Benson's Relaxation Effect in Comparing to Systematic Desensitization on Anxiety of Female Nurses: A Randomized Clinical Trial.

INTRODUCTION: Nursing staffs expose to a high level of anxiety. This study aimed to compare the effect of Benson's relaxation and systematic desensitization methods for decreasing the anxiety score of nurses.
MATERIALS AND METHODS: In a randomized clinical trial, 72 female nurses were assigned randomly to three different groups. Benson's relaxation and systematic desensitization were used as intervention beside control group. After intervention, the Spielberger state-trait anxiety inventory was used for measuring the anxiety score. Analysis of variance (ANOVA), Tukey test, and paired t-test were applied for comparing three group scores.
RESULTS: The ANOVA test showed that a significant difference among three groups regarding scores of posttrait and poststate anxiety (P < 0.05). The Tukey test showed that both Benson's relaxation and systematic desensitization methods were effective in decreasing of the anxiety score of nurses. Moreover, the mean change in trait and state anxiety scores at Benson's relaxation and systematic desensitization groups was more than control group, respectively, and was statistically significant.
CONCLUSION: Both Benson's relaxation and systematic desensitization methods are effective in improvement of the state and trait dimensions of anxiety. However, these methods could be applied in stressful situation among medical staffs of students.

RCT Entities:   Population Interventions Outcomes

Introduction

Psychological stress and anxiety are the most important unfortunate consequence of medical jobs, especially in nursing for coursework, clinical experiences, and personal issues.[12] Nursing staffs expose to a high level of anxiety and stress that can cause a nurse experience fear about poor performance and embarrassment due to inadequate staffing, changes in the working place, and lack of administrative support.[13] Moreover, caring to patients caused a synergism effect on the nurses’ anxiety due to emotional challenges of working with the sick increased acuity of patients and patients’ demands.[1456] Moreover, shifting job beside the high load of work effects on the physical and psychological aspect of medical staffs such as nurses.[789]

Anxiety is the most psychological disorder and the most common response to the stressful condition that could cause the uncontrolled reactions including physical and emotional behaviors. The anxiety is effective on the quality of care in the nurses in clinical place works.[1011] There were medical and nonmedical treatments for muscular relaxation and improvement of anxiety.[12131415] In recent studies, some stress management approaches are assessed in nursing or in the patients for control or improvements of stress or anxiety.[116171819] Some of these relaxation therapy techniques such as applied relaxation, relaxation and imagery, relaxation response mediation, emotional freedom technique, and the combination of relaxation techniques and back massage are used and showed improvement in the quality of life and decrease in pain, anxiety, and stress in patients and staffs.[117] Moreover, the effect of Benson's relaxation technique is assessed in patients for decreasing the pain, stress, and anxiety or for increasing the sleep quality.[2021]

Benson's relaxation is one of the best muscular relaxations that effective on the pulse rate, respiratory function, and heart workload.[14] Benson's technique works by the alignment of hypothalamus and decreasing the sympathetic and parasympathetic practices. Moreover, systematic desensitization was beneficial in decreasing the psychological stress.[22] However, the effect of both Benson's relaxation and systematic desensitization techniques is not assessed for decreasing of nurse's anxiety based on our search. Therefore, the current study aimed to compare the effectiveness of two intervention including Benson's relaxation and systematic desensitization methods for decreasing the anxiety score of nurses against the control group in a randomized clinical trial.

Materials and Methods

In a randomized clinical trial, 110 female nurses recruited in Borujerd, Iran, at 2015. First, informed consent was taken from all eligible individuals, and the Ethical Committee of Arak University of Medical Sciences approved the study protocol. Moreover, this study is registered in the Iranian Registry of Clinical Trials. The primary data including demographic characteristics such as age, gender, education, marital status, job history, and the employee status were obtained. Then, the status of anxiety of individuals determined and who have the anxiety score higher than 43 included in the study. Individuals who did not affect to anxiety based on the Spielberger anxiety scale and who did not consent for participating in the study were excluded from the study. Therefore, 72 female nurses of 84 who have the anxiety score higher than 43 were assigned randomly into three different groups.

