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ASSESSMENT OF THE USE OF PROGRESSIVE RELAXATION
IN A STRESS REDUCTION PROGRAM
by
Linda Morris
A thesis submitted to the faculty of The University of Utah
in partial fulfillment of the requirements for the degree of
Master of Science
College of Nursing
The University of Utah
June 1984
Copyright ~ 1984 Linda Morris
All Rights Reserved
THE UNIVERSITY OF UTAH GRADUATE SCHOOL
SUPERVISORY COMMITTEE APPROVAL
of a thesis submitted by
Linda Morris
This thesis has been read by each member of the following supervisory committee ami by majority vote has been found to be satisfactory,
f ' •
I I
Chainnan: J' Boyle,;' ph. D. , (
' Le}ha Liermhn, R.N. , ph.D.
�)-� � �yJ�-r_
Bobby c� ph.D. �--'
TilE UNIVERSITY OF UTAH GRADUATE SCHOOL
FINAL READING APPROVAL
To the Graduate Council of The University of Utah:
I have read the thesis of Linda Morr is in its final form and have found that (I) its format, citations, and bibliographic style are
consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the Supervisory
Committee and is ready for submission to the Graduate School.
Ph.D.
Linda K. Amos, Ed.D., F.A.A.N. Chairman! Dcan
Approved for the Graduate Council
ABSTRACT
The purpose of this research project was to deter
mine the effectiveness of progressive relaxation for
controlling and minimizing stress in a work setting.
Excessive stress affects health and work perfor
mance. The occupational health nurse should focus on
providing access to preventative health programs which
use relaxation techniques such as progressive relaxation
for stress reduction. Employees should become aware
of the sources of their stress. Through stress reduction
programs, employees may learn to cope with their stress
before it becomes chronic and negatively effects health.
The one group pretest-post test design was chosen
for this study. Participants acted as their own control
group participating in the pretest, a six week progres
sive relaxation regimen, a weekly self-report rating
of tension scale, and the posttest. The effectiveness
of progressive relaxation was measured by Taylor Manifest
Anxiety Scale (TMAS), self-report rating scale of tension,
and blood pressure measurement. Blood pressure measure-
ments were taken pre- and post training by independent
raters.
The sample was composed of 25 volunteers employed
at a local hospital. Most of the participants had com-
pleted one year or more of college and were licensed
female nurses working day and afternoon shift in the
general care area. The sample group ranged in age from
22-62 years.
The study results suggested that the practice of
progressive relaxation could effect a significant de
crease in systolic blood pressure (p <.01), but no
significant changes were found in diastolic blood pres-
sure. The TMAS showed significant decreases in anxiety
at posttest (p<.Ol). The self-report rating scale
did not show significant differences in perceived levels
of tension; future studies should consider an alternate
tool to measure perceived levels of tension. Partici
pants reported decreased physical symptoms of stress
at posttest. Participants rated their own health as
good and their co-worker's health as not as good as
their own.
This study presented limitations in sample selection,
size, and inequality of groups. The one group pretest-
posttest design has inherent threats to internal validity.
Future studies require a larger sample with random
design and a control group. Future studies in hospitals
and other work settings should consider the effects
of work environment, occupation, and shift in relation-
ship to measures of anxiety and blood pressure. v
Follow-
up studies should be done to determine the long term
effects of relaxation techniques on stress reduction
in the work setting.
vi
CONTENTS
ABSTRACT . . . . iv
LIST OF TABLES . ix
ACKNOWLEDGMENTS. x
Chapter
I. INTRODUCTION AND REVIEW OF LITERATURE. . 1
Introduction. Literature Review . .. ..... Problem Statement and Theoretical Framework . . Definition of Terms . .
1 4
15 17
II. METHODOLOGY. 20
Sample/Population . .. ... Data Collection Measurement/Instruments Procedure for Progressive Relaxation. Data Analysis ... . . .
20 21 25 27
III. RESULTS .. 30
IV.
Description of the Sample . . . . 31 Self-Rating of Health Status. 34 Health Complaints . ... 35 Blood Pressure. . . . . . . . . . 36 Self-Report of Tension Scale.. ... 41 Taylor Manifest Anxiety Scale (TMAS). . .. 43 Participants' Prior Methods for Relaxation. 48 Level of Practice and Mastery of Technique. 52 Summary of Results. . . 53
DISCUSSION OF RESULTS
Limitations . . . . . . . . . Indications for Future Study .. Implications of the Study . . .
56
61 66 68
Appendices
A. B. C. D. E.
F. G. H. I . J •
INFORMED CONSENT ...... . PRETEST QUESTIONNAIRE . . . . . SELF-REPORT RATING SCALE ..... POSTTEST QUESTIONNAIRE. . . .. .... UTAH BLOOD PRESSURE PROTOCOL - TWO STEP METHOD. . . . . . . . . . . . .. ... EXERCISE FORMAT . . . . . . . . . . . . SUMMARY OF DEEP MUSCLE RELAXATION . . . . . SHORT RELAXATION EXERCISE . . . . . SAMPLE BLOOD PRESSURE . . . . . . . . . . . SHORT FORM TAYLOR MANIFEST ANXIETY SCORES .
70 72 74 76
79 82 87 89 91 93
SELECTED BIBLIOGRAPHY. . . . . . . . . . . . . . .. 95
viii
LIST OF TABLES
1. Age and Education of Sample Population.
2. Participants Grouped by occupationa , Work Areab , and Primary Shift.
3. Participants Reported Health Related Complaints.
4. Blood Pressure Results Comparison.
5. Elevated Blood Pressure Readings of Five Participants in the Sample.
6. Comparison of Taylor Manifest Anxiety Scale Scores with Self-Report Current Tension Level .
7. Taylor Manifest Anxiety Scale (TMAS) Comparison by Occupation.
8. Comparison of Blood Pressure and TMAS Scores of the Ten Participants Who Used Additional Relaxation Technique or Exercise.
9. Comparison of Sample Blood Pressure .
32
33
37
37
40
44
46
49
92
ACKNOWLEDGMENTS
I wish to express appreciation to Dr. Lawrence
Murphy, Ph.D., with NIOSH in Cincinnati, Ohio, for his
assistance in questionnaire development, and John Sullivan,
Ph.D., University of Utah for questionnaire development
and statistical advice ~nd to my family and Darlene Meservy
for support and encouragement in pursuing this research
project. A special thanks to Bobby Craft, Ph.D., for
his support and guidance through two thesis committees.
CHAPTER I
INTRODUCTION AND REVIEW OF LITERATURE
Introduction
Pressure of everyday living takes a heavy toll
on the physical and mental well-being of people. Prior
to the industrial revolution, epidemics and plagues
were the major causes of disease and death. Although
progress has been made toward minimizing illness, those
conditions thought to be stress related are increasing.
Stress may be a factor in the predisposition to, or
acquisition of organic diseases including colitis, ulcers,
diabetes, allergies, arthritis, heart disease and cancer
(Fischer, 1980; Galton, 1981). Within western culture
it has been estimated that 50 to 80% of all disease
is stress related (Pelletier, 1977, p. 7). Excessive
stress has been described as a spiral in which stress
induced tension negatively changes the ability to perform
which in turn causes further stress (Sharpe & Lewis,
1978). Chronic stress can eventually lead to major
health problems.
Pelletier (1977) states that the medical community
tends to emphasize the cure of pathological disease.
He advocates a shift toward health maintenance and pre-
vention, stressing the consideration of people as the
sum of "mind, body, and spirit." If the prevention
2
of pathological disease is the goal then the whole person
needs to be considered. Consideration of the whole
person emphasizes maintenance of health and prevention
of illness rather than the treatment of established
disorders.
Stress may come from anyone of four major areas
of a person's life including: work and study, marriage
and family, social and interpersonal, or travel and
leisure (Sharpe & Lewis, 1978). In a study of 130 occu-
pations completed by the National Institute of Occupational
Safety and Health, 87 occupations carried a risk of
stress related illness for workers. This study concen-
trated on coronary artery disease, hypertension, ulcers
and nervous disorders through analysis of death certifi
cates, hospital admissions, and mental health records.
Forty of the 130 occupations were associated with stress
related illness at a significantly higher rate than
would be expected in the normal population (Occupational
Stress Proceedings, 1975; Smith, Colligan & Hurrel,
undated) .
Job stress is one of the most prevalent problems
of our time. Chronic stress may be linked to the develop
ment of a number of major illnesses. Workers need to
become aware of the source of their stress so that steps
3
can be made toward stress reduction before stress under-
mines health. The occupational health nurse is in a
position to implement health promotion programs to assist
individuals in learning about stress and stress reduction
so that health is improved and negative effects on work
performance are diminished.
The occupational health nurse contributes to pre-
ventative health care by designing health promotion
programs for the reduction of stress. Occupational
health nursing emphasizes providing care and protecting
the health of the individual from any harmful agents
whether they are chemical, physical, or psychosocial.
It is the responsibility of the occupational health
nurse to increase the individual's awareness of health
hazards and to illicit his/her participation in protecting
and promoting health. When individuals become responsible
for their own health, they can begin to manage the
effects of job stress.
Van Harrison (1978) summarizes the effects of job
related stress on the individual and its relative effects
on society in the following manner:
The costs to the employer include decreased quality of work, increased absenteeism, increased turnover, and the increasing expense of group prepaid health insurance. Job stress can impair the psychological and physical well-being of the individual worker and thereby affect the well being of the worker's family. On the societal level, these effects can be manifest in increased welfare costs, increased
socially disruptive behavior such as alcoholism and drug abuse, and less involvement in the community (Van Harrison, 1978, p. 200).
Literature Review
The Development of Stress
Stress is the result of an individual's interaction
with the environment (Frankenhaeuser, 1979). Genetic
4
physical, and social factors affect a person's perception
and therefore his/her response to stress. These factors
may appear in combination with one another or one of
the factors may be dominant in affecting the person's
ability to cope with stress (Aguilera, 1980; Howard
& Scott, 1965; Newbury, 1979).
All people experience stress as part of daily living.
There is a beneficial level of stress that is necessary
to maintain a happy, healthy, successful life (Sharpe
& Lewis, 1978). It is important to note that positive
events are also stressors. Stress may be caused by
change within the environment or a change within the
individual. Selye (1974) stated that the most powerful
stressors were interpersonal. He reported that opposite
emotions would cause similar reactions within the in-
dividual. It is believed that the destructive effects
of stress do not occur with stress which is related
to pleasant experiences because chronic tension does
not occur with pleasure states (Brown, 1977; Selye,
1974).
Anxiety or stress is characterized by an effort
to solve problems and reach goals. When efforts appear
inadequate, severe anxiety results (Ashton, 1979; Jacob-
son, 1970; Lenz, 1980). The feeling of lack of control
5
over a stressful stimulus is considered a prerequisite for
stress development (Cooper & Crump, 1978). Individual vul-
nerability to stress varies with age, occupation and
educational level (Donova, 1979). In addition, some
individuals may have stress prone personalities like
the Type A personality which has been linked to coronary
heart disease. The Type A personality has been described
as the excessively aggressive, competitive, overworked
person (Friedman & Rosenman, 1974).
