EFFECTS OF APMR IN NURSING STUDENTS 1 Effects of Abbreviated Progressive Muscle ...

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Running head: EFFECTS OF APMR IN NURSING STUDENTS 1

Effects of Abbreviated Progressive Muscle Relaxation on Stress in Jordanian Nursing
Students

Dissertation submitted to
Kent State University College of Nursing
in partial fulfillment of the requirements
for the degree of Doctor of Philosophy

by
Hossam N. Alhawatmeh PhD MSN, RN
(c),
March, 2017
EFFECTS OF APMR IN NURSING STUDENTS ii
Dissertation written by
Hossam Alhawatmeh
BSN, Jordan University of Science and Technology
MSN, Kent State University
Ph.D., Kent State University

Approved by
, Chair, Doctoral Dissertation Committee
Ratchneewan Ross
, Member, Doctoral Dissertation Committee
Barbara Drew
, Member, Doctoral Dissertation Committee
Lori Kidd
, Member, Doctoral Dissertation Committee
Kele Ding

Accepted by
, Director, PhD Program
Vermeersch, Patricia
, Associate Dean for Graduate Programs
Wendy Umbergerr
EFFECTS OF APMR IN NURSING STUDENTS iii
Acknowledgment
I would like to express my deepest appreciation to the chair of my dissertation
committee, Dr. Ratchneewan Ross. She provided me support, advice, guidance, valuable
comments, and suggestions that benefited me much in the completion and success of this
dissertation research. The door to her office was always open whenever I ran into a trouble spot
or had a question about my dissertation research. The completion of this dissertation research
would not have been possible without her help, support and guidance.
I would like to express my gratitude to the members of my dissertation committee, Dr.
Barbara Drew, Dr. Lori Kidd, Dr. Kele Ding, and Dr. Douglas Delahanty. They have provided,
with kindness, their feedback and thought-provoking suggestions, which have been valuable to
me. Also, I would like to thank my professors and colleagues from the Kent State University
College of Nursing who provided insight and expertise that significantly assisted the research
and my progress as a nursing scholar.
This dissertation study was supported by Dr. Richard A. Zeller Nursing Research Fund.
I would like to gratefully acknowledge this financial support for providing the necessary finances
for this dissertation study. I would also like to thank the Center of Nursing Research at the Kent
State University, College of Nursing for their friendly guidance and suggestions during the
process of writing this grant.
I wish to express a sincere thank you to the Dean and instructors at the Jordan University
of Science and Technology, College of Nursing for their invaluable assistance. I would also like
to thank Dr. Bilal and Dr. Ma’mon for helping me in translating the SSSI. I would like to thank
my study’s participants who so graciously agreed to participate in my study. Without them, this
study would not have been completed.
EFFECTS OF APMR IN NURSING STUDENTS iv
Finally, special recognition goes out to my family for their emotional support,
encouragement and patience during my pursuit of advanced degrees in nursing. My
accomplishment would not have been possible without their support. I am especially grateful to
my parents, who encouraged and supported me emotionally and financially. My special gratitude
and love goes to my wife, Raya, and my children, Eleen and Jad, who inspired me and provided
continuous encouragement and support during the entire process. I am also grateful to my
brother, sisters, and friends who have supported me along the way.
EFFECTS OF APMR IN NURSING STUDENTS v
Table of Contents

CHAPTER 1: INTRODUCTION………………………………………………………. 1
Background.…………………………………………………………………............ 1
Research Hypotheses ……………………………………………………………….. 4
Significance.………………………………………………………………………… 4
Theoretical Framework.…………………………………………………………….. 6
CHAPTER 2: LITERATURE REVIEW……………………………………………… 14
Definition of Stress………………………………………………………………….. 14
Stress as Response.……………………………………………………………… 14
Stress as Stimulus.………………………………………………………………. 15
Stress as Transaction.…………………………………………………………… 16
Stress as a Combination of Concepts …………………………………………… 17
Stress in Nursing Education.………………………………………………………… 21
Prevalence of Stress.……………………………………………………………. 21
Sources of Stress among Nursing Students.………………………...................... 23
Comparison between Different Academic Years.…………………..................... 25
Comparison across Cultures.………………………………………..................... 26
Comparison with Students from Other Disciplines.…………………………….. 27
Impact of Stress.…………………………………………………….................... 28
Stress in Jordanian Nursing Students.………………………………………………. 29
Prevalence of Stress and Sources of Stress.…………………………………….. 29
Comparisons between Academic Years.…………………………....................... 31
Comparison to Students from other Disciplines.………………………………... 32
Coping Strategies……………………………………………………………….. 33
Impact of Stress ………………………………………………………………… 34
Stress Management Programs Used in Nursing Students.……………….................. 36
Progressive Muscle Relaxation.………………………………………….................. 38
History of Progressive Muscle Relaxation…………............................... ……... 38
Effect of Progressive Muscle Relaxation………………………………………. 39
Clinical population…………………………………………………………. 40
Non-clinical population…………………………………….......................... 44
Nursing Students……………………………………………....... …………. 46
Research Questions…………………………………………………………………. 47

CHAPTER 3: METHODS…………………………………………………………….... 48
Design……………………………………………………………………............... 48
Setting……………………………………………………………………............... 51
Population and Sample Characteristics…………………………………………… 52
EFFECTS OF APMR IN NURSING STUDENTS vi
Determination of Sample Size…………………………………………………….. 52
Data Collection Instruments………………………………………………............. 53
Self-reporting Instruments…………………………………………………... 53
Covariates and demographic variables…………………………………... 53
Coping Behavior Inventory………………………………........................ 54
Smith Stress Symptoms inventory………………………………………. 55
Physical Instruments………………………………………………………… 56
Blood pressure and heart rate monitor…………………........................... 56
Finger skin thermometer………………………………............................ 57
Experiences of practicing APMR………………………………………………. 58
Intervention………………………………………………………………………... 58
Procedure……………………………………………………………...................... 59
Data Analysis……………………………………………………………………… 62
Data Management…………………………………………………………… 62
Statistical Analysis……………………………………….............................. 63
Ethical Considerations……………………………………………………................ 64

