Wellness room as a strategy to reduce occupational stress : quasi-experimental study

Objective: To compare occupational stress levels of nurse staff working in the surgical unit before and after the intervention “wellness room”. Method: Quasi-experimental study with a sample of 60 nurse staff working in a surgical unit of a teaching hospital in the Southern Region of Brazil. The intervention was conducted in a room in the workplace for six months and consisted of sections of aesthetic care, relaxation, lectures and workshops to reduce occupational stress. Data were collected through the Demand-ControlSupport Questionnaire before and after the intervention, and the comparative analysis was performed by the Wilcoxon test. Results: After the intervention, there was a decrease in demand and an increase in control and in the social support received at work in all professional categories, but the differences were not statistically signifi cant. Conclusion: The intervention “wellness room” reduced occupational stress levels in the sample studied; however, it was not a signifi cant decrease. Descriptors: Occupational Health; Nursing; Stress, Psychological; Working Environment; Clinical Trial. RESUMO Objetivo: Comparar os níveis de estresse ocupacional entre trabalhadores de enfermagem do bloco cirúrgico antes e após a intervenção “sala de bem-estar”. Método: Estudo quase-experimental com amostra de 60 trabalhadores de enfermagem do bloco cirúrgico de um hospital escola da Região Sul do Brasil. A intervenção foi realizada por seis meses e consistiu em seções de cuidados estéticos, de relaxamento, palestras e ofi cinas para redução do estresse ocupacional em uma sala no local de trabalho. Os dados foram coletados pelo Demand-Control-Support Questionnaire antes e após a intervenção, sendo a análise comparativa realizada pelo teste de Wilcoxon. Resultados: Após a intervenção, houve diminuição da demanda, aumento do controle e do apoio social recebido no trabalho em todas as classes ocupacionais da enfermagem, mas as diferenças não apresentaram signifi cância estatística. Conclusão: A intervenção “sala de bem-estar” reduziu os níveis de estresse ocupacional na amostra pesquisada, apesar de não se tratar de diminuição signifi cativa. Descritores: Saúde do Trabalhador; Enfermagem; Estresse Psicológico; Ambiente de Trabalho; Ensaio Clínico. RESUMEN Objetivo: Comparar los niveles de estrés ocupacional entre trabajadores de enfermería de la sección quirúrgica antes y después de la intervención “sala de bienestar”. Método: Estudio cuasi-experimental con una muestra de 60 trabajadores de enfermería del bloque quirúrgico de un hospital escuela de la región sur del Brasil. La intervención se realizó durante seis meses y consistió en sesiones de cuidados estéticos, de relajación, con charlas y talleres para la reducción del estrés ocupacional en una sala del lugar de trabajo. Se recolectaron los datos con el Cuestionario Demanda-Control (Demand-Control-Support Questionnaire) antes y después de la intervención, y el análisis comparativo se realizó con la prueba de Wilcoxon. Resultados: Tras la intervención, disminuyó la RESEARCH Wellness room as a strategy to reduce occupational stress: quasi-experimental study Sala de bem-estar como estratégia para redução do estresse ocupacional: estudo quase-experimental Sala de bienestar como estrategia para la reducción del estrés ocupacional: estudio cuasi-experimental