Holmes and Masuda (1972) studied life changes which
occurred prior to chronic illness and found that 80%
of illness and accidents occurred within a two year
period following major life changes, such as death of
a close friend or relative, marriage, or divorce. Further
research indicates that several factors may affect re-
sponse to life change events. These factors include:
cultural differences, individual personality differences,
biological, psychological, social characteristics, the
timing or clustering of life change events, socioeconomic
status, income, and interpersonal support system (Miller,
1981). Some researchers have reported that although
stress awareness is important, too much attention to
stress may result in fear immobility and avoidance of
life's experiences (Denney, 1981).
The Physiological Effects of Stress
stress related diseases are thought to result from
overactivity of the nervous system affecting specific
organ systems (Benson, 1976; Brown, 1977; Selye, 1965).
Selye described the reaction components of stress as
the "General Adaptation Syndrome. II The body reacts
initially to a condition perceived as threatening by
physiologically preparing to defend itself. This is
the alarm or activation phase in which the sympathetic
nervous system is stimulated and adrenal hormone release
occurs. Hormones are released as a fear response to
prepare the body to "fight or flee" (Frager & Griffis,
1979; Sharpe & Lewis, 1978).
During the activation stage, the body initially
responds to hormonal release during stress by increasing
the release of glucose so that nutrients are available
to the muscles for "fighting or fleeing." Through the
action of adrenocorticotropic hormones, water and sodium
are retained and potassium is excreted which provides
a greater blood volume. The blood vessels constrict
except in the brain and in those muscles necessary for
IIfighting or fleeing." At this time, body temperature
increases to allow more rapid chemical reactions, the
6
deposition of cholesterol is altered, perspiration
increases resulting in changes in the electrical con
ductivity of the skin, and hormones are released which
7
increase stomach acidity. Blood pressure also increases.
The hemodynamic changes at rest in essential hypertension
are similar to those experienced under emotional stress.
Emotional stimuli leads to hypothalmic and pituitary
responses, which when repeated frequently, may cause
sustained high blood pressure (Brod, 1960, 1964;
Bloomfield & Kory, 1978; Brown, 1977; O'Flynn-Comisky,
1979; Wilmore, Long, Mason & Pruitt, 1976).
When the resistance phase occurs, the body releases
chemicals to allow the body to adapt to prolonged stress.
The body begins to repair damage that has been done
during the activation phase. The phase of resistance
helps the person to survive major life stressors, such
as illness or injury. When tension is chronic the body
has no time for repair. The failure of the person to
take physical action to "fight or flee" is the main
cause of tension and stress accumulation (Kraus, 1969).
If the person cannot interrupt the tension, it becomes
chronic, wearing down the person's physical and emotional
health (Bloomfield & Kory, 1978). Selye (1974) described
the wearing down of the person's physical and emotional
health as the phase of exhaustion. The internal signs
of stress are no longer recognized by the individual
(Brown, 1977; Wilmore et al., 1976). Stress may build
up until the person does not relax even when asleep.
There is an excessive amount of residual tension that
takes hours to subside, so that relaxation time may not
be sufficient.
8
Today's urban societies tend to create a high level
of stress which cannot be managed by the primitive "fight
or flight" methods. A person is left to deal with
stressors cognitively, internalizing stresses and ignoring
bodily signals (Benson, 1976). Mood or emotional shifts
including feelings of anxiety, irritability, frustration,
worry, and sion also may be expe~ienced (Bloomfield
& Kory, 1978; Woolfolk & Richardson, 1978). Certain
genetic, personality, and environmental ors increase
vulnerability to stress while relaxation training, outlook
on life, and a healthy lifestyle may serve to protect
the individual from the negative effects of stress
(Douglas & Douglas, 1981).
Stress Reduction
The mind's reaction to stress or pe ion of stress
influence the body's response to stressful situations.
It is believed by some that a relaxed mind is the pathway
to health (Bauman, Brint, Pipper & Wright, 1978). People
who meditate regularly or take relaxation breaks tend
to show more self-reliance and less anxiety (Cooper &
Payne, 1978; Peters, 1977). Miller and Green (1979)
has suggested that blood pressure increases with periods
of chronic stress and that if a person remains relaxed
physiologically and emotionally, blood pressure may not
increase even with age. Benson (1976) states that each
of us has inner protective mechanisms that allow a body
to protect itself from excessive stress. He discusses
the four conditions necessary to gain a bodily response
of relaxation: a quiet room, a passive attitude, com-
fortable position, and the ability to concentrate upon
a simple thought.
9
Studies have demonstrated that the use of a variety
of relaxation techniques produce changes in the body
which are exactly the opposite of those produced under
stress (Benson, 1976~ Brown, 1977; Lader & Mathews, 1970).
Lader and Mathews (1970) tested physiological changes
in response to stress and determined that the measures
did not correlate well at low or moderate levels of
stress, but were correlated in overwhelming stress.
Lazarus, Averill and Opton(1974) suggested using physio
logical, psychological, behavioral, and a self-report
measure to study stress. In Paul's (1969) studies, heart
rate, respiratory rate, muscle tension, and galvanic
skin response were measured. Subjects practicing a
relaxation technique within the laboratory environment
displayed significant changes when compared to subjects
who were told to just sit and relax.
10
Datey (1980) conducted an experimental study with
hypertensive subjects taking antihypertensive drug therapy
adding the use of biofeedback training to the treatment
of the study group. The average age of the treatment
group was 56 years and the average age of the control
group was 57 years. In the experimental group, the
average systolic blood pressure decreased from 158mm
Hg to 140mm Hg, and the average diastolic blood pressure
changed from 103mm Hg to 96mm Hg. The blood pressure
of the control group changed from 160mm Hg to 155mm
Hg and the diastolic blood pressure stayed at 100mm
Hg. The study demonstrated positive effects of biofeed
back training on blood pressure reduction. The control
group displayed no significant changes in blood pressure,
while results of the experimental group were significant
at 2 <.05. In addition, the drug requirement of the
experimental group was reduced by 33%.
Beiman, Graham, and Ciminero (1978) studied the
effects of progressive relaxation training on two hyper
tensive subjects. One subject had refused antihyper
tensive medication and the other had not been able to
attain blood pressure control on antihypertensive medi
cation. Both clients after mastering progressive relax
ation attained blood pressures in the normotensive range
and were still normotensive at the two month followup.
Subjects' self-monitored blood pressures which may have
11
had an effect on the results of the study.
Studies have shown that the use of progressive
relaxation can effectively lower blood pressure. Glas -
gow, Gaarder and Engel (1982) studied 90 hypertensive
patients over a six month period. Participants were
assigned to groups to provide approximately equal
numbers of patients on medication, as well as equivalent
average baseline blood pressure and age. There were
five groups which included a control, biofeedback, pro
gressive relaxation, and groups taught biofeedback/
progressive relaxation, progressive relaxation/biofeed-
back relaxation techniques in that sequence. All of
the participants were taught how to measure their own
blood pressure, provided with a calibrated sphygmomano
meter, and instructed to measure their blood pressure
six times daily on their nonpreferred arm. A health
professional measured blood pressure at the work site
weekly_ All groups including controls decreased blood
pressure from baseline to the end of treatment. The
changes in average professionally determined blood pres
sure (Systolic mm Hg/Diastolic mm Hg) from selection
to the final treatment were as follows: Control -7.3/ 6.0,
progressive relaxation -6.2/-7.0, biofeedback -4.7/
-6.2, progressive relaxation-biofeedback -8.0/-5.6 and
biofeedback-progressive relaxation -13.8/-10.2. Changes
were significantly different from the control group
(2 <.05) for the biofeedback/progressive relaxation
group only. Systolic blood pressure improved signifi
cantly for groups using either progressive relaxation
12
or biofeedback from the beginning to the ending of the
study by analysis of covariance (ANOVA) F (1/73) 8.53,
£<.01. The effect of progressive relaxation on dia
stolic blood pressure change during the same period
was greater than biofeedback F (1/73) = 12.75, 2<.01.
Blood pressure changes for the four behaviorally treated
groups had a combined significance of E <0.01 showing
F (1/57) 287.66 for systolic blood pressure and F
(1/57) = 79.89 for diastolic blood pressure. Progressive
relaxation and biofeedback were equally effective in
lowering systolic blood pressure, but progressive
relaxation lowered diastolic blood pressure more.
Patients receiving both biofeedback and progressive
relaxation maintained consistently lower blood pressures
than those performing either technique separately.
However, the lower blood pressures in the biofeedback
and progressive relaxation groups were not significantly
by Duncan1s k-ratio t-test.
Progressive relaxation was studied at an industrial
site for its effect on blood pressure on 42 volunteers
with a mean age of 50.7 years. Those included in the
study were required to have a diastolic blood pressure
greater than 90mm Hg, a diagnosis of hypertension, or
13
be currently under a physician's care receiving blood
pressure medication. Participants were included in
the study only if they had never previously participated
in any relaxation training. Blood pressures were taken
using automated blood pressure recorders. After eight
weeks of progressive relaxation training, significant
decreases in mean systolic blood pressure from 143mm
Hg to 137mm Hg and mean diastolic blood pressure change
from 98mm Hg to 85.8mm Hg were found. These reductions
were demonstrated even on work days when participants
reported being under a great deal of stress. Mean
systolic blood pressure decreased 11.7mm Hg in clinic
measurements and 7.8mm Hg at the work site. Average
diastolic blood pressure decreased 12.6mm Hg in clinic
measurements and 4.6mm Hg at the work site. Reductions
were significantly better for the subjects, in systolic
blood pressure (2 <.05) and diastolic blood pressures
(2 <.01) (Southam, Agros, Taylor & Kraemer, 1982).
Breeden, Bean, Scandrett, and Kondo (1975) compared
the benefits of biofeedback and progressive relaxation.
It was found that subjects experienced a greater reduction
in muscle tension with biofeedback, but progressive
relaxation tended to decrease anxiety as measured by
electromyogram (EMG), muscle biofeedback levels, and
pretest and post training symptom checklists (Breeden
et al., 1975).
14
In the Staples and Coursey (1975) study, three groups
of 13 males each were trained in either progressive
relaxation, autogenic training, or EMG biofeedback for
stress control. Each group was measured by EMG levels.
The Taylor Manifest Anxiety Scale (TMAS) was given before
and after the training to measure trait anxiety. Trait
anxiety among all groups decreased at posttest as indi
cated by analysis of covariance F = 3.39 (£<.08), but
no significant differences between groups were found.
The subjects in all groups rated their perception of
the relaxed state; the progressive relaxation group
reported greater perception of relaxation than did the
muscle biofeedback and autogenic training subjects.
The progressive relaxation group reported liking their
training more than those in the autogenic group, but
not more than the muscle biofeedback group.
