunlap, 1967. Boyles, P. G. Planning better programs . The Adult Education Association professional development series . New York: McGraw-Hill Book Co., 1981. Branden, N. The psychology of self-esteem . New York: Bantam Books, Inc., 1969": Branden, H. The disowned self . New York: Bantam Books, Inc., 1971. Brenner, M. H. Mental illness and the economy . Cambridge: Harvard University Press, 1973.

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167 Brenner, M. H. Estimating the social costs of national economic policy . A study prepared for the Joint Economic Committee, U. S. Congress, 1976. Campbell, J. The relationship of nursing and self-awareness. Advances in Nursing Science , 1980, 2 (4), 15-25. Caplan, G. The theory and practice of mental health consultation . New York"! Basic Books, 1970. Caplan, G. Mastery of stress: Psychosocial aspects. American Journal of Psychiatry , 1981, 138 (4), 413-420. Carkhuff, R. R. , & Truax, C. B. Lay mental health counseling. Journal of Consulting Psychology , 1965, 2_9, 426-431. Chariff, K. , Duke, J., Level, D. , & Smith, L. The relationships of the variables job satisfaction, locus of control, and role ambiguity among medical-surgical staff registered nurses . Unpublished Master's Thesis, University of South Carolina, Columbia, April 1980. Cheraskin, E. , Ringsdorf, W. M., & Brecher, A. Psychodietetics . New York: Bantam, 1974. Churchill, R., & Crandall, V. J. The reliability and validity of the Rotter Incomplete Sentences test. Journal of Consulting Psychology , 1955, 1_9 (5), 345-350. Claus, K. , & Bailey, J. T. Living with stress and promoting wellbeing. St. Louis, Missouri : C. V. Mosby Company, 1980. Cleland, V. S. The effect of stress on performance. Nursing Research, 1965, H (4), 292-299. Cobb, S. Social support as a moderator of life stress. Psych omatic Medicine , 1976, 38_, 300-314. Cohen, H. A. The nurses' quest for a professional identity . Menlo Park, CA: Addison-Wesley Publishing Company, 1981. Cohen, H. A., & Orlinsky, N. Work stress on critical care units. The Journal of Emergency Medical Services , 1977, 6_ (1), 31-37. Cohen, J. B. Health care, coping and the counselor. Personnel and Guidance Journal , 1978, 56_ (10), 616-620. Combs, A., & Snygg, D. Individual behavior . New York: Harper and Brothers, Publishers, 1949. Connolly, S. G. Changing expectancies: A counseling model based on locus of control. Personnel and Guidance Journal, 1980, 59 (3), 176-180.

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168 Cooper, K. H. T he new aerobics . New York: Bantam Books, Inc., 1970. Cooper, M., & Cooper, K. H. Aerobics for women . New York: Bantam, 1972. Cox, J. G. Loneliness: Its physical effects with college students . Paper presented at APGA National Convention, Washington, DC, April, 1983. Cropley, A. J., & Dave, R. H. Lifelong education and the training of teachers . New York: Pergamon Press, 1978. Daly, N. Andragogy: Implications for secondary, and adult educational programs , 1980, ED 186 627. Dave, R. H. (Ed.). Foundations of lifelong education . New York: Pergamon Press, 1976. Davidson, J. Effective time management . New York: Human Sciences Press, 1978. Davis, A. Let's cook it right . New York: Signet Books, 1970. Davis, A. Let's eat right to keep fit . New York: Signet Books, 1970. Desmond, T. Employee assistance program training program . New Brunswi ck, NJ: Johnson & Johnson, 198'Z. DeVries, H. A. Physiology of exercise for physical education and athletes . Dubuque, Iowa: W. C. Brown Co. , 1974. Dewey, J. Democracy and education . New York: Macmillan, 1916. Dicaprio, N. S. Personality theories—Guides to living . Philadelphia: W. B. Saunders Company, 1974. Dilley, J. Self-help literature: Don't knock it till you try it. Personnel and Guidance Journal , 1978, 56 (5) 293-295. Diskin, E. Yoga for your leisure years . New York: Wagner, 1978. Dohrenwend, B. S., & Dohrenwend, B. P. (Eds.). Stressful life events : "* Their nature and effects . New York: Wiley & Sons, 1979. Donnelly, G. F. How do I know I'm on the right track? RN, 1980(a), 43 (8) 44-46. — Donnelly, G. F. Progressive relaxation? But . . . that sounds like work! RN, 1980(b), 43 (7), 34-36. Donnelly, G. F. Relax? That's easy for you to say! RN, 1980(c), 43 (6), 75-80.