INTRODUCTION
Occupational stress is a common phenomenon among nursing workers and it is widely reported in the literature, especially among those who work in more complex care settings, such as the surgical unit (1)(2) .In this sector, the professionals must provide direct and indirect care to patients and families during the perioperative period.Also, they must master therapeutic and technological devices and are exposed to biological, chemical and physical risks (3)(4) .
Studies carried out in Brazil and abroad demonstrated that stress in this population is multifactorial.However, organizational aspects related to the scope of practice and to the work context are predominant, such as: inflexible hierarchical structure, mainly regarding shifts and rules; incivility and interpersonal problems with members of the multiprofessional team; lack of human and material resources; overload of work and responsibilities; ambiguous and conflicting roles; severity of the patients; and daily contact with suffering and death (1,(5)(6) .
Thus, occupational stress is understood as the conjunction of high demands (high psychological demands related to work rhythm and intensity), lack of control over the work process (insufficient skills and low autonomy) and low social support from managers and peers (low interpersonal interaction and uncooperative environment).This condition, also called "isostrain", may lead to distress and sickness in biopsychosocial functioning (7)(8) .
Research has shown that occupational stress can have undesirable consequences for the health of these workers, for the organization and for the quality of the nursing care, such as psychosomatic illnesses, cardiovascular problems, depression, burnout syndrome, work accidents, absenteeism, presenteeism, high turnover and adverse events (9)(10)(11)(12)(13)(14)(15) .
Therefore, it is imperative to develop primary, secondary and tertiary prevention actions to reduce occupational stress and, consequently, reduce the negative repercussions for the health problems of nursing workers.The most effective interventions for prevention and control of occupational stress combine primary prevention to reduce workplace stressors and secondary prevention to improve workers' stress management skills (16)(17) .
Addressing mental health in the workplace involves knowledge and skills that help prevent occupational stress.Some isolated interventions were considered effective for reducing occupational stress, despite having little scientific evidence, such as mental and physical relaxation techniques, stress management in the organization of work and organizational interventions such as alterations in working conditions, autonomy and interpersonal relations at work.However, there are indications that the combination of these strategies can produce better results in the prevention and control of occupational stress (18)(19) .In addition, only few studies investigated the effectiveness of these interventions to reduce occupational stress in the surgical unit, despite the fact it is a sector that leads to high levels of occupational stress (20) .

OBJECTIVE
The objective of this study was to compare occupational stress levels of nursing workers in the surgical unit before and after the intervention "wellness room".

Ethical aspects
The current ethical recommendations for human research were adopted in the development of this study.The project was approved by the Research Ethics Committee of the State University of Londrina.

Design, setting and period
This is a quasi-experimental study, with pre and postintervention evaluation of a single group.The researchers applied the intervention "wellness room" and observed its effect on the outcome occupational stress.
The study was carried out from January to June 2013 in a teaching hospital in the Southern Region of Brazil, in the surgical unit, which included the surgical center and the material and sterilization center.Approximately 8,100 surgeries occurred every year in this unit, an average of 22 per day, distributed in seven operating rooms that serve 15 surgical specialties.

Population and sample
The study population consisted of the 75 nurse staff working in the surgical unit of the hospital, of which 49 worked in the surgical center and 26 in the materials and sterilization center.The eligibility criteria for participation in the research were: being a nurse working in this sector for at least two months; participating in at least 75% of the activities of the intervention proposed in the study; and not being on a leave.
The 75 professionals met these criteria and participated in the pre-intervention evaluation.However, there were 15 losses of professionals who refused to participate in the postintervention evaluation.Thus, the sample of this study was 60 nurses.

Study Protocol
Initially, the researchers approached potential research participants in the workplace to present the study and explain its development.All the nurses invited accepted to participate in the intervention and responded to the data collection instrument (pre-intervention/baseline evaluation).
The questionnaire elaborated for data collection included socio-demographic and work-related characteristics with data on age, gender, marital status, years of education, professional category, time of experience in the surgical unit, place of work in the surgical unit, work shift, weekly workload and individual monthly income.
Occupational stress was assessed through the Demand-Control-Support Questionnaire, a scale abbreviated by Töres Theorell in 1988 based on the instrument developed by Robert Karasek in 1979 (8) .This questionnaire was adapted and validated for Portuguese by Alves et al. ( 2004) (21) , and it presented good internal consistency (Cronbach's alpha between 0.63 and 0.86) and stability (intra-class correlation coefficient between 0.82 and 0.91).It is a self-report instrument composed of 17 items on a 4-point Likert-type scale measuring three dimensions: demand (five items), control (six items) and social support (six items).
For six months, research participants were enrolled in a program aimed at reducing and controlling occupational stress, called "wellness room".The intervention was performed in a room prepared for this purpose in the workplace, with the following activities: • Physical activity at the workplace: performed daily exercises for 15 minutes in the three work shifts (morning, afternoon and night); taught by a fourth-year physical education undergraduate student from a local university, who was trained for this activity; • "Beauty day": performed monthly, with aesthetic care such as makeup, body massage and skin cleansing; on the same day, breakfast was offered with a free moment for conversation and workers' interaction, as well as a movie section with snacks; • Auricular acupuncture: performed monthly by a professional trained and with experience in the technique; • Lectures and workshops on stress management and coping: held monthly, lasting two hours; conducted by researchers and professionals invited, with experience in the topic; The "wellness room" was used for rest when the activities of this study were not occurring.
At the end of the intervention, the nurses answered the data collection instrument again (post-intervention/completion evaluation).