Prior studies have shown that blood pressure and
anxiety can be diminished when a relaxation technique such
as progressive relaxation is used. Progressive relaxation
was found to assist in blood pressure reduction in studies
by Beiman et ale (1978), Glasgow et ale (1982) and Southam
et ale (1982). Breeden et ale (1975) found the progres-
sive relaxation decreased anxiety as measured by electro
myogram (EMG), muscle biofeedback levels, and symptom
checklists. The Staples and Coursey (1975) study found
significant decreases in Taylor Manifest Anxiety Scale
(TMAS) scores in groups taught autogenic training and
progressive relaxation.
lem Stat
This research project was designed to determine
whether progressive relaxation is an effective stress
reduction technique for the work setting. Progressive
15
relaxation was selected for use as a relaxation technique
in the work setting because it is simple to learn and
does not require special conditions or expensive equipment
to practice. The effectiveness of a short program of
progressive relaxation was measured by results of
self-reported perceived levels of tension, anxiety levels
as measured by the Taylor Manifest Anxiety Scale (TMAS),
and blood pressure measures.
Job stress is one of the most prevalent and intense
kinds of stress experiences. Some sources of stress
that people experience in their daily lives may be altered
so that their lives become less stressful. On occasion,
a total change in work atmosphere may be recommended
for health reasons, but for most people it is not feas
ible. Therefore, it becomes important for the individuals
to learn other ways of coping with work related stress.
Since stress has been indicated as a contributing
factor in many illnesses, it is the responsibility of
the occupational health nurse to implement stress re-
duction programs which assist individuals to learn to
cope with stress. If the individual can learn to cope
with stress, many of the effects of stress on health
and work performance may be lessened. Although health
promotion programs may be initiated in the workplace
16
by any professional, the occupational health nurse is
responsible for the development of comprehensive health
promotion programs aimed at disease prevention and health
maintenance: stress reduction programs are a part of
such measures.
At the present time, few studies have been published
indicating the effectiveness of a stress management pro
gram within the work setting; however, nurses have taught
relaxation programs within industry (Richter & Sloan,
1979). Previous studies have demonstrated that pro-
gressive relaxation appears to be successful in reducing
anxiety (Breeden et al., 1975; Staples & Coursey, 1975).
Since progressive relaxation is a relatively simple
technique to learn and does not require special equipment
or conditions for its effect, industries may cost effec
tively include the technique as part of a stress manage
ment program.
The purpose of this study was to explore if progres
sive relaxation is a useful and practical relaxation
technique for controlling and minimizing stress in a
work setting. Indicators to measure the effects of
17
progressive relaxation were blood pressure measurement,
Taylor Manifest Anxiety Scale (TMAS) scores, and a self-
report scale of tension score. If progressive relaxation
is an effective technique for stress reduction in the
work setting, then the relaxation technique could be
implemented by occupational health nurses in a variety
of industrial and office settings.
The research questions for this project were:
1. Will the perceived level of stress among
participants in the study diminish following progressive
relaxation training as measured by the self-report scale?
2. Will the perceived level of anxiety among par
ticipants decrease following progressive relaxation
training as measured by the Taylor Manifest Anxiety
Scale (TMAS)?
3. Will blood pressure decrease in participants
when systolic and diastolic blood pressure measurements
are compared prior to the study and following progressive
relaxation training?
De inition
Dependent Variables
For purposes of this study, stress is defined as
an individual's response to an environmental stressor.
A stressor is anything which is capable of producing
the anxiety which illicits the physiological response;
it is individually determined by the person's perception
18
of the event. This perception is influenced by the
person's personality and lifestyle. As a result of
perceiving stress, the individual may experience physical
or emotional tension. The concept of stress will be
operationalized in this research project by blood pressure
measurement, the level of anxiety as measured by the
Taylor Manifest Anxiety Scale (TMAS), and the perceived
level of tension as measured by the self-report scale.
Independent Variables
Progressive relaxation is a technique described
by Jacobsen in 1938 as a method of relieving chronic
tension and anxiety. The method involves the systematic
tensing over seven seconds and abrupt relaxing of 16
major muscle groups of the body to increase the in
dividual's awareness of sensations of muscle tension
and relaxation. It is believed that anxiety cannot
exist when muscles are relaxed. Through learning the
16 muscle technique, individuals may learn that they
tend to hold their tension in a particular muscle group
or on one side of the body more than the other (Bern-
stein & Borkovec, 1973; Brown, 1977). Studies have
shown that progressive relaxation should be concentrated
on those areas where people tend to build-up the most
muscle tension (Brown, 1977; Donovan, 1980). After
the person learns the 16 muscle group technique, muscle
groups are combined into seven muscle groups and then
four muscle groups. As the technique is mastered, the
person may begin to recall the feeling of relaxation
experienced by using a key word such as "calm" or
"relaxed" (Bernstein & Borkovec, 1973).
Relaxation is a learned response that is capable
of decreasing tension. Operationally, relaxation was
the feeling experienced with muscle relaxation when
progressive relaxation was practiced and was measured
by response on the self-report scale.
19
In summary, since stress is a contributor to major
health problems in our society, learning a stress reduc
tion technique like progressive relaxation may assist
the individual to minimize the effects of stress on
health and job performance. The occupational health
nurse has a responsibility to provide programs which
can assist the individual to deal with stress so that
health is maintained and major illness avoided. With
increasing costs of medical care, the importance of
preventative health programs is being emphasized. It
is anticipated that this study will show whether or
not progressive relaxation might be a useful and prac
tical relaxation technique for controlling and minimizing
stress in the work setting.
CHAPTER II
METHODOLOGY
Sample/Population
This study used a quasi experimental design to
work with employees at Jaycee Hospital (Jaycee Hospital
is a pseudonym for a [340] bed general hospital in a
suburban area of Salt Lake City, Utah). Volunteers
acted as their own control group participating in the
est, relaxation training regimen, weekly self-rating
scale, and posttest. This design was chosen because
it was difficult to obtain participants for the study
and time considerations did not permit the necessary
length of time required for a random sample.
A convenience sample of volunteers was invited
to participate in this study. Volunteers for the research
project were recruited through posted announcements
in the various units of Jaycee Hospital and through
announcements made by the nurse coordinators in staff
meetings. A conference room was provided by the hospital;
the study was planned to allow volunteers from each
shift to attend the sessions. Arrangements for equipment
and the assistance of three blood pressure raters were
made. Participants included nurses, aides, clerks,
21
and respiratory therapists. Participants were oriented
as to the nature of the study before they signed consent
forms agreeing to participate (Appendix A).
Data Collection Measurement/ Instruments
The self-report rating scale, pretest and posttest
questionnaires were designed for this study and pilot
tested on a group of ten employees at a local firm.
Subjects displayed no difficulty in understanding these
questions: no major weakness or objectionable questions
were found in the pilot test. Open questions were
responded to appropriately with accuracy and relevance.
Respondents answered questions in a consistently similar
way; however, the questions appeared to be sensitive
enough to allow for individual variations. Responses
indicated that the instrument was capable of answering
the research questions asked, suggesting the instruments
were appropriate and valid tools for this study.
The pretest (Appendix B) included several baseline
questions concerning the individuals' general health.
Participants rated their health and the health of their
co-workers on a scale of one to ten. A question about
their co-workers' health was asked to determine if partici-
pants perceived others' health as better or not as good
as their own. Age, educational level, and occupation
have been shown to affect an individual's ability to
22
cope with stressors (Donovan, 1979). Information regarding
these intervening variables was illicited as baseline
data. A question regarding the individual's present
methods for stress reduction was asked to identify those
who might be using progressive relaxation or other
methods. Blood pressure measurement was obtained during
the initial testing period as baseline information.
The subjects were asked to report their perceived
level of tension weekly, using a self-report rating
scale (Appendix C). The self-report rating scale asked
the participant to rate their current level of tension
and the highest level of tension experienced that day
on a scale of one to ten, ten being very high tension.
Since all individuals experience stress on a different
level, this provided an indication of how much stress
the subject perceived himself/herself experiencing.
In addition, the self-report rating scale was included
in the pretest and posttest questionnaires.
The Taylor Manifest Anxiety Scale (TMAS) was admin
istered at the same time as the pretest and posttest.
The Taylor Manifest Anxiety Scale, developed by Taylor
(1956), is a 50 item scale consisting of items drawn
from the Minnesota Multiphasic Personality Inventory.
Several studies have shown the validity of the Taylor
Manifest Anxiety Scale (TMAS) as it correlates with
clinical estimates of anxiety. Buss and associates
23
(1955) compared psychologist interview assessments of
anxiety in 64 participants with scores on the Taylor
Manifest Anxiety Scale. The psychologists' assessments
correlated moderately high (.60) with the rating of
anxiety on the Taylor Manifest Anxiety Scale (TMAS)
(Buss, Wiener, Durkee & Baer, 1955). Zuckerman, Persky,
Eckman, and Hopkin (1967) studied 29 psychiatric patients
and 25 controls who took the Taylor Manifest Anxiety
and Catell's Scales. Results demonstrated good covergent
validity but poor discrimination between tests. Taylor
(1956) reported a reliability-internal consistency of
.82. Studies have shown that the Manifest Anxiety Scale
reflects proneness toward anxiety (Desiderato, 1964)
and measures existent anxiety (Byrne, 1966; Hammes,
1961; McReynolds, 1968). The Taylor Manifest Anxiety
Scale has been used successfully in studies testing
theoretical predictions and in studies requiring assess
ments of anxiety (McReynolds, 1968; Spence & Spence,
1966).
Studies by Buss (1953) and Hoyt and Magoon (1954)
found that many of the items in the Manifest Anxiety Scale
were not valid in predicting cliical anxiety. The 20 most
consistently valid items in the 50 item Manifest Anxiety
Scale were selected (Items 1-16 and 29-32). The 50
item Manifest Anxiety Scale was administered to 744
col students. The scores for 50 item scale were
24
compared with the scores for the 20 item scale. The
reliability of the 50 item was .78 and the reliability
of the 20 item was .76 (Bryne, 1966). The 50 item scale
was selected for this study to allow comparison with
other studies.
The posttest questionnaire (Appendix D) included
perceived level of tension by self-report rating scale,
current general health and medical problems, and questions
concerning how effective the individual perceived the
progressive relaxation technique to be in reducing the
negative effects of stress. Blood pressure measurement
was to be obtained during this time. Participants were
asked to rate the effectiveness of progressive relaxation
on a scale of one to ten when used at home and work.
Questions were asked about the amount of practice time
and perceived mastery level of the technique.
An independent rater took both blood pressure measure
ments on all subjects. Regular adult, large adult,
and pediatric cuffs were available for proper cuff fit
and calibrated prior to use. The pediatric and large
cuff sphygmomanometers were of the aneroid type. The
adult cuff sphygmomanometers were the mercury column
type. The two step method of blood pressure measurement
was used (Appendix E). This procedure is the protocol
followed by the Utah State Department of Health. Sub
jects were encouraged to use progressive relaxation
25
as a means of controlling blood pressure. Those subjects
identified as having elevated blood pressure, 140/90mm
Hg, were referred to their physicians for evaluation
and care.