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169 Donnelly, G. F. Remember . . . you're not in this alone! RN, 1980(d), 43 (7), 30-33. ~~ Draves, B. Teaching free: An introduction to adult learning for volunteer and part-time teachers . Manhatten, KS: The Free University Network, 1976, ED 175 297. Dufty, W, Sugar blues . New York: Warner Books, 1975. y Edelwich, J., & Brodsky, A. Burnout--Stages of disillusionment in the helping professions . Human Sciences Press, 1980. Edwards, P. B., & Bloland, P. A. Leisure counseling and consultation. Personnel and Guidance Journal , 1980, 58 (6), 435-440. Ellis, A., & Harper, R. A. A new guide to rational living . North Hollywood, CA: Wil shire Book Company, 1975. English, D. Effectiveness of a stress reduction training program for women. American Mental Health Cou n selo rs Association Journal, 1983, 5_ (4), 148-155. Erikson, E. H. Identity, youth and crisis . New York: Norton, 1950. Farris, C. Time and life management . Workshop sponsored by the Chamber of Commerce, Jacksonville, Florida, December, 1982. Fitts, W. H. The self concept and situational reactions. The sel f concept and psychopathology . Nashville: Counselor Recordings and Tests, 1972. Flynn, D. W. Investigation of differences in levels of facilitative conditions between beginning and graduating nursing students . Unpublished Master's thesis. Case Western Reserve University, Cleveland, Ohio, August 1975. Flynn, P. A. R. Holistic health—The art and science of care . Bowie, Maryland: Robert J. Brady Co., 1980. Forbes, R. Corporate stress: How to manage stress and make it work for you . New York: Doubleday, 1979. Foulds, M. L. Changes in locus of internal-external-external control: A growth experience. Comparative Group Studies , 1976, 2, 293-300. Frain, M. , & Valija, T. The multiple dimensions of stress. Topics in Clinical Nursing , 1979, 1_ (1), 43-53. Frankl , V. The unconscious god . New York: Simon & Schuster, 1975.

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173 LaRocco, J. M., House, J. S. , & French, J. R. P. Social support, occupational stress and health. Journal of Health and Social Behavior , 1980, 21_, 202-218. Lazarus, R. S. Little hassles can be hazardous to health. Psychology Today , July 1981, pp. 58-62. Lazarus, R. S. Psychological stress and the coping process . New York: McGraw-Hill Book Company, 1966. Lefcourt, H. M. (Ed.). Research with the locus of control construct . New York: Academic Press, 1981. Leininger, M. M. (Ed.). Caring--An essential human need . Thorofare, NJ: Charles B. Slack, Inc. , 1981. Levenson, H. Distinctions within the concept of internal-external control: Development of a new scale. Proceedings of the 80th Annual Convention of the APA , 1972, 1_, 261-262. Levenson, H. Perceived parental antecedents of internal, powerful others and chance locus of control orientations. Developmental Psychology , 1973, 9 (2), 260-265. " Liem, J. H., & Liem, R. Life events, social supports, and physical and psychological well-being . Paper presented at APA, Washington, DC, 1976. Lindbloom, G. , & Faw, T. T. Three measures of locus of control: What do they measure? Journal of Personality Assessment , 1982, 46(1), 70-71. Lindner, A. E. (Ed.). Emotional factors in gastrointestinal illness (Roche Medical Monograph Series). London : Medical Foundation, 1973. Lorimer, R. J., Justice, B., McBee, G. W. , & Weinman, M. Weighting events in life-events research. Journal of Health and Social Behavior , 1979, 20, 306-308. Lukens, L. G. Personality patterns and choice of clinical nursing specialization. Nursing Research , 1965, H (3), 210-221. Luthe, W. (Ed.). Autogenic therapy. New York: Grune & Stratton, 1969. Lynch, J. J. The broken heart: The medical consequences of loneliness in America . New York: Basic Books, 1977. Madders, J. Stress and relaxation . Scarborough, Ontario, Canada: Prentice-Hall of Canada, Ltd., 1979.