Analysis of results and statistics
The data obtained were analyzed using the software Statistical Package for the Social Science (SPSS), version 20.0.Numerical variables did not follow normal distribution, as indicated by the Kolmogorov-Smirnov test.Thus, in the descriptive analyzes, the measures of central tendency and dispersion of the numerical variables were presented in medians and interquartile ranges (25th and 75th percentiles), while categorical variables were presented in frequency and percentage.
The comparison of the occupational stress levels evaluated in the Demand-Control-Support Questionnaire before and after the intervention was performed by the Wilcoxon test according to the professional category.The level of significance was set at p <0.05.

RESULTS
Initially, 75 nurses were included to receive the "wellness room" intervention, of which 80% (n = 60) completed the follow-up (Figure 1).
The characteristics of the nursing workers analyzed in this study are presented in Table 1.There was a predominance of females, working in the day shift and the median time working was 15 years.
No statistically significant differences were found when comparing the scores on the Demand-Control-Support Questionnaire from before and after the "wellness room" intervention according to the professional category.However, there was a decrease in the perception of work demand and an increase in perceived control and social support received at work (Table 2).

DISCUSSION
In this study, the intervention "wellness room" did not significantly reduce occupational stress levels among the nursing staff of the surgical unit analyzed.However, the participants presented a decrease in the perception of psychological demand and an increase in control and in the social support received at work.These findings contribute to the advancement of knowledge, mainly due to the positive results, and because other studies evaluating the combination of mental health interventions with primary and secondary prevention actions were not found in Brazil, even with the high costs for personnel, social and organizational management associated with occupational stress among nurse staff.
Scientific evidence has shown that, among the preventive interventions, multimodal approaches using more than one technique produce better effects on occupational stress and contribute to the creation of mentally healthy workplaces (22)(23) .However, there is no recommendation as to how these interventions can be combined and balanced, but only that they can be targeted to a non-specific population (universal prevention), to high risk population (selective prevention) or to those with emerging symptoms (indicated prevention) (24) .
Literature indicates several occupational risk factors for mental health issues, including psychological demands, job control, social support, organizational justice, job dissatisfaction, and job insecurity (25)(26) .Among these, job control is the object of most of the high-quality intervention studies, which do not aim to modify aspects of work organization.In practice, it is easier to increase workers' resilience than to modify risk factors (27)(28) .
A systematic review found that interventions targeted at problem solving, coping and ways to identify stressors and minimize their impact on work do not have a consistent impact on occupational stress (22) .However, a synthesis of systematic reviews indicated that interventions based on cognitive-behavioral therapies have greater effect in reducing occupational stress when compared to relaxation and meditation (29) .From this perspective, the development of defense strategies is important for nursing workers in order to cope with the daily stress of the surgical unit, however it should not be an isolated method.Musculoskeletal pain was observed in 91.8% of the nursing staff in the surgical unit of a teaching hospital and it led to absenteeism and had a negative impact on quality of life.Thus, muscle conditioning is important for these professionals in order reduce the risk of muscle and spinal injuries, and it can be obtained through physical activity in the workplace (30)(31) .In this sense, a quasiexperimental study carried out with workers from a Brazilian higher education institution identified that physical activity at the workplace reduced musculoskeletal pain, but did not significantly reduce occupational stress levels (32) , a result similar to the present study.The positive effects of physical activity on mental health are well documented; however, the impact of physical activity promoted on the workplace is still controversial.A metaanalysis of 13 interventions and seven observational studies found that the combination of aerobic exercise and relaxation reduced anxiety, but did not reduce occupational stress and absenteeism (33) .The main limitation of primary research involving workplace exercise programs is the lack of information about the type, quantity and intensity of activity required to produce significant benefits (27) .
Self-care has been neglected by health professionals, especially by the nursing staff, who, due to work overload and multiple roles, have insufficient hours of sleep, rest and leisure, irregular physical activity and inadequate nutrition.In addition, they consider that some self-care practices, such as meditation, massage, acupuncture and aesthetic care (skin, nails and hair), are unnecessary in their routine.The sum of these factors can lead to stress and physical, psychological and social issues (34)(35) .
A randomized controlled trial with 93 female health professionals, mostly nursing workers, from a Brazilian hospital found that different levels of massage (monosensory, bisensory and multisensory) significantly reduced stress and cortisol levels and increased self-esteem of the participants in relation to the control group, which did not receive the intervention (35) .These results diverged from those obtained in the present investigation, since massage, associated with other strategies, did not produce a statistically significant reduction on occupational stress.
The use of alternative and complementary therapies for relaxation and stress management -aromatherapy, massage, meditation, music therapy and auriculotherapy -in wellness programs in nurses' workplace has been widely assessed and presented satisfactory results (36) .Despite these promising results, relaxation interventions for reducing stress still present evidence of low to moderate quality, since several studies indicate that there are no significant differences between massage for physical and mental relaxation and meditation techniques, such as mindfulness (18) .
A study conducted in hospital units in Arizona (United States) showed that aromatherapy, more specifically the diffusion of therapeutic lavender essential oil in the nursing work environment in complex care sectors, decreased work-related stress and increased satisfaction, since good olfactory experiences can promote well-being (37) .
Regarding auricular acupuncture, the literature indicates that it reduces not only stress levels, but also anxiety and pain, increasing coping strategies and improving the quality of mental life of the nursing team (38)(39) .
Regarding the lectures and workshops on stress management and coping, a study assessed Norwegian physicians who received interventions based on an integrative approach incorporating psychodynamic, cognitive and educational theories, with daily lectures, group discussions, and physical activity.These interventions did not produce significant changes in the levels of emotional exhaustion, job stress, emotion-focused coping and neuroticism; however, these levels were significantly higher in comparison to the control group (40) .
In general, health promotion programs in the work environment present low and moderate evidence for improved mental health and well-being and decreased absenteeism.Thus, authors conclude that, although such interventions have the potential to prevent mental health problems, additional research is needed to determine the effectiveness of this approach and to identify which components of the intervention produce the most beneficial outcomes (41)(42) .
Another study identified the need for an adequate and prepared physical space for nursing professionals to rest.A rest space is essential to deal with work overload and lack of human resources, as it can provide relief to the workers' fatigued muscles and to their mental health (34) .
There is a considerable body of knowledge and significant advances, but it is clear that effective interventions for the reduction and control of occupational stress are difficult and complex, since they must consider subjectivity, different work contexts and the different stressors to which the workers are subjected.In addition, both the individual and the organization are extremely dynamic, which makes it difficult to control the variables.