Procedure for Progressive Relaxation
Progressive relaxation is based on the relationship
between muscle tension and psychological tension. Each
major muscle group is tensed and held for seven seconds
and then released completely and abruptly, so that the
feeling of relaxation is recognized. The tension begins
in 16 muscle groups which are combined into seven and
then four muscle groups. A short relaxation exercise
was taught initially which includes deep breathing.
The procedure for progressive relaxation is shown in
Appendix F.
Participants were asked to practice the progressive
relaxation exercises at least 10 to 15 minutes per day
at home. The practice area should be free of distrac-
tions. Participants were asked to concentrate on using
the technique in those muscle groups where they exper-
ienced the most tension.
The participants met once per week for one half
hour training sessions over a six week period. The
progressive relaxation exercise was taught at prearranged
times during all three shifts in the hospital. Partici-
26
pants were encouraged to attend the session that most
closely correlated with their work schedule. The pro-
gressive relaxation exercises were conducted by the
researcher. The researcher predetermined that the six
week period could be extended to allow completion of
the program by participants so that the sample size
of 25 participants could be retained.
Schedule of Research Activities
Week One (45 minutes)
Informed consent.
Completion of pretest questionnaire including the self-report rating scale and Taylor Manifest
Anxiety Scale.
Blood pressure measurement.
Learn 16 muscle group progressive relaxation technique.
Provide handout for home practice (Appendix G) •
Week Two (30 minutes)
Practice 16 muscle group progressive relaxation.
Complete self-report rating scale.
Week Three (30 minutes)
Practice 16 muscle group progressive relaxation.
Learn the seven muscle group progressive relaxation.
Complete self-report rating scale.
Week Four (30 minutes)
Practice seven muscle group progressive
relaxation.
Complete self-report rating scale.
Provide seven muscle group technique handout (Appendix H)
Week Five (30 minutes)
Practice seven muscle group progressive relaxation.
27
Learn four muscle group progressive relaxation.
Complete self-report rating scale.
Week Six (45 minutes)
Practice four muscle group progressive relaxation.
The technique of recall was discussed.
Blood pressure measurement.
Completion of the posttest questionnaire including the self-report rating scale and Taylor Manifest Anxiety Scale (TMAS).
Data Analysis
The independent t-test was used to compare the
systolic and diastolic blood pressure measurements
recorded before and after progressive relaxation to
determine significant changes. The t-test also was
used to compare the self-reported measure of perceived
level of tension as rated by subjects during the pretest,
posttest, and on the weekly self-report rating scale.
The level of perceived tension following mastery of
the technique of progressive relaxation was examined
to note significant changes. The current level of tension
was compared with the highest level of tension over
the course of the study by t-test to note significant
differences between these perceived tension levels.
28
The anxiety scores derived from the Taylor Manifest
Anxiety Scale administered prior to teaching progressive
relaxation and after completion of the relaxation program
were compared to see if there was a significant differ
ence between the scores by t-test. The self-report
rating scale, a measure of perceived tension level,
was compared on pretest and posttest with the Taylor
Manifest Anxiety Scale (TMAS) to determine if similar
trends existed between perceived tension and anxiety
levels.
The intervening variables of age, occupation, work
area, and shift were examined by ~-test as they related
to anxiety scores and blood pressure to see if differences
could be found in scores based upon these variables.
When differences were noted in Taylor Manifest Anxiety
Scale scores in occupational groups, results were further
examined by a ~-test of the difference to account for
results that might have occurred as a result of testing
differences.
Comparison of mean practice time and mean perceived
effectivness of the technique of progressive relaxation
were compared with outcome measures of blood pessure
and Taylor manifest Anxiety Scores. When differences
29
were noted in outcome measures between groups according
to additional relaxation method used, additional relax
ation method groups were compared according to mean
practice time.
Reported symptoms of stress were compared at pretest
and posttraining to determine if a change in reported
symptoms occurred. The participant's rating of their
own health status and that of their co-workers were
examined to determine attitude changes between pre-
and posttest.
Those participants reporting use of additional
relaxation techniques and exercise for stress reduction
were compared on pretest and posttest mean blood pressure
measurement, mean self-report rating scale and mean
Taylor Manifest Anxiety Scale scores to determine whether
participants currently using another technique for stress
reduction benefited by receiving progressive relaxation
training.
In summary, this study was conducted with volunteers
in a hospital setting. A six week progressive relaxation
program was implemented. Measurements of anxiety (Taylor
Manifest Anxiety Scale) and blood pressure measurements
were obtained at the pretest and posttest. In addition,
a weekly self-report of perceived tension was obtained.
Participants were compared on these measures prior to and
after the introduction of progressive relaxation techniques.
CHAPTER III
RESULTS
The study of the usefulness of progressive relaxation
in a hospital work setting was begun in June 1983 with
the cooperation of Jaycee Hospital. The hospital provided
a quiet room for the implementation of the research
project and release time for participants. The unit
coordinators announced the study during their staff
meetings and encouraged participation in the project.
Recruitment of volunteers for the sample posed
some difficulties. This may have been due to changes
which were being implemented in the organization of
nursing services at the time of the study. Immediately
prior to the study, the hospital began the process of
changing from the "team leading" form of nursing care
to the "total patient care" concept of nursing. Layoffs
of some auxiliary personnel had occurred due to these
changes. There was much discussion of job related stress.
Because layoffs had occurred, some personnel may have
been fearful that participation in the study would be
viewed as admittance to high levels of stress. Since
the organizational change required personnel to attend
eight two-hour classes in addition to their work hours,
some personnel may have felt saturated with meetings
or did not have the necessary time to
the study.
Demographic Characteristics
icipate in
Twenty-five persons employed at Hospital
31
volunteered for the research project. The sample con
sisted of one male and 24 females. Participants ranged
in age from 22 to 62 years. The mean age was 36.8 years
with a standard deviation of 11.8 years. Table 1 shows
the breakdown of the study population by age and edu-
cation. Forty-four percent of the sample were in the
age group of 21 to 30 years; the remaining 14 participants
were evenly distributed throughout the remaining three
age groups.
Eighty-four percent, or 21 participants, had com
pleted one year of college or more (Table 1). Since
licensed nursing requires some advanced education and
many of the participants in the study were nurses, the
high number of participants with some college education
could be expected. Three of the participants had com
pleted high school and one participant completed primary
school. Ten participants had completed four or more
years of college.
Table 2 shows the demographic distribution of
participants by occupation, work area, and the shift
32
Table 1
Age and Education of Sample Population
Characteristics Numbers Percentage 2:-0
Age in years 21-30 11 44 31-40 5 20 41-50 4 16 50+ 5 20
Education Primary 1 4 High School 3 12 College ( 1 yr. or more) 21 84
Table 2
. a Participants Grouped by Occupatlon ,
b Work Area , and Primary Shift
Chatacteristics
occupation RN LPN Aide Other (clerks and respiratory therapists)
Work Area ICU, CCU, Semi-ICU General Care OB/Gyn/Nursery Other (Clerks and RT)
Primary Shift Day Afternoon Night Rotate
Numbers
11 7 2 5
3 16
3 3
12 7 3 3
33
Percentage g. o
44 28
8 20
12 64 12 12
48 28 12 12
Note. aOccupation: RN=Registered Nurse; LPN=Licensed Practical Nurse; AIDE=Nurses Aide; RT=Respiratory Therapist; Clerk=Ward Clerk.
b ICU , CCU, Semi-ICU Intensive Care Unit, Coronary Care Unit, and Special Care Unit; OB/Gyn/Nursery= Obstetrics, Gynecology, and Nursery.
34
they most frequently worked. The factors of occupation,
primary shift, and work area may affect the physical
and mental stress of the hospital employee.
Participants most frequently worked day-shift in
the general care area (64%) and were registered nurses
(44%). The general care area (GC) is a medical and
surgical patient care area. Other participants were
licensed practical nurses (28%), aides (8%) or clerks
and respiratory therapists (20%), and worked in critical
care areas (12%), obstetrics (12%), or other areas within
the hospital (12%), on afternoons (28%), nights (12%)
or rotating shifts (12%). It was speculated that workers
in intensive care (ICU), coronary care (CCU), and special
care (semi-ICU) areas where patients are more critically
ill might experience greater levels of stress than those
in other areas because more "life and death" decision
making is required. Unfortunately, the numbers of par
ticipants in this study were too small to test this
hypothesis. In addition, it was believed that work
schedules might contribute to the job stress experienced
by subjects; however, again the small sample size did
not permit for this type of analysis.
Self-Rating of Health Status
The 25 participants were asked to rate their own
health on a scale of one to ten, one denoting poor health
and ten indicating excellent health. The participants'
view of their own health did not vary significantly
from the pretest to the posttest. Twenty percent of
the participants (5) reported a health level of five
to seven on the health scale, while 80% (20) reported
their health in the eight to ten wellness area of the
scale.
The participants were asked to rate the health
35
of their co-worker's on a scale of one to ten. The
pretest findings showed that 15 participants (60%) rated
their co-worker's health between eight to ten, nine
participants (36%) viewed it at five to seven, and one
(4%) at four or below on the rating scale. At posttest,
14 participants or (56%) viewed their co-workers' health
as eight to ten on the wellness area of the scale and
11 participants (44%) viewed their co-workers health
as five to seven on the scale. Participants consistently
rated their own health as good and their co-worker's
health as not as good as their own. This could be the
result of participants recognizing health problems in
others more easily than they were able to recognize
problems in themselves. The possibility exists that
participants were able to see the effects of stress
more in their co-workers.
Health Complaints
The pretest and posttest questionnaire included
a question requesting participants to report any medical
36
problems. Table 3 shows that 13 participants (52%)
reported complaints or disease which may be viewed as
stress related. Seven participants (28%) reported similar
complaints on the posttest.
Some of the complaints and diseases reported, such
as hypertension and heart disease, would not be resolved
through the introduction of a relaxation technique
although blood pressure may be decreased to some degree.
Table 3 shows that the changes from pretest to posttest
responses occurred in the reports of asthma, neck and
back pain, and frequent cold or flu. It is unknown
what accounted for these changes in response. It is
possible the progressive relaxation program may have
contributed.
Blood Pressure
Blood pressure measurements were obtained on all
subjects prior to learning progressive relaxation and
after the final progressive relaxation training session
at the time of the posttest. Independent raters followed
the Utah State Health Department's two-step method of
blood pressure measurement. The individual blood pressure
measurements at pretest and posttest are presented in
Appendix I.
Table 4 shows mean systolic baseline blood pressure
was 124 with a range from 154mm Hg to 102mm Hg and
standard deviation (SD) of 13.5. Posttest systolic
37
Table 3
Participants Reported Health Related Complaints
Complaint or Disease Pretest No. Posttest No.
Asthma 2 0
Headache 1 1
Neck and back pain 2 0
Frequent cold or flu 3 1
Hypertension 4 4
Heart disease 1 1
13 (52%) 7 (28%)
Table 4
Blood Pressure Results Comparison
Baseline SD X Change Combined t (pJ Posttest SD
X systolic 124 13.5 -7 11.9 2.98 .007
range 154-102
X diastolic 78 11.8 -5 12.3 1.91 .067
blood pressure ranged from 168mm Hg to 98mm Hg with
a standard deviation of 15.8. Between the pretest and
posttest, the mean systolic blood pressure decreased
from 124mm Hg to 117mm Hg, a mean change of 7mm Hg.