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174 Mannino, F. V., MacLennan, B. W. , & Shore, M. F. The practice of mental health consultation. New York: Gardner Press , Inc. , T57F: Martin, H. W. , & Prange, A. J. The stages of illness-Psychosocial approach. Nursing Outlook , 1962, ^0 (30), 168-171. Maslach, C. Burned out. Human Behavior , 1976, 5_, 16-22. Maslow, A. H. Motivation and personality . New York: Harper & Row, 1954, T9TW. Masuda, M. , & Holmes, T. H. Magnitude estimations of social readjustments. Journal of Psychosomatic Research , 1967, 11, 219225. ~~ Mazzati , D. S. Secrets from the golden door . New York: William Morrow & Co. , 1977. McCaulley, M. Relationship of psychological type to dropout in nursing GainesvilleTTTi CAPT, 1967. McCaulley, M. Application of the MBTI to medicine and other health professions" Gainesville, FL: CAPT, 1977. McQuade, W. , & Aidman, A. Stress . New York: Bantam Books, 1974. Menninger, R. W. Coping with life's strains. U. S. News and World Report , May 1, 1978, 80-83. Michaels, D. R. Too much in need of support to give any? American Journal of Nursing , 1971, 71_ (10), 1932-1935. Miller, D. I. Characteristics of graduate students in four clinical specialties. Nursing Research , 1965, 1_4 (2), 106-113. Miller, M. J. Cantaloupes, carrots, and counseling: Implications / of dietary interventions for counselors. Personnel and Guidance Journal , 1980, 58 (6), 421-424. ' Moustakas, C. E. Loneliness . New York: Prentice-Hall, Inc., 1961. Murphy, M. M. Stress management classes—A health promotion tool. The Canadian Nurse , 1981, 77_ (6), 29-31. Murray, R. B., & Zentner, J. P. Nursing assessment and health promotion through the life span . Englewood Cliffs, NJ: PrenticeHall , Inc., 1979. Myers, I. B. Introduction to type . Gainesville, FL : CAPT, 1962. Myers, I. Gifts differing . Palo Alto, CA: Consulting Psychologists Press, T9~8TT

