Relationship of Frequent Mantram Repetition to ...

Relationship of Frequent Mantram Repetition to Emotional and Spiritual Well-Being in Healthcare Workers Jill E. Bormann, PhD, RN, Sheryl Becker, MN, RN, Madeline Gershwin, MA, RN, Ann Kelly, MSN, APRN, BC, Laureen Pada, MSN/MBA, RN, Tom L. Smith, PhD, and Allen L. Gifford, MD

abstract Background: Healthcare workers report high levels of stress in the workplace. To determine how to reduce stress, the authors examined the effectiveness of frequently repeating a mantram (a word with spiritual meaning) on emotional and spiritual well-being. Methods: A pretest-posttest design was used to measure stress, state/trait anxiety and anger, quality of life, and spiritual well-being in a convenience sample (N = 42) of hospital workers completing a mantram intervention program. Results: Significant improvements were found in stress (p < .001), trait-anxiety (p = .002), trait-anger (p = .02), quality of life (p = .001), and spiritual well-being (p = .003). When examining the effects of mantram practice, trait-anxiety and religious and spiritual well-being were significant (p < .05). Conclusion:Improvements inemotional and spiritual wellbeing may be mediated by frequent mantram repetition.

H'ealthcare workers, particularly nurses, have reported .high levels of stress that are closely linked to a wide range of health outcomes (Sullivan, Kerr, & Ibrahim, 1999). A review of 64 studies on stress management interventions offered in the workplace has indicated the most common techniques used to reduce stress are progressive muscle relaxation (DeBerry, 1981-1982; Schneider et al., 1995), mindfulness meditation (Kabat-Zinn & Chapman-Waldrop, 1988; Kabat-Zinn et al., 1992), transcendental meditation (Alexander, Swanson, Rainforth, & Carlisle, 1993; Benson, 1983; Jevning, Anand, Biedebach, & Fernando, 1996; Seeman, Dubin, & Seeman, 2003), biofeedback (Jacobs, Benson, & Friedman, 1996), and cognitive-behavioral skills (Murphy, 1996). Other examples include autogenic training (Takaishi, 2000), hypnosis (Bilkis & Mark, 1998; Saletu, 1987), and guided imagery (Eller, 1999). 218

A combination of these techniques has been more successful than single techniques on a variety of physical and psychological health outcomes. However, these traditional meditative and relaxation techniques often require silence, solitude, and interruption in daily activity to be practiced. The purpose of this study was to examine the feasibility and effectiveness of frequently repeating a silent mantram (a word or phrase with spiritual meaning) on stress, quality of life, and measures of spiritual well-being in a volunteer group of healthcare workers. Unlike other forms of meditation or relaxation techniques, mantram repetition can be used throughout the workday (Bormann, 2005). It offers the practical advantage of being implemented any time, day or night, without special equipment or need for a quiet environment (Easwaran, 1998/2001; Oman & Driskill, 2003). This is especially useful to healthcare providers who routinely deal with crises and who may benefit from a portable, easy, and inexpensive tool in the workplace (Bormann, 2005). In addition, mantram repetition incorporates spirituality, a factor that is becoming recognized as a vital component in health and well-being (Hawks, Hull, Thalman, Dr. Bormann is Research Nurse Scientist, VA San Diego Healthcare System, andAdjunct Nursing Research Professor,School of Nursing, San Diego State University, San Diego, California.Ms. Becker and Ms. Gershwin are Nurse Case Managers,Nursing Service, and Ms. Padais Patient Health Education Coordinator,VA San Diego HealthcareSystem, San Diego, California.Ms. Kelly is Nurse Educator,NationalUniversity and VA San Diego HealthcareSystem, San Diego, California.Dr.Smith is Principal Statistician,University of CaliforniaSan Diego, San Diego, California. Dr. Gifford is Associate Professor of Public Heath and Medicine, Boston University,and Associate Director,VA Bedford CenterforHealth Quality, Outcomes and Economic Research, Boston, Massachusetts. The views expressed in this articleare those of the authors and do not necessarilyrepresent the views of the Departmentof Veterans Affairs. Address correspondence to JillE. Bormann,PhD, RN, VA San Diego HealthcareSystem IIZN-1, 3350 La Jolla Village Drive, San Diego, CA 92161. Email: jilL [email protected],or visit http://jillbormann.com.