The sample size calculated based on the standard deviation and acceptable power and alpha error. According to sample size calculation, 24 individuals should be assess in each group. For the first group, Benson's relaxation method was applied, and for the second group, systematic desensitization was used. In Benson's relaxation group, the guideline of muscular relaxation heard by headphone and fulfilled for three sessions and each session continued for 20 min. Moreover, in systematic desensitization group, a skilled, trained therapist the participants’ nurses for three sessions and 20 min in each session. Third group was the control. The anxiety score measured among the individuals of three groups at the baseline and 1 month after the study inception.

Spielberger state-trait anxiety inventory (STAI) was used for measurement the anxiety score in both intervention and control groups. This questionnaire measured the two important dimensions of anxiety including state anxiety and trait anxiety. The state anxiety scale measures the emotions of the individuals in the snapshot time as time of responding to the questionnaire. Moreover, the trait anxiety scale evaluates the general emotions of individuals.[2324] The STAI scale include forty items comprising twenty items measuring the state anxiety and twenty other items measuring trait anxiety. Each item score varied between 1 and 4 and the total score of each dimension of Spielberger questionnaire changes from 20 to 80. The higher score shows more anxiety of the individuals. The anxiety was defined as the Spielberger questionnaire calculated for a individual higher than 43. A score of <43 represented normal. The reliability and validity of the Spielberger questionnaire is assessed in Iran by Abdekhodae and Mahram study.[25]

Data analysis

Mean and standard deviation were used for description of data and variables. The normality of the anxiety scores had assessed by Kolmogorov–Smirnov test in each group. Based on normality results of the dependent variables among three studied groups, parametric test was used. Analysis of variance (ANOVA) was applied for comparing the anxiety score among three groups and Tukey test was used for post hoc test. Paired t-test utilized for assessing the statistical difference between baseline measurements and final scores in each group. All the statistical analysis was conducted in SPSS software (Version 18.0. Chicago, USA: SPSS Inc.).

Results

The mean age of participants was 34.5 ± 5.3 years and varied since 25–51 years. The mean of job history was 5.12 ± 3.04 years. The results in Table 1 show the baseline measurements analysis. Based on the results, there was no significant difference among three studied groups regarding the age of participants, job history, and pretrait and prestate anxiety scores. In addition, the education level was no significant in three groups (P = 0.594). Therefore, the randomization method was adequate for random allocation of recruited individuals in three groups.

Table 1

The baseline measurements analysis in three studied groups including systematic desensitization, Benson's relaxation, and control

The ANOVA was conducted to compare the posttrait and poststate anxiety among three groups [Table 2]. The F-test showed that a significant difference among three groups regarding scores of posttrait and poststate anxiety (P < 0.05). Moreover, the changes of scores in trait and state anxiety were statistically significant (P < 0.05). The Tukey post hoc test was used to compare groups one by one, and the results showed that Benson's relaxation method was similar to systematic desensitization method in decreasing the trait and state anxiety score (P = 0.903). Therefore, both Benson's relaxation and systematic desensitization intervention methods were effective in decreasing of the anxiety score of nurses. However, the effect of systematic desensitization was more than Benson's relaxation methods but is not significant.

Table 2

Comparing the posttrait and poststate anxiety scores in three studied groups including systematic desensitization, Benson's relaxation, and control

Table 3 shows the mean changes in trait and state anxiety scores in three groups and these changes were statistically significant. In post hoc analysis, there was no significant difference in two intervention groups. Nevertheless, there was a significant difference between two intervention methods and control group by Tukey test (P < 0.05). The mean change in trait anxiety scores at Benson's relaxation and systematic desensitization groups was more than control group, respectively, and was statistically significant (−6.5 vs. 0.167, P = 0.013 and −7.5 vs. 0.167, P = 0.023). Moreover, the mean change in state anxiety scores in two intervention groups was more than control group, respectively, and was statistically significant (76.5 vs. −0.625, P = 0.007 and −7.5 vs. −0.625, P = 0.008).

