DOI: 10.7860/JCDR/2016/22569.

8674
Original Article

The Effect of Stress Management Training

Community Medicine

through PRECEDE-PROCEED Model on

Section

Occupational Stress among Nurses and

Midwives at Iran Hospital, Iranshahr
Mahnaz Didehvar1, Iraj Zareban2, Zahra Jalili3, Nour-Mohammad Bakhshani4,
Mahnaz Shahrakipoor5, Abbas Balouchi6

ABSTRACT collection instruments included the Nursing Stress Scale (NSS).

Introduction: Occupational stress is a major factor in hindering The training program was held in two 4-hour-long sessions for
the performance of nurses and midwives and developing three months from 1st January to 31st March 2013.
physical and mental complications in them. Given that these Results: The results showed a significant increase in the
two groups are in direct contact with patients more than other PRECEDE scores of both groups by the end of the program,
medical staff and stress management training can be effective as compared to the baseline. A significant decrease was also
in the reduction of occupational stress among the nurses and observed in the stress scores of both groups. There was no
midwives. difference between groups in these regards.
Aim: This study was set out to compare the effect of a PRECEDE- Conclusion: The PRECEDE-based stress management training
PROCEED based stress management training program on the is effective in the reduction of occupational stress among the
occupational stress of the nurses and midwives. nurses and midwives.
Materials and Methods: This quasi-experimental study was
conducted on the aforementioned nurses and midwives. Data

Keywords: Depression, Nursing, Workplace stressors

Introduction of collaboration in doing tasks, supervisor support, occupational

Nursing is a stressful job, insufficient manpower is a factor autonomy, and workload and role clarity.
contributing to job dissatisfaction, stress, burnout and ultimately Stress management involves an increase in an individual’s self-
leaving the nursing profession [1]. Nurses are regularly affected control ability when facing situations, people, events and excessive
by workplace stressors, which can jeopardize their physical and demands. In a study by Chan on stress management among the
mental health [2]. The US National Council for Occupational Safety nursing and midwifery students, it was found that Chi Kung (a
and Health has introduced nursing among the top 40 high-stress traditional Chinese exercise) was effective in reducing stress [8]. In
jobs [3]. According to statistics announced by the Iranian Nursing their study, Bruneau et al., demonstrated that stress management
Organization (INO), 75% of nurses are suffering from stress, programs had little effect in reducing stress among nurses [11].
depression and a variety of physical and mental disorders [4]. The PRECEDE model is a framework for the process of systematic
There are several stressors against midwives in the delivery development and evaluation of health education programs. The
room, including the undesirable environment, suffering patients, first 5 phases are:
dealing with obstetric emergency, burden of keeping the patients Phase 1 - Social Diagnosis (Community Forums, Nominal Groups,
safe, rotating work shifts and lack of interest in the profession Focus Groups, Surveys and Interviews),
[5]. Considerable evidence suggests that the quality of obstetric
Phase 2 - Epidemiological Diagnosis (vital statistics, years of
experience is greatly correlated with the midwife-pregnant
potential life loss, disability, prevalence and morbidity),
relationship, even though little research has been conducted on
the emotional issues among midwives [6]. According to a study Phase 3 - Behavioural and Environmental Diagnosis (personal and
by Mackin et al., 78% of midwives stated that insufficient time environmental factors),
to carry out their responsibilities is an important stressor [7,8]. A Phase 4 - Education and Organizational Diagnosis (Predisposing
study conducted by Hauck on Australian midwives, the stressors Factors (knowledge, beliefs and values), Enablers (accessibility,
were identified to be dissatisfaction with the working conditions, availability and skills),
feelings of worthlessness and adequate support [9]. Phase 5 - Administrative and Policy Diagnosis (the analysis of
According to a comparative study on the stressors among nurses policies, resources and circumstances prevailing organizational
and midwives, it was revealed that factors such as inadequate situations that could hinder or facilitate the development of the
resources, night work, unorganized work and shift work were health program) [12].
more frequent among midwives than nurses, whereas other The PRECEDE-PROCEED model is the most prominent tool
factors such as shortage of personnel, unexpected situations, for designing and administering an experimental intervention to
incurable patients and conflict with colleagues were more frequent change high-risk behaviours. Designed by Green and Kreuter
among nurses. Moreover, the stress levels were nearly identical [12], the PRECEDE-PROCEED model has been adopted within
in factors such as unreasonable expectations of patients and long-term, experimental health promotion programs. It provides
modern technology [10]. The two groups were different in terms a framework that helps health planners and policy-makers
Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): LC01-LC05 1
 Mahnaz Didehvar et al., The Effect of Stress Management Training through PRECEDE-PROCEED www.jcdr.net