The Journal of Continuing Education in Nursing • September/October 2006 • Vol 37, No 5

& Richins, 1995; Miller & Thoresen, 2003). Research has shown high correlations between quality of life and spiritual well-being (Brady, Peterman, Fitchett, Mo, & Celia, 1999; Ellison & Jonker-Bakker, 1983; Mytko & Knight, 1999; Tuck, McCain, & Elswick, 2001). Mantram repetition is actually an ancient practice found in nearly all spiritual traditions that has been applied to modern times in the form of a "rapid-focus tool" for training attention and calming the mind (Easwaran, 2005; Flinders, Flinders, & Gershwin, 1994). As a mind-body intervention, it is not considered a traditional "relaxation technique" per se, although, with practice, it can lead to a physiological state of relaxation. Its primary mechanism is one of directing attention away from intrusive thoughts and toward a chosen word or phrase (often with spiritual meaning) that provides comfort. Its value and benefits are believed to be cumulative with consistent practice. Implementation involves the same two basic steps as Benson's relaxation response: (1) mentally repeating the word and (2) passively disregarding any other thoughts that intrude (Benson, 1983, 1993, 1996). METHODS Design A non-experimental, pretest-posttest design was used to evaluate the intervention program, which was taught in group meetings over 5 weeks (90 minutes/ week). Self-report questionnaires were collected in the first and last classes. Mantram practice was measured using wrist-worn counters, daily tracking sheets, and a self-report question. Nurses and social workers earned continuing education credit for attending. Intervention The program was based on The Mantram Handbook (Easwaran, 1998/2001), which was provided as the course textbook. The curriculum consisted of five classes employing the following outline: Class 1-How to Choose a Mantram; Class 2-How to Use and Track Mantram Practice; Class 3-Developing One-Pointed Attention; Class 4-Slowing Down; and Class 5-Putting It All Together. The course included lectures, group discussions on how to incorporate mantram repetition in daily life, and experiential exercises, including mantram practice during classes. Participants received a manual of experiential exercises created for facilitating mantram practice and discussion. They were asked to choose a mantram from a list of recommended sayings from several major spiritual traditions (Bormann, 2005; Easwaran, 1998/2001). For example, options included the Hindu sayings "Rama Rama," an invocation for joy within, and "Om Prema," a call for univer-

Frequent Mantram Repetition • Bormann et aL

sal love; the Buddhist phrase "Om Mani Padme Hum," a blessing of the heart; the mantram of St. Francis of Assisi, "My God and My All"; a Native American prayer to the Great Spirit, "0 Wanka Tanka"; and the Judaic sayings "Barukh Atah Adonoi" and "Shalom," which mean "Blessed are you, Lord" and "peace," respectively. During the course, the concepts of one-pointed attention and slowing down were taught as complementary skills for enhancing mantram practice. One-pointed attention is defined as focused concentration on the mantram in the mind or on a selected task or activity of one's choice, without multi-tasking. One-pointed attention is necessary to mentally repeat a mantram. Practicing one-pointed attention as frequently as possible during daily activities is believed to enhance mantram repetition. One homework assignment was to practice one-pointed attention by choosing to do only one thing at a time and to become aware of the tendency for multi-tasking. For example, preparing medications in the workplace requires one-pointed attention. Slowing down is defined as living intentionally without hurry, and may require resetting priorities and eliminating unnecessary commitments. American culture values speed, but hurrying often creates time pressure. Becoming aware of how fast paced our lives are allows an opportunity to slow down intentionally and prioritize activities. Within the mind, mantram repetition aids in slowing thoughts. While externally engaged in an activity, slowing down improves efficiency and safety. All three skills-mantram repetition, one-pointed attention, and slowing down-work together synergistically to reduce stress (Bormann, 2005; Easwaran, 2005). Throughout the course, practicing mantram repetition during non-stressful times such as before falling asleep or while waiting in lines was emphasized to promote an association between the word and a physiological state of calm. If practiced consistently and frequently, mantram repetition is believed to modify or buffer the stress response because of this mind-body association. Theoretical Framework and Hypotheses The hypothesized model of the stress response (Biondi & Picardi, 1999) was modified by Bormann for this study. In this model, work demands lead to increased symptoms of stress, anxiety, and anger, which contribute to reductions in quality of life and spiritual well-being. These symptoms of stress are modified when using mantram repetition, which interrupts intrusive thoughts that trigger the stress response. By redirecting negative thoughts to a mantram, symptoms of stress, anxiety, and anger are modified or attenuated. When stress is reduced, quality of life and spiritual well-being subsequently improve. 219