The difference between pretest and posttest systolic
blood pressure was a significant decrease in ! (24)
= 2.98, £ = .007, with a combined standard deviation
of 11.9.
The mean diastolic baseline blood pressure was
38
78 with a range of 98mm Hg to 60mm Hg and standard
deviation of 11.8. Posttest mean diastolic blood pressure
was 73mm Hg with a range from 90mm Hg to 60mm Hg and
standard deviation of 8.4. The change of mean diastolic
blood pressures from 78 to 73 (5mm Hg) was nearly sig
nificant (![24] = 1.91, £ = .067). Significant statisti
cal differences among participants according to occupation
were not found in blood pressure measurements.
Prior to initiation of this study, six of the par
ticipants were on blood pressure medication and continued
with their medication throughout the research project.
Participants taking blood pressure medication had a
mean systolic blood pressure at pretest of 140mm Hg
and a systolic mean at posttest of 131mm Hg. The dia
stolic mean blood pressure of this group at pretest
was 90mm Hg. The diastolic mean decreased to 81mm Hg
at posttest.
39
For purposes of this study, a systolic blood pressure
of 140 and a diastolic blood pressure of 90 or greater
was considered an elevated blood pressure as determined
by Utah State Department of Health protocol. Table
5 shows that five participants had blood pressure measure
ments greater than 140/90 at some point in the study.
Three participants with elevated blood pressure were
31 years of age or under and two of the participants
were 54 years of age or older. Participants with ele
vated blood pressure readings were closely divided
according to shift worked, with two participants working
day shift, two participants working evening shift, and
one participant working night shift. Four participants
worked in the general care area, and one participant
worked in no particular specialty area. Two of the
participants with elevated blood pressure were registered
nurses; one licensed practical nurse, one nurses aide
and one ward clerk also had elevated blood pressure.
No pattern could be found in the work environment that
showed any relationship to blood pressure elevations.
As can be seen in Table 5, the systolic pretest
blood pressure of one participant decreased from 154mm
Hg to 122mm Hg at the posttest and the diastolic blood
pressure of 98mm Hg decreased to 84mm Hg at the posttest.
Two participants had a higher systolic blood pressure
at the posttest with 150mm Hg and 168mm Hg respectively.
Age
28
28
31
54
59
Table 5
Elevated Blood Pressure Readings of Five
Participants in the Sample
Sys
148
138
154
140
146
Sys 2
122
150
122
130
168
Dia
82
88
98
96
90
40
Dia 2
88
80
84
76
84
41
Both of these individuals showed a decrease in diastolic
blood pressure from pretest to posttest, one decreasing
from 88mm Hg to 80mm Hg and the other decreasing from
90mm Hg to 84mm Hg.
All of the participants with elevated blood pressure
showed a decrease in their diastolic blood pressure
at the posttest except for one individual who had a
pretest diastolic blood pressure of 82mm Hg and had
a posttest diastolic blood pressure of 88mm Hg. This
particular individual was on blood pressure medication
and the dosage was changed during the course of the
study.
Self-Report of Tension Scale
A self-report rating scale of tension was used
in the pretest and posttest and at the weekly progressive
relaxation sessions. Participants rated their current
level of tension on a scale of one to ten, one meaning
low and ten high tension. Participants also were asked
to rate their highest level of tension experienced during
that day on the same scale. The self-report scale was
administered following the weekly practice sessions
of progressive relaxation. It was thought that there
would be a difference between the highest level of tension
scale and the current level of tension, and that since
the scale was given following progressive relaxation
training sessions, the current level of tension scale
would show a lower tension level than the highest level
of tension scale.
42
During the six week course of the study, the weekly
self-report measures of high tension did not differ
significantly by !-test from the pretest rating. Current
levels of tension measured weekly did not differ signifi
cantly on the self-report tension scale from the pretest
except during week three when participants reported
that their current level of tension increased. This
reported increase was significant, !(24) = 2.77, E = .011.
The participant~ highest level of tension for the third
week of the study also was elevated, but not signifi
cantly. Weekly comparisons between the highest levels
of tension experienced during the day and the partici
pants' current levels of tension showed no significant
difference.
The participants' pretest self-reported highest
levels of tension ranged from two to ten with a mean
of 7.08 (SD = 2.18). The posttest self-reported highest
level of tension ranged from two to ten with a mean
of 6.84 (SD = 2.23). This change was not significant.
The current levels of tension ranged from two to ten
at pretest with a mean of 6.64 (SD 1.98); the posttest
range was two to eight with a mean of 4.36 (SD = 1.78).
This also was not significant.
43
Taylor Manifest Anxiety Scale (TMAS)
The Taylor Manifest Anxiety Scale (TMAS) was given
before and after the study to measure trait anxiety.
The potential range was from zero to 50, 50 meaning
high anxiety and scores close to zero showing a low
anxiety level. The test was scored by giving the partici-
pant one point when their answer matched the test answer.
This scoring procedure was suggested by Coursey (Coursey,
R. Personal Communication, February, 1984).
The Taylor Manifest Anxiety scores at pretest ranged
from six to 28 with a mean score of 18.76 (SO 8 . 1 ) .
Posttest scores ranged from three to 35. The post test
mean was 16.48 (SD = 8.8). This decrease in trait
anxiety between the pretest and posttest Taylor Manifest
Anxiety Scale mean scores was significant, ! (24) =
3.31, Q = .003. Short form Taylor Manifest Anxiety
Scale scores are presented in Appendix J.
TMAS Score and Reported Level of Tension
Table 6 shows the pretest and posttest scores of
the Taylor Manifest Anxiety Scale and self-reported
current levels of tension of all participants. As can
be seen by a (*) in Table 6, 13 participants reported
a self-report current tension level of seven or greater
on the pretest. At the posttest, three participants
reported a self-report current tension level of seven
Table 6
Compar on of Taylor Manifest Anxiety Scale Scores
with Self-Report Current Tension Level
TMAS Tension TMAS 2 Tension
23* 6 22* 4
25* 6 19 2
15 7* 19 6
10 3 7 6
20 7* 15 6
33* 6 31* 7*
13 8* 11 6
10 6 5 5
19 7* 16 6
10 3 8 2
20 7* 20 4
38* 8* 34* 2
19 10* 12 5
23* 9* 26* 4
9 8* 3 3
18 10* 12 8*
35 10 35* 7*
17 10 13 2
11 2 9 4
23* 6 23* 4
16 6 15 2
24 * 6 17 4
16 7* 23* 3
16 3 12 3
6 5 5 4
44
2
45
or greater. Eight participants had TMAS scores greater
than 20 on the pretest and seven participants had TMAS
scores greater than 20 at the posttest. As can be seen,
only one subject on pretest and two on posttest had
high scores on both measures.
Bryne (1974) reports previous studies show mean
TMAS scores for university students of 15.36 (Vassiliou,
Georgas & Vassiliou, 1967), while medical patients have
had mean TMAS of 13.3 Neuropsychiatric patients have
higher mean scores (26.2) on the Taylor Manifest Anxiety
Scale (Matarazzo, Guze & Matarazzo, 1955). For this
study, a score greater than 20 was chosen as an indicator
of anxiety. Reference could not be found in the liter
ature indicating what was considered a high level of
anxiety score.
occupation and TMAS Scores
Participants by occupation were compared in Taylor
Manifest Anxiety Scale scores using independent t-tests
to compare registered nurses with all others in the
study. Table 7 shows there were 11 participants in
the RN group with a mean TMAS score of 16.3 (SO = 5)
at the pretest. The posttest TMAS mean of this group
was 12.4 (SO = 5.2). The other 14 participants had
TMAS mean score at the pretest of 21.8 (SO = 9). The
TMAS posttest mean of these 14 participants was 20.9
(SO = 9.3). The registered nurse group showed a signifi-
46
Table 7
Taylor Manifest Anxiety Scale (TMAS)
Comparison by Occupation
Post- t-test Group No. Pretest Posttest Pretest significance
RN 11 mean 16.3
SD 5
vs. others 14 mean 21.8
SD 9
Value
Significance
12.4
5.2
20.9
9.3
mean diff. -3.9
SD diff. 2.3
mean diff. -1
SD diff. 3.7
~ .L
-E-
-1.91 2.82 2.39
.072
.011
.026
47
cantly lower Taylor Manifest Anxiety Scale scores from
the other participants, t (23) - 3.44, E .011.
Differences between pretest and posttest Taylor Manifest
Anxiety Scale scores were analyzed by !-test to compare
registered nurses with all other participants to account
for testing effects. The registered nurse group showed
a pretest-posttest mean difference of -3.9 (SO = 2.3).
The other participants including licensed practical
nurses, nursing aides, respiratory therapists, and ward
clerks had a pretest-posttest mean difference of -1
(SO = 3.7), which also showed significantly lower TMAS
score, ! (23) 2.39, E = 0.26.
The lower Taylor Manifest Anxiety Scale scores
for the RN group seem surprising since registered nurses
are ultimately responsible for the patient care provided
in their area. Because of prior layoffs involving only
auxiliary personnel, the registered nurses may have
felt more secure in their position than some of the
other participants. It is important to note that since
the change to total patient care, licensed practical
nurses were assuming a wider range of responsibility
which may have increased their stress levels. Bryne
(1966, 1974) discusses the effect education has on the
Taylor Manifest Anxiety Scale Scores, and indicates
that studies have shown that the TMAS scores tend to
be lower among participants who have some university
48
education. University students have had a mean TMAS
score of 15.36; high school students have had a mean
TMAS score of 18.7; and those having a grammar school
education have had a mean score of 20.5 in prior studies
(Bryne, 1974). The differences noted in this study
in Taylor Manifest Anxiety Scores by occupation may
be explained by the higher educational level of registered
nurses.
Participants' Prior Methods for Relaxation
The pretest questionnaire asked the participants
to describe their prior methods of achieving relaxation
to determine how many participants already used some
form of relaxation technique. Six participants (24%)
reported having no prior technique for reducing stress.
Nine participants (36%) had a hobbie or some form of
diversion such as music, reading, sewing, or sleeping.
Six participants (24%) used exercises such as jogging,
bicycle riding, or aerobics to relieve stress. A type
of muscle relaxation technique was used by two partici
pants (8%); two participants used some other method
of relaxation such as a combination of hypnosis, trans
cendental meditation, or breathing exercises.