effectively design health programs based on the assessment and Sciences, Tehran University of Medical Sciences, Shahid Beheshti
analysis of situations. The most basic assumption in this model is University and Tarbiat Modarres University, whose opinions and
the active participation of the audience. According to a research modifications were applied to the content [18].
by Hazavei et al., stress management based on the PRECEDE- The new questionnaire constructed under the PRECEDE-
PROCEED model affected the nurses through time management,
PROCEED framework contained 11 items about stress and coping
problem-solving and relaxation [13]. Unlike the aforementioned
strategies scored on a range from 0 to 22, where correct responses
research, the application of the PRECEDE-PROCEED was not
were assigned 0, I Don’t Know was assigned 1 point and incorrect
effective in reducing the Taenia infection in Nepal due to non-
responses were assigned 2 points. The attitude questionnaire
behavioural factors such as wrong government policies [14].
contained nine items, scored on a 5-point Likert scale from 9 to
Study of Moeini et al., about “The impact of cognitive behavioural
stress management training program on job stress in hospital 45, where higher scores indicated more positive attitude towards
nurses: Applying PRECEDE Model” showed training programs the dangers of stress and importance of coping strategies. The
based on PRECEDE model might be effective in decreasing job enablers included four items about adoption of coping skills and
stress in nurses [15]. Although study of LiChi Chiang et al., that availability of educational resources (scored zero and one), access
conducted on Parents with asthmatic children in Taiwan revealed, to educational resources (scored zero and one) and skills to utilize
the theory based educational program had a good effect on self- the resources properly, somewhat properly and improperly (scored
management behaviours. From the repeat measurement analysis, from zero to two). The reinforcers questionnaire contained four
we can understand the changing trend of the determinants, items concerning the encouragement of others and positive feeling
behaviours, and outcome indicators [16]. after stress coping behaviours (scored zero and one). The stress
Nurses and midwives are two groups of medical staff in direct coping behaviour questionnaire contained 12 items, 8 of which
contact with patients more than others. They closely touch the were responded as Yes-No scored zero and one, one item was
patient’s pain, suffering and even death. Hence, the stress on scored from 0 to 2, another item was scored from 0 to 3 and the
nurses and midwives is undeniable. Given that nurses and other four assessed the desirable behaviours scored from 0 to 3.
midwives experience a great deal of stress every day, appropriate The minimum and maximum scores given to the behavioural items
measures should to be taken to maintain their performances at were 0 and 26. The validity of the questionnaire was achieved
optimum levels. With regard to the fact that nurses and midwives through a panel of experts. Z Hosseini et al., in study on nurses
are stressed differently, this study attempted to figure out whether a revealed reliability of NSS approved in Cronbach’s alpha 0.97 [19].
PRECEDE-PROCEED-based stress management training course The enablers were notification of weekly educational messages
can reduce stress in both groups. about the material discussed in workshops and sending SMS
on stress management, distribution of free relaxation CDs and
Materials and Methods posting materials on the educational board. The reinforcers were
trainer’s internal incentive and encouragement of both groups
Design and Participants
to adopt stress management behaviours and individual positive
This was a quasi-experimental, intervention research carried out
feeling after such behaviours. A poster addressing the participants
on nurses and midwives working at Iran Hospital in Iranshahr. The
was hung on the entrance gate of the hospital. Process evaluation
training program was held in two 4-hour-long sessions for three
and review of progress toward preset goals were carried out
months from 1st January to 31st March 2013.
during the implementation of the training course. The effectiveness
The sample involved a total of 62 participants of whom 40 were
was evaluated based on completing the PRECEDE-PROCEED
nurses and 22 were midwives. In the first stage, the samples with
questionnaire and the checklists one month after the training. In the
moderate to high stress levels were selected and the inclusion
final evaluation, the questionnaires and checklists were completed
criteria were applied. The inclusion criteria were, holding a bachelor’s
again three months after the training course. The variable in both
degree in nursing or midwifery, regular, contract, project or plan
groups were assessed based on the questionnaires in three stages
employment, lack of mental illnesses, owning a mobile phone,
no history of participation in stress management courses. The of before, one month after and three months after the training
exclusion criteria were, refusal from completing the questionnaire course. Given that the participants worked on a shift basis, the
or attending the educational classes. Having obtained the consent sessions were held in a way to avoid interfering with their routine
of subjects in both groups, the questionnaires were handed out jobs. The training sessions were arranged in three groups of
and then received. 20, 21 and 21 members on separate days. The variables were
measured and compared in both groups. The design constraints
Instrument included the nature of shift work at the hospital and the fact that
The data collection tools included questionnaires containing nurses and midwives could not participate simultaneously in the
several items about demographic characteristics, Nursing Stress classes. Hence, the course was held for three groups containing
Scale (NSS) and a questionnaire designed based on PRECEDE- 20, 21 and 21 subjects separately. Due to insufficient manpower
PROCEED aimed at assessing the current situation. Designed and tight work shifts, some of the nurses could not participate in
by Gary-Toft and Anderson [17], the NSS contains 34 items the sessions on two consecutive days. This issue was resolved by
measuring the occupational stress among nurses. The items were asking the nurses to attend classes held for other groups.
scored on a 5-point Likert scale. Scores less than or equal to 68
indicated low stress, between 69 to 103 indicated medium stress Statistical analysis
and more than or equal to 104 indicated high stress. The NSS The data were analyzed through SPSS 16.0 using descriptive
contains 34 clauses covering seven areas including-suffering and statistics, t-test and repeated measures.
death of patients seven, conflict with physicians five, inadequate
preparation three, lack of support three, conflict with other nurses Ethical Consideration
five, job pressure six uncertainty about treatment five. The content The ethical considerations in this research project involved the right
validity of the NSS was achieved through translation and back- to withdraw and announcement of the results to participants and
translation by language specialists. Then, the validity of the authorities. This study approved in ethics committee of Zahedan
questionnaire was confirmed by 11 proficient professors from University of Medical Science.
schools of nursing and midwifery at Iran University of Medical
2 Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): LC01-LC05
www.jcdr.net Mahnaz Didehvar et al., The Effect of Stress Management Training through PRECEDE-PROCEED