TABLE 1

OUTCOME VARIABLES, INSTRUMENTS, AND INTERNAL CONSISTENCY RELIABILITIES Variable

Instrument

Format

Stress

Perceived Stress Scale

10 items, 5-point Likert

.88

Anxiety

Spielberger State-Trait Anxiety Inventory


State-Anxiety .93, Trait-Anxiety .91

Anger

Spielberger State-Trait Anger Inventory


State-Anger .91, Trait-Anger .78

Quality of life

Quality of Life Enjoyment & Satisfaction Short Form


.88

Total Spiritual Well-Being Scale

Spiritual well-being


.94

Religious Well-Being Subscale

10 items

.95

Existential Well-Being Subscale

10 items

.88

The study tested the following hypotheses: workers completing the mantram course will demonstrate (1) a significant decrease in perceived stress and state/trait anxiety and anger scores and (2) a significant increase in quality of life and spiritual well-being between pretest and posttest. State levels of anxiety and anger refer to how participants feel about questionnaire items right now, in the moment, whereas trait levels of anxiety and anger refer to how they generally feel. Quality of life refers to participants' satisfaction with various life areas, such as physical and mental health status, work, family relationships, leisure time, economic status, sexual function, and living situation. Total spiritual well-being consists of religious well-being with items related to one's relationship to God or a Higher Power and existential well-being with items related to meaning and purpose in life.

Sample Institutional review board approval was obtained prior to enrolling participants in the program. The population consisted of employees from the Veterans Affairs San Diego Healthcare System, a large medical center dedicated to the care of veterans. E-mails and flyers were used to promote the course throughout the medical center. The classes were free and no financial incentives for participating were given. The same two psychiatric nurses taught all courses. Data were collected between April 2001 and December 2003. Ninety-three healthcare workers registered for the course and were invited by the instructors to participate in the research at the end of the first class; 62 gave informed consent and were included in this study. Half of the participants were nurses and half were hospital staff. Participants' ages ranged from 30 to 62 years, with a mean of 47.8 years (SD = 8.33 years); 87.5% were women. Of the 33 participants who reported ethnicity,

220

Cronbach's alpha

26 (79%) were white, 3 (9%) were Asian, 2 (6%) were Hispanic, 1 (3%) was African American, and 1 (3%) was identified as Other. Thirty-nine participants (62.9%) had perfect attendance and the rest (37.1%) attended 4 of 5 classes. Of the total participants, 42 (68%) had complete sets of weekly mantram tracking data for statistical analysis. Due to its exploratory nature, additional measures were added to the study, creating different sample sizes for each outcome measure.

Measures Outcomes were measured by the following instruments that have reported validity and reliability: Cohen's Perceived Stress Scale (Cohen, Kamarck, & Mermelstein, 1983; Cohen, Revicki, Nabulsi, Sarocco, & Jiang, 1998), the Spielberger State/Trait Anxiety Inventory and the Spielberger State/Trait Anger Inventory Short Form (Spielberger, 1972, 1983; Spielberger, Jacobs, Russel, & Crane, 1983), Endicott's Quality of Life Enjoyment and Satisfaction Short Form (Endicott, Nee, Harrison, & Blumenthal, 1993), and the Spiritual Well-Being Scale (Ellison & Jonker-Bakker, 1983; Life Advance Inc., n.d.; Paloutzian & Ellison, 1982). Internal consistency reliability was determined for each instrument using Cronbach's alpha (Table 1). Mantram usage was tallied using wrist-worn counters (golf scorers) to track the daily frequency of mantram repetition from week 2 through week 5 outside of class. Because it is impractical to count each repetition of a word or phrase, counters were used to track the number of times participants remembered to initiate repeating a series or "session" of mantrams. Participants recorded their daily totals on sheets collected weekly by instructors. In the last class, participants were also asked, "During the past week, on the days you repeated your mantram, how often per day on average did you initiate repeating your mantram?"