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175 National Training Laboratory Institute. Social change: Ideas and applications , 1978, 8 (4). _ Norbeck, J. S. The use of social support in clinical practice. Journal of Psychosocial Nursing and Mental Health Services , 1982, 20 (12), 22-29. Nowicki, S. Personality correlates on the Norwicki-Strickland locus of control scale for adults. Psychological Reports , 1973(b), 33, 267-270. Nowicki, S., & Duke, M. A locus of control scale for non-college as well as college adults. Journal of Personality Assessment , 1974, 38, 135-137. Nowicki, S. Internal vs. external control in reinforcement and reaction to frustration. Journal of Personality and Social Psychology , 1973(a), 25_, 3^W. Nowicki, S. , & Strickland, B. R. A locus of control scale for children. Journal of Consulting and Clinical Psychology , 1973, 40, 148-155. Nuckolls, K. B., Cassel , J., & Kaplan, B. H. Psychosocial assets, life crisis, and prognosis of pregnancy. American Journal of Epidemiology , 1972, 95_, 431-441. Oleck, L. H., & Yoder, S. D. Holism or hypocrisy? Perspectives in Psychiatric Care , 1981, 1_9_ (2), 65-68. Ottens, A. J. The counselor and coronary heart disease. Personnel and Guidance Journal , 1977, 56_ (2), 81-84. Page, E. Looking at types . Gainesville, FL : CAPT, 1983. Parrino, J. J. From panic to power—The positive use of stress . New York: John Wiley & Sons, 1979. Patterson, C. H. Relationship counseling and psychotherapy . New York: Harper and Row Publishers, Inc., 1974. Patterson, N. H. A study of stress management skills. Unpublished research, University of Florida, Gainesville, 1981. Pearlin, L. I. Lieberman, M. A., Menaghan, E. G. , & Mullen, J. T. The stress process. Journal of Health and Social Behavior , 1981 , 22, 337-356. Pelletier, K. R. Mind as healer, mind as slayer . New York: Delta, 1977. Pelletier, K. R. Toward a science of consciousness . New York: Delta, 1978.

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176 Pera, G. College stress. Nutshell , 1981, 33-43. Peterkin, B. P., Kerr, R. L. , & Shore, C. J. Diets that meet the dietary goals. Journal of Nutriti on Education, 1978, 10 (1), 15-18. ~ Phares, E. J. Locus of control in personality . Morristown, NJ: General Learning Press, 1976. Piaget, G. Overcoming barriers to communication in business and professions. Seminar presented by Institute for the Advancement of Human Behavior, Nassau, Bahamas, December, 1980. Pincus, H. A. Linking general health and mental health systems of care: Conceptual models of implementation. American Journal of Psychiatry , 1980, 137 (3), 315-320. Podboy, J. A counseling service for hospital staff members. Hospital and Community Psychiatry , 1980, 31_ (3), 206-207. Porter, R. A., Peters, J. A. , & Heady, H. R. Using community development for prevention in Appalachia. Social Work, 1982, 27 (4), 302-307. — Priesner, J. A proposed model for the nurse therapist. In Reihl & Ray (Eds.). Conceptual models for nursing practice . New York: Appl eton-Century-Crofts, 1980. Pritkin, N. The Pritkin program for diet and exercise . New York: Gross and Dunlap, 1979. Rahe, R. H. Life change measurement clarification. Psychosomatic Medicine , 1978, 40 (2), 95-98. Rappaport, J. Community psychology: Values, research and action . New York: Holt, Rinehart and Winston, 1977. Reifler, B., & Eaton, J. S., Jr. The evaluation of teaching and learning by psychiatric consultation and liaison training programs. Psychosomatic Medicine , 1978, 40 (2), 99-106. Robinson, L. Liaison nursing—psychological approach to patient care . Philadelphia : F. A. Davis Company, 1974. Roe, A. The psychology of occupations . New York: John Wiley & Sons, 1956. Rogers, C. R. Counseling and psychotherapy . Boston: HoughtonMifflin, 19^2": Rogers, C. R. Client-centered therapy . Boston: Houghton-Mifflin, 1951.