Results Variable Time Mean and Mean and Independent

The average age was 31.4±5years for nurses and 29.6±6.27 years standard standard T
deviation for deviation for
for midwives. Moreover, 60% of nurses were married and 40% nurses midwives
were single, while 59.1% of midwives were married and 40.9% Reinforcer Before intervention 1.22 + 1.14 1.18 + 0.66 p= 0.872
were single.
One month after 3.77 + 0.47 3.6 + 0.65 p=0.345
In terms of employment status, 15% of nurses were regular, 80% intervention
were contract-based, 2.5% were agreement-based and 2.5% Three months after 3.90 + 0.37 3.9 + 0.37 p=0.923
were plan-based. As for the midwives, 27.3% were regular, 59.1% intervention
were contract-based, 9.1% were agreement-based and 4.5% RM ANOVA p<0.05 p=0.0001
were plan-based. The average work experience was 4.5±0.92 Enabler Before intervention 12.7 + 1.1 9.5 + 1.4 p=0.494
(Year) for nurses and 5.5±0.04 (Year) for midwives. In terms of
One month after 16.5 + 1.02 16.09 + 1.26 p=0.843
work shift, the 17.5% of nurses were morning fixed and the rest intervention
were rotating shift, whereas 9.1% of midwives were morning fixed Three months after 16.55 + 1.19 16.13 + 1.16 p=0.194
and 90.9% were rotating shift. Concerning the number of night intervention
shifts, 17.5% of nurses had no night shifts, 12.5% had less than RM ANOVA p<0.05 p=0.0001
5 night shifts a month, 10% had 10 night shifts a month, and the
Enabler Before intervention 1.27 + 1.8 0.95 + 1.6 p=0.494
rest had over 10 night shifts. As for the midwives, 9.1% had no
[Table/Fig-2]: The mean scores of enablers and reinforces among nurses and
night shifts, 4.5% had less than 5 night shifts a month, 27.3% had midwives at Iran Hospital, Iranshahr.
over 10 night shifts a month and the rest had 6-10 night shifts.
The groups were matched in terms of age, marital status, work
Variable Time Mean and Mean and Independent
experience, shift work, employment status and the number of standard standard T
night shifts. Moreover, the p-values in all variables were greater deviation for deviation for
than 0.05. nurses midwives
Behaviour Before intervention 12.025 + 3.34 10.9 + 2.5 p= 0.208
Before the intervention, there were no statistically significant
differences between the nurses and midwives in terms of mean One month after 15.875 + 4.77 15.4 + 3.8 p= 0.725
intervention
scores of predisposers, reinforcers, enablers, behaviour and
occupational stress (p>0.05). After the intervention, the mean Three months after 16.37 + 4.4 15.5 + 4 p= 0.451
intervention
scores of awareness, attitude, reinforcer, enable and behaviour
RM ANOVA p=0.0001 p=0.0001
indicated a significant increase in the two stages (one month
and three months after the training) in the two groups. Moreover, Job stress Before intervention 112.8 + 17.46 112 + 17.4 p=0.235

the mean score of stress significantly decreased (p<0.05). In One month after 103.85 + 25.52 105 + 20 p =0.856
intervention
comparison of the two groups of nurses and midwives, the mean
scores of all constructs except awareness indicated no significant Three months after 93.15 + 28.79 86.8 + 25 p=0.39
intervention
difference after intervention. The mean score of awareness was