Table 8 shows those participants who used some
form of additional relaxation technique or exercised
to relieve stress and compares these participants in
blood pressure readings and Taylor Manifest Anxiety
Table 8
Comparison of Blood Pressure and TMAS Scores of the Ten Participants Who
Used Additional Relaxation Technique or Exercise
Method Used by Three Subgroups No. Age Systolic Systolic 2 Diastolic Diastolic 2 TMAS TMAS 2
Exercise ( 6 ) 26 110 110 60 70 25 19 29 123 118 84 68 10 7 24 24 118 76 66 10 8 38 20 104 83 74 9 3 42 120 122 70 74 18 12 25 120 116 90 70 24 17
Muscle relaxation ( 2 ) 44 120 108 88 70 20 15 35 120 118 60 90 16 12
Other methods a ( 2 ) 42 112 98 72 68 13 11 39 102 106 70 68 19 16
Additional relax-I ation technique or exercise group mean ( 10) 34 117 112 75 72 16.4 12
Total Group Mean ( 25) 37 124 117 78 73 18.8 16.5
Note. ~ypnosis , Transcendental Meditation, Breathing Exercises.
Does not include hobbie/diversion. ~
\.0
Scale scores at the pretest and posttest.
None of the ten participants using an additional
relaxation technique or exercise had blood pressures
greater than 140/90 at the pretest or posttest. The
50
mean systolic blood pressure for these ten participants
at pretest was 117mm Hg and decreased to 112mm Hg at
posttest. Both of these means were lower than the total
group means at pretest (124mm Hg) and posttest (117mm
Hg). The diastolic mean blood pressure of the additional
relaxation technique or exercise group was 75mm Hg at
pretest, and decreased to 72mm Hg at posttest. These
means did not differ as much as the total study group's
diastolic blood pressure means of 78 (pretest) and 73mm
Hg (posttest). The additional relaxation technique
or exercise group had a mean age of 34.4 years while
the mean age of the total study group was 36.8 years.
The mean Taylor Manifest Anxiety score of the additional
relaxation technique or exercise group was 16.4 at the
pretest and 12 at the posttest. The Taylor Manifest
Anxiety Scale score means for the total study group
were 18.76 at pretest and 16.48 at posttest.
When comparing the mean scores of each group divided
according to method of additional relaxation technique
or exercise used, the subgroup having no prior technique
(~ = 6) for reducing stress had the largest decrease
in systolic blood pressure (10mm Hg). All the other
subgroups using additional relaxation techniques of
exercise had mean systolic blood pressure decreases
51
of 5-7mm Hg, except for the hobbie or diversion subgroup
who showed no mean change. Again, the subgroup having
no prior relaxation method (n = 6) showed the largest
decrease in mean diastolic blood (8.8mm Hg). Those
subjects in the exercise subgroup (~ = 6) or those sub-
jects in the muscle relaxation subgroup (~ 2) had
mean decreases in diastolic blood pressure between
6-6.9mm Hg. Those subjects in the other methods subgroup
(~ = 2) or hobbie or diversion subgroup (~ = 9) had
minimal mean changes in diastolic blood pressure. These
results suggest that participants having had no prior
method of dealing with stress gained the most benefit
from participating in progressive relaxation exercises.
When analyzing mean TMAS scores of participants
grouped by type of additional relaxation method used
or lack of additional method, all subgroups decreased
to a mean TMAS score range of 11-16.8 except for the
hobbie or diversion subgroup which increased from 20.6
at pretest to a mean of 21.2 at the posttest. The reason
is not clear at the present time. The data may suggest
that persons in the hobbie or diversion subgroup have
already achieved the level of relaxation they are capable
of achieving. It may be that progressive relaxation
is not a suitable technique for stress reduction in
52
members of this subgroup and the use of other relaxation
methods should be explored.
Level of Practice and Mastery of Technique
The (25) participants reported practicing an average
of 4.3 days weekly over the six week research project
for a mean of 7.9 minutes per day. Participants were
asked to rate on a scale of one to ten their major
location of use of the technique and where they perceived
the technique as most effective. Eighteen participants
reported using the technique most frequently (scaled
six to ten) at home, while seven participants used the
technique most frequently at work. Seventeen partici-
pants reported the technique as effective for use at
work (scaled six to ten), and 21 reported it as effective
for home use (scaled six to ten).
As could be predicted, participants' perceived
level of mastery increased with the number of days spent
practicing. Those practicing less than four days per
week reported a mean mastery level of 5.6 and those
practicing six to seven days per week reported a mean
mastery level of 6.7.
Interestingly, the largest decrease in systolic
blood pressure (13mm Hg), and diastolic blood pressure
(9.1mm Hg) occurred among the seven participants prac-
ticing less than four days. Only three participants
in the group practicing less than four days per week
were using an additional relaxation technique or exer
cising. This relationship between less practice time
and decreased blood pressure was certainly not expected
and is a curious finding.
Summary of Results
53
Twenty-five employees of Jaycee Hospital volunteered
for this research project. The majority of the sample
consisted of female nurses working day and afternoon
shift in the general care area of the hospital.
On the self-rating health scale, participants tended
to rate their own health as good and their co-worker's
health as not as good as their own. Health complaints
of asthma, neck and back pain, and frequent colds de
creased from the pretest to the posttest. The mean
systolic blood pressure of participants decreased from
124mm Hg at est to 117mm Hg, a significant decrease
(E = .007). The mean diastolic blood pressure of partici
pants decreased from 78 to 73mm Hg, which was nearly
significant (£ = .067). Participants' mean Taylor Mani
fest Anxiety Scale scores decreased significantly between
the pretest and posttest (E = .003).
A self-report rating scale of tension was used
in the pretest and posttest and at the weekly progressive
relaxation sessions. The self-report rating scale of
tension did not differ significantly during the course
54
of the study from the pretest measure. Current levels
of tension measured weekly did not differ significantly
from the pretest except at week three when the current
level of tension was significantly higher (2 = .011).
Weekly comparisons between the highest levels of tension
and current tension showed no significant difference.
Those participants using the additional relaxation
methods of physical exercise, muscle relaxation tech
niques or other relaxation techniques that do not include
muscle relaxation techniques had lower mean diastolic
and systolic blood pressure and TMAS scores at the pretest
than other subgroupsj they also had posttest decreases
similar to the total group in these blood pressure and
TMAS measures. The results of this study showed those
participants in the subgroup having no additional method
of relaxation prior to this study had the largest im
provements in blood pressure, while the participants
in the hobbie or diversion subgroup showed the least
benefit.
Participants reported prcticing the progressive
relaxation technique an average of 7.9 minutes per day
for an average of 4.3 days weekly during the six week
period of this research project. Participants reported
using the technique most frequently at home, but that
they found it an effective technique for work or home
use. The mean perceived mastery level of the participants
increased with the number of days the participants
practiced the technique.
55
The findings of this study suggest that progressive
relaxation techniques may assist in stress reduction.
CHAPTER IV
DISCUSSION OF RESULTS
The purpose of this study was to determine the
effectiveness of progressive relaxation as a technique
for stress reduction in the work setting. If the tech-
nique was effective in a work setting, then subjects
may learn to cope with their stress and reduce tensions
before stress becomes chronic and stress related illness
develops. In addition, progressive relaxation could
be used in different work settings with a variety of
participants who might benefit from learning such a
technique.
The first question examined was whether blood pres
sure would decrease in participants when systolic and
diastolic blood pressure measurements are compared prior
to the study and following progressive relaxation train
ing. Results of this research project indicate a signifi
cant (E <.01) decrease in systolic blood pressure of
the participants over the course of the study. Diastolic
blood pressure also decreased among participants from
pretest to posttest and approached significance (E <.07).
These results indicate some support for the effectiveness
of progressive relaxation in reducing stress. Due to
the small sample size in this study and the inequality
of groups, blood pressure results could not be compared
by area of specialty, occupation or shift.
The second question examined was whether perceived
level of anxiety among participants would decrease
following progressive relaxation training. There was
57
a significant decrease (E<.01) in the level of anxiety
as measured by the Taylor Manifest Anxiety Scale between
pretest and posttest measures of study participants.
This finding further supports the effectiveness of pro-
gressive relaxation in stress reduction. It was found
also that registered nurses, as a group, had significantly
lower anxiety than the other participants in the study
(E<.01). This seemed surprising since registered nurses
ultimately are responsible for patient care, and it
was expected that this additional responsibility would
increase their stress. In addition, during the time
of this study, licensed practical nurses were assuming
more responsibility for patient care which could have
increased their stress levels. It may have been that
the lower anxiety level among registered nurses was
related to their higher level of education, since studies
show lower Taylor Manifest Anxiety scores among persons
with higher education levels (Bryne, 1974). An increased
level of education may enable persons to cope better
cognitively with additional stress. Further exploration
58
into this occurrence is warranted.
The third question examined in this study was whether
the perceived level of tension among participants would
diminish following progressive relaxation training.
Comparisons of the perceived current level of tension
with the highest level of tension expressed weekly on
the self-report scale did not show a significant differ
ence. This may have been due in part to the variability
with which people practiced progressive relaxation,
trainer related variables, or environmental influences.
There may have been some participant error in marking
current level of tension and the highest level of tension
experienced during the day, since several participants
rated their current level of tension higher than their
highest level of tension. The lack of correlation between
perceived tension and Taylor Manifest Anxiety Scale
scores suggest that the self-report of perceived tension
scales may not have been a valid and reliable tool.
Participants consistently rated their health as
better than they rated the perceived health of their
co-workers. Participants also reported a decrease in
stress related complaints including neck and back pain,
headaches and colds following instruction and practice
of progressive relaxation which suggests that progressive
relaxation may have assisted in decreasing tension so
that some of the symptoms related to chronic tension
also decreased. Further study is indicated to observe
trends in reported symptoms.
Participants in this study were grouped according
to additional method of relaxation or exercise used
prior to this study. There were five groups including
a hobbie or diversion group, physical exercise group,
muscle relaxation technique group, another technique
for relaxation, and a group reporting no prior method
of relaxation. Those participants using an additional
form of relaxation or exercising prior to this study
displayed a lower systolic and diastolic mean blood
pressure at the pretest. The mean blood pressures of
this additional relaxation or exercise method group
decreased (systolic = 5mm Hg, diastolic = 3mm Hg), but
59
not by as many mm Hg as in the total group of participants
(systolic = 7mm Hg, diastolic = 5mm Hg. The partici-
pants having no prior method of relaxation showed the
largest decrease in mean systolic (lOmm Hg) and mean
diastolic (8.8mm Hg) blood pressure at the posttest.
The hobbie or diversion group showed no mean decrease
in systolic blood pressure and a minimal decrease in
mean (2mm Hg) diastolic blood pressure at the posttest.
As expected, results suggest that progressive relaxation
is most beneficial to those participants who have no
prior form of relaxation and that even those participants
who are using a prior form of relaxation can benefit
60
from progressive relaxation exercise.
The TMAS score difference between pre- and posttest
anxiety (TMAS) scores in the additional relaxation or
exercise group were slightly higher (4.4) than those
of the total group of participants (2.3). The mean
TMAS score of the hobbie or diversion group increased
at the posttest. The reason for this is not clear.
The hobbie or diversion group actually reported prac
ticing the progressive relaxation technique during the
course of the study a little longer (mean = 8.9 minutes)
than the total group of participants (mean = 7.9 minutes).
Possibly participants in the hobbie or diversion group
had already attained the relaxation possible for them
or it may be that this group was composed of people
who did not respond to progressive relaxation techniques
for various reasons.