Limitations of the study
The convenience sampling can be cited as a limitation of the present study, since the participants were in only one group and in a single hospital, which prevents the generalization of the results.Also, 20% of the participants who received the intervention refused to answer the last evaluation, which may also affect the analysis.Another limitation of this investigation was the evaluations carried only at the baseline and at the conclusion of the intervention, with no long-term followup.Thus, future studies should include time series evaluations and follow-up the participants in order to verify the long-term effects of the intervention.Also, future studies should investigate, in addition to self-report measures, the biological parameters of the stress reaction, such as cortisol, in order to confirm the effect of the intervention on occupational stress.

Contributions to the nursing area
The results of the study indicate the viability of developing and using a "wellness room" in the workplace, with actions that promote self-care, improve social support among the team, increase physical activity, offer physical and mental relaxation, and provide educational practices about stress management and coping, all aiming for reducing stress among nurse staff in the surgical unit.The fact that it did not produce statistically positive effects is important for the scientific evidence produced by systematic reviews with meta-analysis, since it reduces the positivity bias of the studies that use this design.This study represents an advance in knowledge when it demonstrates that wellness actions offered by the institution reduce demand and increase control and social support for nursing staff.

CONCLUSION
The intervention "wellness room" reduced the perception of demand and increased control over the work process and the social support received in the work and, thus, reduced the levels of occupational stress among nursing workers of the surgical unit studied.However, this decrease was not statistically significant.

Table 2 -
Comparison of the scores on the Demand-Control-Support Questionnaire dimensions before and after the "wellness room" intervention, according to professional category (n=60), Brazil, 2013