greater in midwives than nurses [Table/Fig-1-3]. RM ANOVA p=0.00209 p=0.00041
[Table/Fig-3]: The mean scores of behaviour and job stress among nurses and
The pearson correlation test showed no significant relationship midwives at Iran Hospital, Iranshahr.
between the scores of behaviour and demographic characteristics
such as age, marital status, spouse’s education, employment
status, work experience, shifts and the number of night shifts. Discussion
Moreover, the Pearson correlation test showed that there is The findings showed that the changes in the scores given to the
a significant relationship between the change in the score of constructs of PRECEDE-PROCEED Model increased and the
behaviour, changes in the enabler and attitudinal change among stress score decreased significantly in both groups of nurses and
midwives. However, the change in the score of behaviour among midwives after the training compared to before training. Similar
nurses was only correlated with change in the score of enabler. study of Moeini et al., about “The impact of cognitive behavioural
According to the NSS, the greatest stress levels among nurses stress management training program on job stress in hospital
and midwives involved uncertainty about treatment both before nurses: Applying PRECEDE Model” showed training programs
and after treatment. based on PRECEDE model might be effective on decreasing job
stress in nurses [15]. However, the comparison of the two groups
Variable Time Mean and Mean and Independent of nurses and midwives revealed no significant differences in the
standard standard T scores given to reinforcers, enablers and attitudes after the training
deviation for deviation for
nurses midwives course. Nonetheless, there was a significant difference in the score
of awareness, so that the mean score of awareness in midwives
Awareness Before intervention 11 + 2.39 11.5 + 2.77 p= 0.554
was higher than that in nurses after the training course. In three
One month after 19 + 2.1 20.6 + 1.2 p= 0.002 months after the training course, the stress score decreased in
intervention
midwives compared to nurses, even though it was statistically
Three months after 14 + 3.13 17.3 + 2.3 p=0.002
insignificant. There was no research found similar to the current
intervention
one.
RM ANOVA p<0.05 p<0.05
The reinforcers in this study were self-encouragement and
Attitude Before intervention 38 + 3.34 38.4 + 3.3 p=0.929
encouragement by others and individual positive feeling after
One month after 42.07 + 4.53 41.45 + 3.27 p=0.574 adopting stress management strategies. The mean score of the
intervention
reinforcer in both groups of trained nurses and midwives significantly
Three months after 43.67 + 6 41.13 + 5.7 p=0.109 increased after the training course, even though the two groups
intervention
progressed equally, indicating an insignificant difference. In their
RM ANOVA p<0.05 p=0.009 study, Hazavei et al., identified an increase in the mean score
[Table/Fig-1]: The mean scores of predisposes (awareness, attitude) among nurses of the enabler as a factor contributing to the modification of oil
and midwives at Iran Hospital, Iranshahr. consumption pattern [20]. The consistent studies in this regard

Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): LC01-LC05 3

 Mahnaz Didehvar et al., The Effect of Stress Management Training through PRECEDE-PROCEED www.jcdr.net

are those conducted by Nazari, Nadrian et al., and Mohebbi et occupational stress [35]. According to a research by Taylor (1991)
al., [21-23]. exercising and music are equally effective in reducing stress [36].
This study identified the learning skills and their level of adoption as According to one of the report by Russler, there was no difference
enablers. The mean score of this construct indicated a significant between the two groups, one of which receiving a placebo for
increase in two intervention groups after training, even though curtailing stress and the other writing down the stressors [37].
there were no significant differences between the two groups.
Consistent with this study were the results obtained by Shauna et Limitation
al., [24]. Unlike this study, Zigheymat found no significant difference Limitation of the current study was insufficient participant’s
between the mean scores of enablers in the experimental group contribution for completing the study.
and the control after intervention [25].
The mean scores of awareness before training were identical with
Conclusion
no significant difference between the two groups, even though Although stress inherently differs in nursing and midwifery from
it indicated a significant difference after training unlike the other certain perspectives, this study demonstrated that adoption of
constructs. This could probably be due to the researcher’s job in the PRECEDE-PROCEED Model in stress management planning
a closer contact with midwives rather than nurses. Mohebbi et can be greatly effective for both groups. The stress levels in
al., conducted a study on enhancing awareness in assertiveness both groups were more than 104 before training. However, they
training on decisiveness of high-school students [23]. Orooji et dropped to the average range (69-103) after training. It is hoped
al., examined the higher awareness after training based on the that the authorities arrange for stress management training
PRECEDE-PROCEED Model in preventive behaviours against courses based on the PRECEDE-PROCEED Model, taking a great
brucellosis among adolescents living in Khomein [26]. In another step in curtailing stress and promoting the health and efficiency
study, Polcyn employed the PRECEDE-PROCEED Model to identify of nurses and midwives. It is recommended that other health
factors associated with smoking among adolescents, indicating education models be assessed in further studies on occupation
that there is a significant difference between the experimental and stress among medical staff.
control groups in terms of awareness [27].
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PARTICULARS OF CONTRIBUTORS:
1. Lecturer, Department of Public Health, Iranshahr University of Medical Sciences, Iranshahr, Iran.
2. Assistant Professor, Department of Public Health, Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran.
3. Lecturer, Department of Medical, Faculty of Medical, Science and Research Branch, I.A.U, Tehran, Tehran, Iran.
4. Professor, Department of Clinical Psychology, Children and Adolescent Health Research Center,
Department of Clinical Psychology, Zahedan Univer, Zahedan, Sistanvbalouchistan, Iran.
5. Assistant Professor, Department of Biological Statistics, Faculty of Health, Zahedan University of Medical Sciences,
Zahedan, Sistanvbalouchistan, Iran.
6. Student, Department of Nursing, Faculty of Nursing and Midwifery,
Zabol University of Medical Sciences, Zabol, Sistanvbalouchistan, Iran.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Iraj Zareban,
Assistant Professor, Department of Public Health, Health Promotion Research Center,
Zahedan University of Medical Sciences, Zahedan, Iran. Date of Submission: Jul 03, 2016
E-mail: ganjresearch@gmail.com Date of Peer Review: Aug 01, 2016
Date of Acceptance: Aug 12, 2016
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Oct 01, 2016

Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): LC01-LC05 5