As could be expected, the participants practicing
progressive relaxation more days during the week showed
decreases in mean systolic and diastolic blood pressure
and TMAS score on the pretest-posttest. The participants
practicing the technique less than four days per week,
however, showed larger decreases in systolic and dia
stolic mean blood pressure. This finding may be due
to an artifact such as random noise or malfunction of
equipment during the blood pressure measurements, or
some other unknown reason. Future study with a larger
61
sample should examine practice time against the anxiety
measures and blood pressure measures used in this study.
Results of this study suggest that systolic blood
pressure and anxiety levels as measured by the Taylor
Manifest Anxiety Scale among participants may be decreased
significantly with learning progressive relaxation but
results of this research project cannot be generalized
because of some limitations of the study.
Limitations
Due to the small sample size, generalizations regard
ing results of TMAS score, self-report rating score
and blood pressure measurement could not be attempted.
The sample size was not large enough to group subjects
according to participant work area, shift, or occupation
and then analyze differences in measurements of self
rating scales, blood pressure and TMAS scores among
groups. Since the sample consisted of volunteers,
selection effects or sampling error may have occurred
so that decreases in blood pressure and anxiety levels
found might have been due to differences inherent in
the volunteer group and not to the introduction of pro
gressive relaxation. Participants were not evenly divided
by sex and age. The participation of only one male
may be because fewer men work in hospitals. The partici
pants were young, which may be attributed to the fact
that hospital nursing is very demanding and hospitals
tend to hire younger people.
62
In addition, younger people
may be more aware of stress and motivated to volunteer
for studies such as this one.
In order to retain the sample group of 25 partici
pants, numerous individuals had to be taught progressive
relaxation on an individual basis. This may have resulted
in some variations in trainer effectiveness as well
as differences in blood pressure measurement, self-
rating scales and anxiety levels in these participants.
The participants' level of tension was monitored
weekly on the self-report scale. Behavior has a tendency
to change when it is monitored which limits the ability
to interpret the results as causal. Responses on the
self-report scale and post test questionnaire may have
been affected by the novelty of learning a new technique,
participants' awareness of participation in a study,
or a desire to provide the researcher with the answer
which participants perceive to be sought by the re
searcher.
It was not possible to control either the amount
of practice time or completion of data collection instru
ments. Some participants left questions blank which
made accurate analysis of the TMAS and questionnaire
results difficult.
This study used the one group pretest-post test
design. Due to the nature of this design, numerous
threats to internal validity or extraneous factors may
have influenced anxiety measures and blood pressure
rather than the introduction of progressive relaxation.
Since the pre- and posttests were given six weeks
apart, change producing events, history effects may
63
have occurred. For example, participants may have
adjusted to the total patient care form of the nursing
which was introduced in the hospital prior to the study.
It could be suggested that as participants successfully
adapted to these changes, their stress levels decreased.
There may have been maturation effects which influ
enced the findings of this study. Since this study
was conducted during the summer months, participants
had a chance to get out of doors, increasing the oppor
tunity to exercise and enjoy nature which may have
increased their ability to relax. The fact that this
study was implemented just after the change to the total
patient care form of nursing may have produced greater
responsiveness in the participants to the introduction
of progressive relaxation than would have been present
if the study had been conducted at another time.
Testing effects may have influenced the study's
finding since subjects taking a test for the second
time usually improve their score; the pretest may have
allowed subjects to anticipate answers on the posttest.
Since the participants knew they were identifiable to
64
the researcher, some may have attempted to provide answers
they believed were sought by the investigator. Some
of the more extreme questions on the Taylor Manifest
Anxiety Scale may have been discussed among participants
prior to the posttest, thus some test-retest or practice
effect may have occurred. In addition, instrumentation
effects may have occurred. Slight alterations in rater
hearing of blood pressure may have occurred during the
interval between the pretest and posttest. In the one
group pretest-post test design there are several threats
to external validity which must be considered. Inter-
action of testing with the intervention may have occurred.
For example, the pretest may have affected the partici
pants' attitude and willingness to be persuaded to focus
on increasing the effects of progressive relaxation.
Thus the effect of the practice of progressive relaxation
observed on the posttest may be specific to the partici
pant~ exposure to the pretest.
In addition, interaction of selection with treatment
effects may have occurred. Volunteerism may have effected
the outcome of the study since volunteers differ from
other groups and there were no control groups or random
assignment in this study. Since the study was conducted
in one hospital, there may have been some characteristics
of this hospital environment which made the introduction
of progressive relaxation more effective. A future
study representative of differing hospitals should be
considered.
Reactive arrangements or participant knowledge
of participation in a research study may have affected
participant attitude and therefore the results obtained
65
in this study. The fact that participants were pretested
may have been enough to begin reactive arrangement effects.
Although the study was conducted in an informal atmos
phere, the presence of the researcher may have made
participants aware of the research study. It would
be beneficial in future studies to have someone other
than the researcher to teach progressive relaxation
and obtain the measurements.
Due to the limitations of this research project,
future studies should attempt to obtain a larger sample.
Further studies using experimental designs including
random sampling and control groups should be considered.
This study used volunteers in a hospital setting. Par
ticipants were generally young female nursing personnel.
Since volunteers introduce the bias of self-selection
and may differ in character from the normal population,
future study samples should be random. If an experi
mental design were used, the relationship of progressive
relaxation to stress reduction could be shown with more
confidence. When a one group design is used, as in
this study, extraneous factors, such as changes occurring
as a result of time or changes in the work setting may
occur. These extraneous factors cannot be controlled
in a one group design study such as this one and these
factors may have influenced the outcome of the study.
Indications for Future Study
66
Future studies could provide training in two to
three group sessions followed by practice with individual
ized tape recordings. This could be a potentially
effective means of training larger numbers of subjects.
The individualized tape recording practice time should
be accompanied with periodic group meetings over a two
month period so that more personalized contact is main
tained. Other studies may include a discussion of life
style factors, time management and conflict resolution
with learning the relaxation technique of progressive
relaxation to provide a more complete program of stress
reduction.
Future study of progressive relaxation in other
hospitals should include a large enough sample size
to permit analysis of the results of anxiety measures
and blood pressure measurements among participants by
work area, occupation, and shift. If a larger sample
with more equality between groups could be tested, results
would be more representative of the population and there
fore more confidence in the results could be assumed.
The self-report scale did not show statistical
67
significance in this study. It may be useful to substi
tute the Mattson's Anxiety-Relaxation Scale for the
self-report scale in future research. Mattson's Anxiety
Relaxation Scale was used by Staples and Coursey (1975)
to study effects of progressive relaxation. The Mattson's
Anxiety-Relaxation Scale consists of ten scales which
give conflicting descriptive adjectives to rate a person's
perceived level of relaxation and anxiety. It is suffi
ciently short enough that it could be used weekly follow
ing progressive relaxation sessions.
A future study should include some long term follow
up of participants. For example, the participants could
be asked one month after the relaxation training sessions
if they are still practicing the technique. A repeat
anxiety measure, as well as blood pressure measurement,
could be obtained. This would be done to determine
if progressive relaxation has beneficial long term
effects. Future studies could include blood pressure
measurement prior to the last relaxation session and
at the time of the posttest in order to follow blood
pressure trends more accurately. In addition, a blood
pressure reading one week after the posttest may provide
some follow-up data. Results of this study have suggested
that progressive relaxation may be of benefit in stress
reduction. Similar studies in other settings with larger
sample groups and more rigorous designs are indicated.
Follow-up studies are required to study the long term
effects of a progressive relaxation program.
Implications of the Study
Results have suggested that relaxation techniques
taught at work can assist in effectively decreasing
anxiety levels and blood pressure measurement. Since
stress has been shown to be a contributing factor in
68
many illnesses, it is important to include stress reduc
tion programs in the work place. The occupational health
nurse is in a position to advocate stress reduction
programs and demonstrate their cost effectiveness.
The occupational health nurse should provide access
to stress reduction programs at the workplace. The
various programs could be initiated by having short
stress reduction classes before and after work. As
cost effectiveness is shown over time by research studies,
employers may begin to realize the benefit of offering
stress reduction programs to all employees during working
hours.
Future studies of stress reduction programs in
hospitals and other work settings should focus on specific
work areas in order to design programs that fit various
employees' needs. For example, a stress reduction program
for a nurse or a ward clerk may be different between
an obstetrical unit and intensive care area. Relaxation
techniques should be combined to suit area and occupation
69
needs. There is a great deal of discussion about "burn
out" in hospitals. Nurses are aware that shift work,
patient load, and the work area may increase stress
levels. Many nurses perceive the problem as frustrating
and nonresolvable. Programs offered in the work setting
may give nurses some sense of control. This study sug
gested a progressive relaxation program conducted in
a work setting may assist hospital employees to reduce
stress as measured by anxiety measures and blood pressure.
Other stress reduction programs could include an emphasis
on lifestyle and coping skills in addition to relaxation
techniques. Such programs may improve job performance,
prevent the development of major health problems and
improve employee moral. Employees may begin to view
management as more caring and concerned about employee
welfare which, in turn, may improve job performance.
APPENDIX A
INFORMED CONSENT
71
I, , agree to participate voluntarily and at no cost, in the study of stress reduction using the technique of progressive relaxation in which muscle groups are alternately tensed for seven seconds and then relaxed completely. As a participant in this research, I understand that I will need to complete data collection forms on two separate occasions. I will be obligated to attend an introductory session and five half-hour training sessions over a six week period. Time for completing the data collection forms will be provided during the introductory and final training sessions. Blood pressure measurements will be taken in conjunction with each session. I understand that if I am found to have high blood pressure, I will be referred to my physicians care. I have been informed that I am to practice the progressive relaxation technique daily for a ten minute period.
I have been informed that the general results of the study will be published, but that individual information about me will be kept confidential.
There are no known potential risks to the subjects in learning the stress reduction skills. Benefits to one's health may result from the program through decreased blood pressure, muscle tension, and anxiety. The program may help participants better cope with stresses experienced on the job and at horne.
Inclusion in this study is voluntary; I understand that refusal to participate in this study is an option which I am free to choose. I may withdraw from the study at any time if I so desire. The investigator will answer any questions. Contact Linda Morris.
Signature
Date
APPENDIX B
PRETEST QUESTIONNAIRE
lD number Blood Pressure
1. Age
2. Sex
3. How many years of schooling have you completed:
(0-6 Primary; 7-9 Junior High; 10-12 High School; 13-17 College; 18-21 Graduate School)
4. Occupation ---------------------5. Area of specialty
6. Shift
lCU, CCU, Semi-lCU Psych General Care Obstetrics/Gyn Surgery/PAR Other
Mainly days Mainly afternoons Mainly nights Rotate to all three shifts
7. Describe your general health
8.
9.
10.