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TABLE 2

RESULTS OF MANTRAM INTERVENTION ON OUTCOMES USING ANALYSIS OF VARIANCE (ANOVA)

Outcomesa

Pretest Mean (SD)

Time Effects ANOVA F (do

p

(6.34)

28.44 (1.41)

.001

29.7 (10.33)

2.44 (1.23)

Posttest Mean (SD)

Perceived stress (n = 42)

19.0

(5.48)

State-anxiety (n= 24)

33.5

(10.28)

Trait-anxiety (n = 26)

38.5

(9.76)

34.6

(9.27)

11.70

(1.25)

.002

State-anger (n = 34)

10.8

(1.80)

10.3

(1.08)

3.29

(1.33)

.08

Trait-anger (n = 35)

16.2

(3.15)

15.3

(3.45)

5.94

(1.34)

.02

Quality of life (n = 36)

49.9

(8.46)

56.0

(5.78)

30.46 (1.35)

.001

Existential well-being (n = 33)

46.8

(7.93)

50.0

(7.71)

14.54

.001

Religious well-being (n = 33)

44.1

(13.05)

45.2 (13.15)

Total spiritual well-being (n= 33)

90.9

(19.30)

94.9 (18.16)

14.6

(1.32)

1.57 (1.32) 10.09

(1.32)

.14

.22 .003

'Higher scores indicate greater amounts of the variable.

Analysis To test the hypotheses of the effects of the mantram course on outcomes, repeated measures analysis of variance (ANOVA) models were run on all variables. A secondary analysis was done to assess the specific effect of mantram practice on outcomes. The sample was divided into high and low mantram user groups. Then 2 group (high and low mantram users) by 2 time (pre-intervention and post-intervention) repeated measures ANOVA models were performed on each outcome. The relationship between selfreported mantram practice and counter-tracked mantram practice was also assessed using a Pearson correlation. RESULTS Hypothesis Testing Results of repeated measures ANOVA models demonstrated significant pre-intervention to post-intervention reductions in perceived stress, trait-anxiety, and trait-anger, but not in state-anxiety or state-anger, thus partially supporting hypothesis 1. There were significant increases in quality of life and existential and total spiritual well-being, but no change in religious well-being, partially supporting hypothesis 2 (Bormann, Becker, Gershwin, & Kelly, 2004). To maintain an overall alpha value of .05 with 9 tests, Bonferroni's correction with an a value of .006 was used. Five of six outcomes were still significant at a p level of less than .006. These data are presented in Table 2. Not surprisingly, these healthcare workers had higher levels of perceived stress (M = 19.0; SD = 5.48) than the general population (M = 11.9; SD = 6.9) (Cohen & Williamson, 1988). On measures of anxiety and anger,