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177 Rogers, C. R. On becoming a person. Boston: Houghton-Mifflin, 1961. Rosen, A., & Patterson, N. Stress management and skills fatigue . Paper presented to Baptist Hospital Life Flight program, December 1980. Ross, C. E. , & Mirowsky, J. A comparison of life-event weighting schemes: Change, undesirabil ity, and effect-proportional indices. Journal of Health and Social Behav ior, 1979, 20, 166177. — Rotter, J. B. Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs , 1966, 80 (1, Whole No. 609). " "" " " Rotter, J. B., Chance, J. E., & Phares, E. J. Applications of a social learning theory of personality . New York: Holt, Rinehart and Winston, 1954, 1972. Rotter, J. B., Rafferty, J. E., & Schanchtitz, E. Validation of the Rotter Incomplete Sentences Blank for college screening. Journal of Consulting Psychology , 1949, 1_3, 348-356. Rotter, J. B., & Rafferty, J. Manual for the RISB-college form . New York: The Psychological Corporation, 1950. Routine walking program benefits all ages. WHJ's Family Focus Newsletter , 1981 (Winter), 2. Roy, C. Adaptation: A conceptual framework for nursing. Nursing Outlook , 1970, 1_8 (3), 42-45. Roy, C. The Roy Adaptation Model. In Reihl & Roy (Eds.). Conceptual models for nursing practice. New York: Appleton-Century-Crofts , tot: Rozman, D. Meditating with children . Boulder Creek, CA: University of the Tress Press, 1975. Ryan, R. S., & Travis, J. W. The wellness workbook , Berkeley, CA: Ten Speed Press, 1981. Salat, B., & Cooperfield, D. Well-being: Advice from the do-ityourself journal for healthy living . Garden City, NY: Anchor Satir, V. Peoplemaking . Palo Alto, CA: Sciences Behavior Books, Inc. , 1972": Schafer, R. B. The self-concept as a factor in diet selection and quality. Journal of Nutritional Education, 1979, 11, 37-39.

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178 Schwartz, G. E. Stress management in occupational settings. Publ ic Health Reports , March-April, 1980, 99-108. Schrivner, R. A. Handling stress makes dollars and sense. Occupational Health Nursing , March 1981, 17-18. Seiler, G. , & Messina, J. Toward professional identity: The dimensions of mental health counseling in perspective. American Mental Health Counselors Association Journal , 1979, 1_ (1 ) , 3-8. Seligmann, M. E. P. Helplessness: On depression, development and death . San Francisco: W. H. Freeman and Co. , 1 975. ~ Selye, H. Stress without distress . New York: Signet, 1974. Selye, H. The stress of life . New York: McGraw Hill, 1976. Selzer, M. A. The role of the consultant in the case conference: Some neglected aspects. Psychiatry , 1981, 44, 68-69. Sethi, A. S. Using meditation in stress situations. Dimensions in Health Service , 1980, 24-26. Shaffer, M. Life after stress . New York: Plenum Press, 1982. Sharpe, R. , & Lewis, D. Thrive on stress . Andersonville, Indiana: Warner, 1977. Shealy, C. N. Just what does "holistic" medicine mean? Patient Care , October 15, 1981 , pp. 181-210. Sherman, A. R., Lewis, K. J., & Guthrie, H. A. Learner objectives for a nutrition education curriculum. Journal of Nutrition Education , 1978, 10 (2), 63-65. " '" Speilburger, C. Understanding stress and anxiety . New York: Harper & Row Publishers, 1979. Steele, D. W. The Counselor's response to death. Personnel and Guidance Journal , 1977, 164-167. Stein, L. I. The doctor-nurse game. Archieves of General Psychiatry , 1967, 1_6, 699-703. ~" Stoddard, A. The University of North Florida Mariner . Jacksonville, FL: 1983.