CHAPTER 4: RESULTS……………………………………………………………….. 65
Demographic Characteristics and Coping Behaviors………………………………. 65
Overall Sample…………………………………………………………………. 65
Experimental group…………………………………………………………….. 65
Control group……………………………………………………........................ 65
Data Screening and Cleaning……………………………………………………….. 68
Attrition…………………………………………………………………………. 68
Outliers……………………………………………………….............................. 68
Missing……………………………………………………….............................. 70
Normality……………………………………………………………………….. 71
Homogeneity of Variance………………………………………………………. 71
Sphericity…………………………………………………….............................. 72
Reliability……………………………………………………………………….. 72
Comparison between Groups on Demographic Variables……………….................. 73
Comparison between Groups on Dependent Variables………………….................. 73
Hypotheses Testing……………………………………………………..................... 74
First hypothesis…………………………………………………......................... 74
SBP………………………………………………………............................. 75
DBP…………………………………………………………......................... 76
HR…………………………………………………………………………... 76
FST…………………………………………………………......................... 77
Self-reports of stress……………………………………………………………….. 77
Second Hypothesis………………………………………………….................... 79
EFFECTS OF APMR IN NURSING STUDENTS vii
SBP…………………………………………………………......................... 79
DBP……………………………………………………………..................... 80
HR…………………………………………………………………………... 81
FST………………………………………………………….......................... 83
Self-reports of stress………………………………………........................... 84
Post Hoc t-test…………………………………………………………............... 88
Experiences of APMR………………………………………………………….. 90

CHAPTER 5: DISCUSSION………………………………………………………….... 93
Results Summary…………………………………………………………………… 93
Discussion of Results…………………………………………………………......... 94
BP………………………………………………………………………………. 94
HR………………………………………………………………………………. 95
FST……………………………………………………………........................... 97
Self-reports of stress……………………………………………………………. 98
Limitations and Recommendations for Future Research……………........................ 100
Nursing Implications…………………………………………………....................... 103
Conclusion………………………………………………………………….............. 105
References…………………………………………………………………………......... 106
EFFECTS OF APMR IN NURSING STUDENTS viii
APPENDICES
Appendix A: Informed Consent (English Version)……………………………... 126
Appendix B: Informed Consent (Arabic Version)…………………………......... 130
Appendix C: Self-reporting Questionnaire (English Version)…………………... 133
Appendix D: Self-reporting Questionnaire (Arabic Version)…………………… 137
Appendix E: Omron Blood Pressure/Heart Rate Monitor………………………. 140
Appendix F: Finger Skin Temperature Thermometer…………………………... 142
Appendix G: APMR Protocol (Smith, 2002)…………………………………… 143
Appendix H: Tests of Normality………………………………………………... 147
EFFECTS OF APMR IN NURSING STUDENTS ix
LIST OF TABLES
Table 1.2: Definitions of Terms…………………………………………………….. 12

Table 3.1: Characteristics of Sample and Group Comparison

on Demographic & Confounding Variables………………………………………… 67

Table 3.2: Levene's Test of Homogeneity of Variances for Dependent

Variables in 3 Times of Measurement………………………………………………. 72

Table 3.3: Chronbach’s Alpha for SSSI and CBI……………………………............ 73

Table 3.4: Baseline Group Comparison on Dependent Variables…………………... 74

Table 3.5: Means and Standard Deviations on Dependent Variables

by Study Groups…………………………………………………………………….. 75

Table 3.6: Results of RM ANOVA for Experimental Group (n= 14)………………. 78

Table 3.7: Results of RM Measures ANOVA for Control Group (n= 14)………….. 79

Table 3.8: Analyses of Variance on Dependent Variables Across Three

Repeated Measures by Group……………………………………………………….. 88

Table 3.9: Results of t-tests for dependent variables by group

in time 2 and time 3 measurements………………………………………………….. 89

Table 3.10: Experience of APMR …………………………………………………... 91
EFFECTS OF APMR IN NURSING STUDENTS x
LIST OF FIGURES
Figure 1.1: ABC Relaxation Theory (Smith, 2005)…………………………………………….. 8
2

Figure 1.2: Substruction Based on Smith’s ABC Relaxation Theory…………………………… 11

Figure 3.1: Outlier on Self-reports of Stress in Time 2………………………………………….. 68

Figure 3.2: Outlier on Self-reports of Stress in Time 3………………………………………….. 69

Figure 3.3: Outlier on HR in Time 3…………………………………………………………….. 70

Figure 3.4: SBP Means for Experimental Group and Control Group…………………………… 80

Figure 3.5: DBP Means for Experimental Group and Control Group………………................... 81

Figure 3.6: HR Means for Experimental Group and Control Group

including the subject with outlier in the analysis………………………………………………... 82

Figure 3.7: HR Means for Experimental Group and Control Group

excluding the subject with outlier from the analysis…………………………………………….. 83

Figure 3.8: FST Means for Experimental Group and Control Group…………………………… 84

Figure 3.9: Means of Self-reports of Stress for Experimental and Control Group

after Excluding Subjects with Missing Values…………………………………………………. 85

Figure 3.10: Means of Self-reports of Stress for Experimental and Control Group

with Imputed Values…………………………………………………………………………….. 86

Figure 3.11: Means of Self-reports of Stress for Experimental (group1) and Control Group

(group2) after Excluding Subjects with Outliers………………………………………………… 87