Frequent Mantram Repetition - Bormann et aL

this sample had higher levels of trait-anxiety (M = 38.5; SD = 9.76) and trait-anger (M = 16.2; SD = 3.15), but they had lower levels of state-anxiety (M = 33.5; SD = 10.28) and state-anger (M = 10.8; SD = 1.80) compared to the population norms for trait-anxiety (M = 34.9; SD = 9.19), trait-anger (M = 18.4; SD = 6.36), state-anxiety (M = 35.7; SD = 10.40), and state-anger (M = 14.2; SD = 5.73) (Spielberger, 1983; Spielberger et al., 1983; Spielberger, Sydeman, Owen, & Marsh, 1999). Similarly, this sample had lower levels of quality of life (M = 49.9; SD = 8.46) and total spiritual well-being (M = 90.0; SD = 19.30) compared to the population norms for quality of life (M = 55.1; SD = 7.0) (Gelfin, Gorfine, & Lerer, 1998) and total spiritual well-being (M = 99.8; SD = 16.01) (Ellison, Paloutzian, & Bufford, 1991). In the secondary analysis, high and low mantram user groups were created by dividing mantram practice at the mean. High mantram users (n = 24) practiced an average of 8.1 (SD = 2.34) sessions per day compared to low mantram users (n = 18) with an average of 3.0 (SD = 0.95) sessions per day. A 2 group (high and low mantram users) by 2 time (pre-intervention and post-intervention) ANOVA demonstrated significant group by time effects for trait-anxiety, religious well-being, and total spiritual well-being (Figure). This provides evidence that high mantram users had significant reductions in trait-anxiety and increases in both religious and total spiritual wellbeing compared to low mantram users. Participants verbally reported using counters to track their mantram practice. To further assess adherence to mantram repetition, a Pearson correlation between counter-tracked mantrams and self-reported mantram practice

221

Trait Anxiety F (1,31) = 4.41; p < .05 46

0 U) 1 0 C) 0,

44

0 U)

36

42 40 38 34 32 30

Pretest

Posttest

Religious Well Being F(1,31) = 4.69; p < .05 50 48 0) 46 44 42 40 38 36 U) A-. 0 U) C cc

Pretest

Posttest

Total Spiritual Well Being F (1,31) = 7.57; p < .01 60 55 50 45 40 35 30

AF-

Pretest

Posttest

High Mantram Users

-

---

A

-

* Higher

Low Mantram Users

scores = greater amounts of variable

Figure. Pre-intervention to post-intervention scores* on trait anxiety, religious well-being, and total spiritual well-being by high and low mantram users.

during the last week of the course resulted in a significant positive relationship (r = .8 3 ;p < .001; n = 31).

222

DISCUSSION Results of this exploratory study demonstrate that frequent mantram repetition is a feasible and effective stress management strategy for use in the workplace. It is an ancient yet innovative technique that incorporates a spiritual element, which was shown in this study to support improvements in quality of life and spiritual wellbeing. Classes required only a trained facilitator, text materials, and classroom space, making this educational experience convenient and practical for many settings. In this sample of primarily female healthcare workers, there were significant reductions in perceived stress and trait scores of anxiety and anger, but not state scores. One explanation for no difference in state scores is that workers filled out questionnaires at the end of class, a time when they were probably less anxious or angry. Instead, participants reported overall general reductions of perceived stress, trait-anxiety, and trait-anger, indicating that the effects of the course were experienced, in general, outside of the class. These findings support using trait measures for future research. There were also significant pre-intervention to postintervention improvements in quality of life, existential spiritual well-being, and total spiritual well-being, but not religious well-being. These findings may be explained by the emphasis on the spiritual, rather than religious, nature of the course. Participants were encouraged to choose their own mantrams with a spiritual and personal meaning. Spirituality was discussed as a coping resource without dependence on religious dogma or church doctrines. One strength of this study was the evaluation of the frequency of mantram practice using both real-time assessment with personal counters and retrospective assessment of mantram use with a self-report question in the last week of the course. Despite having no control group, interpretation of the data was strengthened by a 2 group (high and low mantram users) by 2 time (preintervention and post-intervention) analysis. As for the effects of mantram practice, high mantram users reported significant reductions in trait-anxiety and significant increases in both religious and total spiritual well-being compared to low mantram users. This finding suggests mantram repetition is useful for managing anxiety and enhancing one's spiritual and religious resources. This finding also suggests that mantram practice in itself provides a unique contribution to stress reduction beyond the group intervention experience. This study evaluated the overall effect of a mantram group intervention and examined the specific effects of high versus low mantram repetition or practice. Both effects were not consistently present for each outcome. For example, changes in trait-anxiety and total spiritual

The Journal of Continuing Education in Nursing • September/October 2006 • Vol 37, No 5

well-being were related to both group participation and high mantram practice. Changes over time for perceived stress, trait-anger, quality of life, and existential spiritual well-being were related to group participation but not to high mantram practice. Change in religious well-being was related to high mantram practice but not to group participation. These discrepancies might be explained as a lack of power due to small sample size, or perhaps the sample actually received uniquely different benefits from the group experience and amount of mantram practice. There are several limitations to this study, indicating the need for further research. There was no control group and the sample was small, non-random, and primarily female. We also did not identify the words chosen by participants. Attending a weekly support group alone may have contributed to improvements and there was no follow-up. More research using larger, more diverse samples and experimental designs is warranted.