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179 Sturner, R. A., Granger, R. H. , Klatskin, E. H.» & Ferholt, J. B. The routine "well -child" examination. Clinical P ediatrics, 1980, 1_9 (4), 251-260. Super, D. The psychology of careers: An introduction to vocational development . New York: Harper, 1957. Taylor, C. B., & Fortmann, S. P. Essential hypertension. Psychosomatics , 1983, 24_ (5), 433-448. Thoits, P. A. Conceptual methodological and theoretical problems in studying social support as a buffer against life stress. Journal of Health and Social Behavior , 1982, 23_, 145-159. Trygstad, L. Simple new way to help anxious patients. RN, December 1980, 28-32. — Turner, R. J. Social support as a contingency in psychological wellbeing. Journal of Health and Social Behavior , 1981, 22_, 357-367. Van deReit, V. Introduction to psychosynthesis . Workshop presented at New Frontiers in Counseling: Accountabil ity through Credibility. Gainesville, FL: February 10-12, 1977. Volcier, C. , Galvin, R. M., & Thompson, D. Stress: Can we cope? Time , June 5, 1983, pp. 48-54. Wallis, C, Galvin, R. M. , & Thompson, D. Stress: Can we cope? Time , June 5, 1983, 48-54. Watson, J. Nursing: The philosophy of science and caring . Boston: Little, Brown & Co. , 1979. Wiggins, F. K. Stress Management and Prevention Class, Jacksonville. FL: Florida Junior College, 1978. Williams, A. W. , Ware, J. E., Jr., & Donald, C. A. A model of mental health, life events and social supports applicable to general populations. Journal of Health and Social Behavior , 1981, 22, 324-336. Williams, D. An analysis of nursing state board scores according to Myers-Briggs personality types. Doctoral Dissertation, University of Florida, 1975. Dissertation Abstracts International , 1976, 36, 5167A. Williams, R. J. Nutrition in a nutshell . Garden City, New York: Doubleday and Co. , 1962. Winstead-Fry, P. The scientific method and its impact on holistic health. Advances in Nursing Science , 1980, 2_ (4), 1-7.

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Winston, S. Getting organized . New York: Warner Books, 1978. Wolpe, J. Psychotherapy by reciprocal inhibitation. Stanford, CA: Stanford University Press, 1958. Yahn, G. The impact of holistic medicine, medical groups and health concepts. Journal of American Medical Association , 1979, 242 (20), 2202-2205. Yorde, B., & Wittmer, J. M. Stress indicators . Nelsonville, Ohio: Counseling, Stress Management and Biofeedback Associates, March 1979. Yura, H., & Walsh, M. Human needs two and the nursing process . Norwalk, Connecticut! Appleton-Century-Crofts , 1982. Yura, H., & Walsh, M. Human needs three and the nursing process Norwalk, Connecticut: Appleton-Century-Crofts, 1983.

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BIOGRAPHICAL DATA Nancy Pearle Hord Patterson is a native of Gainesville, FL. She was born January 19, 1943, to Crystal and J. Harvey Hord. She was educated entirely at P. K. Yonge, University of Florida's Laboratory School. Following her graduating in 1960, she attended Florida State University for a brief time. She is the mother of three daughters: Nancy Katherine Gil lis, Crystal Leigh Gil lis, and Caren Louise Gill is. When her family moved to Jacksonville, FL, in 1968, she entered an associate degree nursing program at Florida Junior College, graduating in 1971. She continued her education in the Department of Psychology at the University of North Florida in Jacksonville, receiving her bachelor's and master's degrees in 1976 and 1978, respectively. She was accepted into the doctoral program in the Department of Counselor Education at the University of Florida in 1977. Her career path has taken her through in-patient and out-patient psychiatric settings, adolescent day treatment programs, and into a successful private practice in the Jacksonville area. She is also involved in the continuing education of nurses, and presently teaches human relations courses for nurses, the general public, and business and industry. She resides with her husband, William P. Patterson, in Jacksonville. 181

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182 I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. jet. J. Lat*ser^Chairperson PVofessor\of,'Counselor Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a diss-eTtation for the degree of Doctor of Philosophy. P. J/Jseph .'Jittmer^/Cochairperson Professor of Counselor Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Jo Ann Patray Associate Professor of Nursing I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. t / J /Robert J. Ofummond 7 Professor of Counselor Education This dissertation was submitted to the Graduate Faculty of the Division of Curriculum and Instruction in the College of Education and to the Graduate School, and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. April, 1984 Dean for Graduate Studies and Research

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UNIVERSITY OF FLORIDA 3 1262 08285 2194


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