Excellent 10 9 8
Describe the
Excellent 10 9 8
Describe your
Very tense 10 9 8
Describe the today
Very tense 10 9 8
7 6 5 4 3
health of most of
7 6 5 4 3
current level of
Very 7 6 5 4 3
highest level of
Very 7 6 5 4 3
Poor 2 1
your co-workers
Poor 2 1
tension
relaxed 2 1
tension experienced
relaxed 2 1
11. List any past or curent medical problems:
12. Describe the techniques and outlets you have used
73
in the past to reduce tension and help you cope with stress:
APPENDIX C
SELF-REPORT RATING SCALE
ID number
1. Describe your current level of tension
Very tense 10 9 8 7 6 5
Very relaxed 432 1
75
2. Describe the highest level of tension you experienced today
Very tense 10 9 8 7 6 5
Very relaxed 432 1
APPENDIX D
POSTTEST QUESTIONNAIRE
77
ID Number Blood Pressure
1. Describe your general health
Excellent Poor 10 9 8 7 6 5 4 3 2 1
2 • Describe the health of most of your co-workers
Excellent Poor 10 9 8 7 6 5 4 3 2 1
3 • Describe your current level of tension
Very tense Very relaxed 10 9 8 7 6 5 4 3 2 1
4 • Describe the highest level of tension experienced today
Very tense Very relaxed 10 9 8 7 6 5 4 3 2 1
5. List any past or current medical problems:
6. About how many days per week would you say you took time out to practice the relaxation method? days.
7. On the days when you did practice, about how many minutes did you practice on the average? minutes.
8. On the days when you did practice, how often did you do it twice daily?
9. Are you currently practicing progressive relaxation?
Regularly Not at all 10 9 8 7 6 5 4 3 2 1
10. How often have you used the relaxation method to help you during stressful or tension producing situations?
At Work: not effective 1 2 3 4 5 6 7 8 9 10 very effective
At Home: not effective 1 2 3 4 5 6 7 8 9 10 very effective
Other: not effective 1 2 3 4 5 6 7 8 9 10 very effective
78
11. How effective do you feel the method is right now in helping you relax?
At Work: not effective 1 2 3 4 5 6 7 8 9 10 very effective
At Home: not effective 1 2 3 4 5 6 7 8 9 10 very effective
other: not effective 1 2 3 4 5 6 7 8 9 10 very effective
12. How much mastery would you say you have right now of the progressive relaxation method?
No mastery at all 1 2 3 4 5 6 7 8 9 10 Complete mastery
APPENDIX E
UTAH BLOOD PRESSURE PROTOCOL - TWO STEP METHOD
80 #s
1. Clients should be seated for five minutes and are requested to delay smoking or drinking beverages containing caffeine as this may alter blood pressure readings.
2.
3.
Client should be sitting straight with both feet flat on the floor.
Expose the upper right arm. Use the left arm only if the right arm cannot be used due to prior injuries, etc.
4. Make certain the upper right arm is at the level of the heart, elbow slightly flexed, forearm with the palm facing upwards and firmly supported on a flat surface.
5. The blood pressure cuff should be applied so that the cuff is one-inch above the antecubital fossa with the inflatable bladder centered over the brachial artery.
6. Wrap the cuff snugly around the upper arm.
7. Be certain you are using the proper size cuff. Many cuffs now have straight line markings on adjoining surfaces of the cuff and when the markings overlap or fall within the prescribed area, this indicates a properly sized cuff.
8. Inflate the cuff while palpating the radial artery pulse until the pulse is obliterated. Make note of the pulse obliteration level and deflate. This level will closely approximate the systolic blood pressure.
9. Calculate the peak inflation by adding 30mm Hg to the level at which the radial pulse disappeared. Palpate the brachial artery and place the stethoscope over the area.
10. Allow at least 30 seconds to lapse between pulse obliteration and auditory measurement. Rapidly inflate cuff to peak inflation level. Deflate at 2mm Hg per second. If deflation is slower than that, venous congestion develops and the diastolic reading could be elevated.
11. Record the blood pressure on the client's questionnaire sheet and place your initials by the reading. It is necessary that the same person take the blood pressure reading on the client at the beginning and ending of the study.
81
Adapted from Cardiovascular Disease/Hypertension Control Program: Minimum Requirements for Blood Pressure Certification. State of Utah Department of Health, Bureau of Chronic Disease Control, 1982.
APPENDIX F
EXERCISE FORMAT
83
Short Relaxation Exercise
A short relaxation exercise will be taught initially.
Exhale slowly. Let your shoulders sag. Relax your
face. Unclench your teeth. Drop your jaw and smooth
your forehead. Breathe slowly and deeply, letting your
body begin to feel heavy.
Progressive Relaxation
There are 16 muscle groups to tense and relax.
Make sure you are comfortable. Try not to move unneces-
sarily once the practice session begins so that distrac-
tion is avoided. Fill your lungs with air and let your
mind trace the air as you breathe in and out. As you
breathe out feel the tension leave your body. Now,
focus your attention on the muscles of your right forearm.
Notice the feeling of tension as you make a tight fist
and hold it (total of seven seconds). Now, relax.
Notice the difference between the feeling of tension
and relaxation. Let all the tension go, focusing your
attention on the pleasant feelings of relaxation flowing
through your muscles. Similar instructions will be
given when tensing each muscle group.
Muscle Area
Rt/Lt Hand & Forearm
Rt/Lt Upper Arm
Procedure
Form a tight fist
Press elbow down into chair armrest, moving upper arm toward rib cage.
Muscle Area
Upper Face
Central Face
Lower Face
Neck
Chest, Shoulder Upper Back
Stomach
Rt/Lt Thigh
Rt/Lt Calf
Rt/Lt Foot
Seven Muscle Group Procedure - Muscle Area
Rt/Lt Hand Arm
Facial Muscles
Procedure
Raise eyebrows as high as you can, or frown.
84
Squint your eyes tightly, wrinkle your nose.
Bite your teeth together and pull the corners of your mouth back.
Pull your chin toward your chest while pulling your head back with your rear neck muscles.
Take in a deep breath, hold it, while trying to touch shoulder blades together.
Pull the muscles of the stomach in while trying to press them downward.
Bend the knee forward with muscles in the back of the thigh, while bending it in the opposite direction with the muscle on top of your thigh.
Bend your foot toward the shin as if trying to touch it with your toes.
Point the toe turn the foot inward and at the same time curl your toes (limit tension to five seconds).
Procedure
Hold arm out in front of you with elbow at 45 degrees and make a fist.
Raise the eyebrows or frown, squint the eyes, wrinkle up the nose, bite down, and pull the corners of the mouth back.
Seven Muscle Group Procedure - Muscle Area
Neck and Throat
Chest Shoulders, Upper Back and Abdomen
Rt/Lt Thigh, Calf, and Foot
Four Muscle Group Procedure - Muscle Area
Hand and Arm
Face and Neck
Chest, Shoulder, Upper Back and Abdomen
Thigh, Calf and Foot
Recall
Procedure
Pull chin toward chest, while pulling the head back with the rear neck muscles.
Take a deep breath, hold it,
85
pull shoulder blades back and together, while pulling the stomach in or pushing it out.
Lift the leg off the chair slightly, while pointing the toes and turning the foot inward.
Procedure
Hold both arms out in front of you with the elbow bent at 45 degrees and make a fist with both hands.
Combine the facial muscle and neck procedure as given in the seven muscle group.
Same as seven muscle group procedure.
Lift both legs off the chair slightly while pointing the toes and turning the foot inward. (This should only be done in a stable chair and if doubt, work each leg separately.)
The subject goes through the four muscle group
procedure focusing on what the release of tension feels
like. The subject begins to learn to relax remembering
what the muscale group felt like when it was relaxed.
The subject focuses on the sensation of letting go and
feeling his/her muscles become more and more deeply
relaxed.
86
APPENDIX G
SUMMARY OF DEEP MUSCLE RELAXATION
88
You can learn to relax all large muscle groups
in your body. The method requires that you tense (tighten
up and hold the tension) and then relax the muscle.
Each time you do this, concentrate on the difference
in body sensations and feelings between the tension
and relaxation. Learning these feelings will help you
become aware of any tense muscles which you can then
relax. Try to practice this exercise two times daily
for ten minutes in a quiet place as free from distractions
as possible. The exercise progresses as follows:
Right hand and forearm - 2 times Left hand and forearm - 2 times Biceps - bend each elbow - once Triceps - arms stretched out - once Forehead - wrinkle up - once Eyes - close tightly - once Tongue - pressed up to roof of mouth - once Neck - head pressed back - once Neck - head pressed back, roll head to the left
and right - 2 times Shoulders - shrugged up - 2 times Chest - deep breath, hold it, exhale slowly 2
times Stomach - hold it in - 2 times Stomach - hold it out - 2 times Lower back - arch it up - 2 times Thighs - press down on heels - 2 times Calves - toes forward - 2 times Shins - toes up and back - 2 times
APPENDIX H
SHORT RELAXATION EXERCISE
90
Exhale slowly, let your shoulders sag. Relax your
face. Unclench your teeth. Drop your jaw and smooth
your forehead. Breathe slowly and deeply, letting your
body begin to feel heavy.
R/L Hand/Arm
Facial
Neck/Throat
Torso
R/L Leg/Foot
Seven Muscle Group Technigue
Hold your arm out in front of you with the elbow bent at 45 degrees and make a fist.
Raise your eyebrows or frown. Squint your eyes, wrinkle up the nose, bite down, and pull the corners of your mouth backc
Pull the chin toward the chest while pulling the head back with the rear neck muscles.
Take a deep breath. Hold it. Pull the shoulder blades back and together, while pulling the stomach in or pushing it out.
While sitting on a chair. lift your thigh with your leg straight pointing the toes and turning foot inward.
APPENDIX I
SAMPLE BLOOD PRESSURE
92
Table 9
Comparison of Sample Blood Pressure
Systolic Systolic 2 Diastolic Diastolic 2
118 116 60 60 110 100 60 70 110 102 60 64 123 118 84 68 120 108 88 70 118 100 82 62 112 98 72 68 130 128 84 84 102 106 70 68 124 118 76 66 130 120 78 80 138 150 88 80 122 110 80 66 140 130 96 76 120 104 83 74 120 122 70 74 146 168 90 84 154 122 98 84 110 108 60 70 148 122 82 88 110 120 70 78 120 116 90 70 114 100 76 62 120 118 60 90 140 118 90 74
APPENDIX J
SHORT FORM TAYLOR MANIFEST ANXIETY SCORES
94
The short-form 20 item portion of the Taylor Manifest
Anxiety Scale (TMAS) also indicated a drop in anxiety,
! (24) - 2.83, E = .009. The pretest mean score on
this scale was 6.4 with a standard deviation of three
and the posttest mean was 5.3 with a standard deviation
of 3.3.
Pretest
8 8 7 4 9
10 6 4 6 5 6
13 5 9 o 6
11 4 5 7 6
10 6 3 1
Raw Short TMAS Scores
Posttest
9 7
10 2 6 8 4 3 2 3 7
12 2 7 o 4
11 2 1 9 5 7 7 3 2
Difference
1 -1
3 -2 -3 -2 -2 -1 -4 -2
1 -1 -3 -2 o
-2 o
-2 -4
2 ·-1 -3
1 o 1
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