CONCLUSIONS Findings provide preliminary support that a 5-week mantram intervention program for hospital workers results in significant improvements in measures of perceived stress, trait-anxiety, trait-anger, quality of life, existential spiritual well-being, and total spiritual well-being. Results showed that for some outcomes, after dividing the sample into high and low mantram users, changes over time from pre-intervention to post-intervention were mediated by mantram practice. These findings are consistent with the literature, indicating that mind-body-spiritual therapies provide multiple benefits and increase the feeling of well-being (Astin, Shapiro, Eisenberg, & Forys, 2003; Bormann, Gifford, et al., 2006; Bormann, Oman, et al., 2006; Jacobs, 2001).

Implications Healthcare workers are a highly stressed population. It is not surprising to find that healthcare worker stress contributes to poor health outcomes and impairs quality of life (Murphy, 1996). Innovative stress management programs, especially those acknowledging aspects of one's spirituality, could be offered as continuing education in the workplace, making them convenient and accessible. Stress management interventions with a spiritual component may enhance workers' psychological health and improve spiritual well-being (Bormann, 2005). Mantram repetition is an innovative strategy that is portable, easy to implement, and inexpensive. Results of this preliminary study suggest mantram repetition may be an effective intervention strategy for use among healthcare workers, and more research is warranted. Mantram group intervention in the form of continuing education and mantram practice shows promise for reducing anxiety

Frequent Mantram Repetition • Bormann et al.

key points Frequent Mantram Repetition Bormann, J. E., Becker, S., Gershwin, M., Kelly, A., Pada, L., Smith, T. L., et al. (2006). Relationship of Frequent Mantram Repetition to Emotional and Spiritual Well-Being in Healthcare Workers. The Journalof ContinuingEducationin Nursing, 37(5), 218-224.

1Healthcare

worker stress contributes to poor health outcomes and impairs quality of life, leading to reduced quality of care.

2

3

Mantram repetition is an innovative stress reduction strategy that is portable, convenient, easy to implement, and inexpensive.

Mantram repetition is useful for managing anxiety and enhancing spiritual and religious resources to reduce stress among healthcare workers.

in the workplace and for deepening spirituality in healthcare workers-all of which may improve quality of life.

ACKNOWLEDGMENTS The authors thank the Department of Veterans Affairs in San Diego, California,and the VA Office of Academic Affiliation for support; the Institute of Nursing Research at San Diego State University School of Nursing and the Gamma Gamma Chapterof Sigma Theta Tau InternationalHonor Society for partialfunding; and the UCSD Clinical Research Center NIH grant M01 RR0087 for infrastructure support. We acknowledge the contributions of Eknath Easwaranfrom the Blue Mountain Centerof Meditation, and Nilgiri Press(www.easwaran.org), Tomales, CA; also, special thanks to Walter Boyle, ITS, and computer support.Portionsof this paperwere presented at the State of Science Congress 2002 in Washington, DC; the Western Institute of Nursing Conference 2002 in Palm Springs, CA; and the Western Institute of Nursing Conference 2004 in Portland,OR.

REFERENCES Alexander, C. N., Swanson, G. C., Rainforth, M. V., & Carlisle, T. W. (1993). Effects of the transcendental meditation program on stress reduction, health, and employee development: A prospective study in two occupational settings. Anxiety, Stress & Coping: An InternationalJournal,6, 245-262. Astin, J. A., Shapiro, S. L., Eisenberg, D. M., & Forys, K. L. (2003). Mind-body medicine: State of the science, implications for practice. Journalof the American Board of Family Practice,16, 131-147. Benson, H. (1983). The relaxation response: Its subjective and objective historical precedents and physiology. Trends in Neurosciences, 6,281-284. Benson, H. (1993). The relaxation response. In D. Goleman & J. Gurin (Eds.), Mind/body medicine: How to use your mind for better health (pp. 233-257). Yonkers, NY: Consumer Reports Books. Benson, H. (1996). Timeless healing. New York: Scribner. Bilkis, M. R., & Mark, K. A. (1998). Mind-body medicine: Practical applications in dermatology. Archives of Dermatology, 134, 1437-1441. Biondi, M., & Picardi, A. (1999). Psychological stress and neuroendocrine function in humans: The last two decades of research. Psychotherapy and Psychosomatics,68, 114-150.