Table 3

Comparing the changes in trait and state anxiety scores in three studied groups including systematic desensitization, Benson's relaxation, and control in pre- and post-intervention

Discussion

Based on our results, Benson's relaxation and systematic desensitization were effective methods for decreasing in the nurses’ anxiety in both state and trait dimensions. Moreover, there was no significant difference between two intervention methods regarding state and trait anxiety. Nevertheless, the mean of changes in anxiety score was higher in the systematic desensitization. The staff in medical workplaces are exposed to a variety of stresses and high risk for anxiety disorders. Therefore, delay in primary prevention, early diagnosis, and control of anxiety disorder caused continually of psychological effects. Furthermore, preventive methods for control and decreasing of anxiety are important.[26] The effects of different methods were used for control or improvement in the anxiety of nurses or patients in some studies.[161727282930]

Desensitization training for declining of anxiety was used in one of the intervention groups in the current study, and our results showed a higher level of anxiety in control group than desensitization group. Similar results observed in Maredpour et al.'s study that the systematic desensitization was effective on examination stress of male students[22] and Rajiah and Saravanan's study in reduce test anxiety among 1st-year pharmacy students.[3] However, systematic desensitization exposed the physiological and cognitive aspects of people could decrease the stress or anxiety. Muscular relaxation with training of the stressful situations prevents from the unwilling reactions and acts as a new response for recent stressful stimulants.[22] Moreover, in systematic desensitization, the individuals trained about the methods of relaxation regarding the environmental pressures and caused to prevent from disturbing physiological effects.[31]

In the current study, Benson's relaxation was effective in the anxiety level of nurses in comparing to the control group. This method was used in Mahdavi et al.'s study and in that showed changes in perceived stress, anxiety, and depression of hemodialysis patients.[18] Other studies conducted for decreasing stress and anxiety by Benson's relaxation in rheumatoid arthritis patients,[28] patients awaiting abdominal surgery,[32] women undergoing breast biopsy,[33] and patients with rheumatoid arthritis patients[28] and for pain and quality of life of hemodialysis patients.[21] In another study, the skill training program was effective in decreasing the anxiety and improving general health status of homemaker women.[34]

However, there are different methods for relaxation that could be effective on anxiety or pain decreasing or improvement in quality of life and happiness. Nevertheless, Benson's relaxation method is more common and acceptable in comparing other method due to the simple education and training and is effective on the different scope of symptoms including pain, anxiety, depression, self-stem, self-efficacy, and quality of life.[1318202128] These effect due to the effect of relaxation on the hypothalamus and decreasing in the sympathetic nervous system and catecholamine and consequently balance in heart rate, pulse rate, respiratory, and muscular spasms.[1335]

Our results showed a significant difference between before and after of intervention in two intervention methods of relaxation. Based on the recent of other study, the relaxation methods have not any side effect on the nurses and could be effective on the anxiety of nurse in the workplaces. However, these methods are more effective when conducted in the peace places with positive attitude and in comfortable situations.[14]

Conclusion

Benson's relaxation and systematic desensitization are effective methods in decreasing the anxiety of nurses that worked in the medical places. Both methods could be effective in improvement of the state and trait dimensions of anxiety. Moreover, there was no significant difference between Benson's relaxation and systematic desensitization methods in decreasing of the state and trait anxiety. However, these methods could be applied in stressful situation among medical staffs of students.

Financial support and sponsorship

This study was supported by Arak University of Medical Sciences, Arak, Iran.

Conflicts of interest

There are no conflicts of interest.