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Bormann, J. E. (2005). Frequent, mantram repetition: A jacuzzi for the mind. Topics in Emergency Medicine, 27, 163-166. Bormann, J. E., Becker, S., Gershwin, M., & Kelly, A. (2004). Mantram repetition for managing stress in veterans [abstract]. Communicating NursingResearch Conference Proceedings,37, 340. Bormann, J. E., Gifford, A. L., Shively, M., Smith, T. L., Redwine, L., Kelly, A., et al. (2006). Effects of spiritual mantram repetition on HIV outcomes: A randomized controlled trial. Journal of BehavioralMedicine, 29, 359-376. Bormann, J. E., Oman, D., Kemppainen, J. K., Becker, S., Gershwin, M., & Kelly, A. (2006). Mantram repetition for stress management in veterans and employees: A critical incident study. Journal of Advanced Nursing, 53, 502-512. Brady, M.J., Peterman, A. H., Fitchett, G., Mo, M., & Cella, D. (1999). A case for including spirituality in quality of life measurement in oncology. Psycho-Oncology, 8(5), 417-428. Cohen, C., Revicki, D. A., Nabulsi, A., Sarocco, P. W., Jiang, P. (1998). A randomized trial of the effect of Ritonavir in maintaining quality of life in advanced HIV disease. Advanced HIV Disease Ritonavir Study Group. AIDS, 12, 1495-1502. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journalof Health & Social Behavior,24, 385-396. Cohen, S., & Williamson, G. M. (1988). Perceived stress in a probability sample of the United States. In S. Spacapan and S. Oskamp (Eds.), The social psychology of health: The Claremont symposium on appliedsocialpsychology (pp. 31-67). Newbury Park, CA: SAGE Publications. De Berry, S. (1981-1982). An evaluation of progressive muscle relaxation on stress related symptoms in a geriatric population. InternationalJournalof Aging & Human Development, 14, 255-269. Easwaran, E. (1998/2001). The mantram handbook (4th ed.). Tomales, CA: Nilgiri Press. Easwaran, E. (2005). Strength for the storm: Creating calm in difficult times. Tomales, CA: Nilgiri Press. Eller, L. S. (1999). Effects of cognitive-behavioral interventions on quality of life in persons with HIV. InternationalJournalof Nursing Studies, 36, 223-233. Ellison, C. W., & Jonker-Bakker, I. (1983). Spiritual well-being: Conceptualization and measurement. Journalof Psychology and Theology, 11, 330-340. Ellison, C. W., Paloutzian, R. F., & Bufford, R. K. (1991). Norms for the spiritual well-being scale. Journalof Psychology and Theology, 19, 56-70. Endicott, J., Nee, J., Harrison, W., & Blumenthal, R. (1993). Quality of life enjoyment and satisfaction questionnaire: A new measure. PsychopharmacologyBulletin, 29, 321-326. Flinders, T., Flinders, R., & Gershwin, M. (1994). The RISE response: Illness, wellness, and spirituality - a proven program of relief for people coping with cancer, HIV, chronic pain and tension. New York: Crossroads. Gelfin, Y., Gorfine, M., & Lerer, B. (1998). Effect of clinical doses of fluoxetine on psychological variables in healthy volunteers. American Journalof Psychiatry,155, 290-292. Hawks, S. R., Hull, M. L., Thalman, R. L., & Richins, P. M. (1995). Review of spiritual health: Definition, role, and intervention strategies in health promotion. American Journalof Health Promotion, 9, 371-378. Jacobs, G. D. (2001). Clinical applications of the relaxation response and mind-body interventions. Journalof Alternative and Complementary Medicine, 7(Suppl. 1), S93-S101. Jacobs, G. D., Benson, H., & Friedman, R. (1996). Topographic EEG mapping of the relaxation response. Biofeedback & Self Regulation, 21, 121-129.

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Jevning, R., Anand, R., Biedebach, M., & Fernando, G. (1996). Effects on regional cerebral blood flow of transcendental meditation. Physiology & Behavior,59, 399-402. Kabat-Zinn, J., & Chapman-Waldrop, A. (1988). Compliance with an outpatient stress reduction program: Rates and predictors of program completion. Journalof BehavioralMedicine, 11, 333-352. Kabat-Zinn, J., Massion, A. 0., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., et al. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journalof Psychiatry,149, 936-943. Life Advance, Inc. (n.d.). The Spiritual Well-Being Scale. Retrieved February 3, 2003, from http://www.lifeadvance.com. Miller, W. R., & Thoresen, C. E. (2003). Spirituality, religion, and health: An emerging research field. The American Psychologist, 58, 24-35. Murphy, L. R. (1996). Stress management in work settings: A critical review of the health effects. AmericanJournalof Health Promotion, 11(2), 112-135. Mytko, J. J., & Knight, S. J. (1999). Body, mind and spirit: Towards the integration of religiosity and spirituality in cancer quality of life research. Psycho-oncology, 8, 439-450. Oman, D., & Driskill, J. D. (2003). Holy name repetition as a spiritual exercise and therapeutic technique. Journalof Psychology and Christianity,22, 5-19. Paloutzian, R. E, & Ellison, C. W. (1982). Loneliness, spiritual wellbeing, and quality of life. In L. A. Peplau & D. Perlman (Eds.), Loneliness: A sourcebook for current therapy (pp. 224-237). New York: Wiley-Interscience Publication. Saletu, B. (1987). Brain function during hypnosis, acupuncture and Transcendental Meditation: Quantitative EEG studies. Advances in BiologicalPsychiatry,16, 18-40. Schneider, R. H., Staggers, E, Alexander, C. N., Sheppard, W., Rainforth, M., Kondwani, K., et al. (1995). A randomised controlled trial of stress reduction for hypertension in older African Americans. Hypertension, 26, 820-827. Seeman, T. E., Dubin, L. E, & Seeman, M. (2003). Religiosity/spirituality and health: A critical review of the evidence for biological pathways. American Psychologist, 58, 53-63. Spielberger, C. D. (1972). Current trends in theory and research on anxiety. In C. Spielberger (Ed.) & E. S. Barrat, Anxiety: Currenttrends in theory and research (Vol. 1, pp. 3-19). New York: Academic Press. Spielberger, C. D. (1983). Manualfor the State-TraitAnxiety Inventory STAI (Form Y). Palo Alto, CA: Consulting Psychologists Press, Inc. Spielberger, C. D., Jacobs, G., Russel, S., & Crane, R. (1983). Assessment of anger: The state-trait anger scale. InJ. N. Butcher & C. D. Spielberger (Eds.), Advances in personality assessment (Vol. 2, pp. 159-187). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Spielberger, C. D., Sydeman, S. J., Owen, A. E., & Marsh, B. J. (1999). Measuring anxiety and anger with the State-Trait Anxiety Inventory (STAI) and the State-Trait Anger Expression Inventory (STAXI). In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment (pp. 993-1021). Mahwah, NJ: Lawrence Erlbaum Associates. Sullivan, T., Kerr, M., & Ibrahim, S. (1999). Job stress in healthcare workers: Highlights from the National Population Health Survey. HospitalQuarterly, 2, 34-40. Takaishi, N. (2000). A comparative study of autogenic training and progressive relaxation as methods for teaching clients to relax. Sleep and Hypnosis, 2(3), 132-136. Tuck, I., McCain, N. L., & Elswick, R. K., Jr. (2001). Spirituality and psychosocial factors in persons living with HIV. Journal of Advanced Nursing,33, 776-783.

The Journal of Continuing Education in Nursing - September/October 2006 •Vol 37, No 5