MILITARY MEDICINE, 175, 7:487, 2010

Stress Gym: Feasibility of Deploying a Web-Enhanced Behavioral Self-Management Program for Stress in a Military Setting CAPT Reg Arthur Williams, NC USNR (Ret.)*; Bonnie M. Hagerty, PhD, RN, BC†; CAPT Steve J. Brasington, MC USN‡; CDR Joseph B. Clem, MC USN§; David A. Williams, PhD|| ABSTRACT Stress and depression can adversely impact the performance of military personnel. Cognitive-behavioral (CBT) interventions for managing stress are efficacious in traditional face-to-face formats, but the Internet supports a broader reach of these programs. This study reports on the feasibility of using an Internet-based self-help stress-management intervention in military personnel. There were 142 officers/enlisted sailors at a Naval Medical Center who completed the program. Evaluation of the program titled “Stress Gym” was positive for the user interface, content, feasibility, and satisfaction. Positive evaluation was not influenced by rank/status, sex, or previous deployment. Stress ratings also decreased significantly while using the program. These data support Stress Gym as being an online CBT-based selfhelp intervention that is feasible to deploy, accepted by the intended end users, and demonstrates the intended goal of reducing stress.

INTRODUCTION There is mounting evidence that psychiatric illnesses affect the lives and performance of a significant number of active duty military.1–4 For example, Hoge and colleagues2 found that 19.1% of service members returning from Iraq, 11.3% returning from Afghanistan, and 8.5% from other locations reported problems with mental health. A second study of the 103,788 veterans from Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) seen at VA health care facilities between 2001–2005, found that 25,658 or 25% qualified for a mental health diagnosis; and of those, over half qualified for two or more distinct mental health diagnoses (e.g., depression, anxiety, PTSD).5 Stress arising from deployment and war zone experiences as well as the anticipation of adverse events can contribute to mental health problems in those who are particularly at risk.6 Even in those not predisposed to mental health problems, stress can interfere with routine daily performance. Despite the ubiquitous nature of stressors in the context of the military, surprisingly little work has been devoted to strategies aimed at decreasing them.7 An exception to this has been several studies supporting the utility of using behaviorally based interventions for stress in U.S. Navy recruits.8–10 On the basis of Lazarus and Folkman’s11 model of cognitive appraisal, a series of studies were conducted examining factors associated with depression in U.S. Navy recruits,10 and *School of Nursing and Psychiatry, †School of Nursing, and ||School of Anesthesiology, Medicine, Psychiatry, and Psychology, Medical School, University of Michigan, 400 N. Ingalls Building, Ann Arbor, MI 48109. ‡Mental Health Services, Naval Medical Center, Portsmouth, VA 23708. §Department of Psychiatry, Naval Medical Center, Portsmouth, VA 23708. The information or content and conclusions presented in this article do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by, the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, Department of the Navy, or the U.S. government.

the effectiveness of a cognitive–behavioral self-help intervention in reducing stress in recruits.8,9 In the initial intervention study funded by the TriService Nursing Research Program,9 at-risk recruits were randomly assigned to one of two groups: a cognitive–behavioral intervention for reducing risks associated with stress and a nonintervention group. A third group (control) was also studied, composed of recruits who were not at risk and who did not receive an intervention. Percentages of recruits in the study successfully completing basic training were 86% of the intervention group, 74% of the nonintervention group, and 84% of the comparison group. Recruits at risk and who received the intervention had significantly fewer transfers and separations from the Navy. The self-help intervention described above was used in a second, larger, randomized trial comparing a division of recruits getting the intervention with a division of recruits not receiving the intervention. The recruits in the division receiving the intervention developed significantly greater group cohesion, greater problem solving skills, and better perceived social support, while reporting less anger than the control group. Cost-effective analysis showed that if the intervention was fully implemented by the Navy with all recruits in basic training, cost savings per year would be an estimated $18.6 million. The cost to train facilitators and run the groups would be $1.5 million, still leaving a cost savings of $17.1 million. Sailors in the study that successfully completed basic training were followed after 2 years in the fleet. The sailors receiving the intervention remained in the Navy at a 1% higher rate than the nonintervention sailors.8 Despite this self-help program demonstrating efficacy, several barriers impede broader adoption of such a program for military use. Barriers include: (a) training of large numbers of group facilitators to implement this face-to-face intervention on a large scale, (b) facilitating sufficient time in recruits’ schedules to permit regularly scheduled group meetings with the facilitators, and (c) overcoming the perception that such a

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Stress Gym: Web-Based Program for Stress in a Military Setting

program would be cost prohibitive. These barriers (i.e., access to therapists, patient burden, and cost) are not unique to the military and similarly impede the movement of otherwise efficacious nonpharmacological interventions into mainstream health care. In response to these barriers, clinicians are exploring new delivery platforms that can facilitate access to these interventions in more cost-effective and efficient ways. Internet and computer-based interventions are promising platforms for delivering mental health interventions that also address many of the barriers just mentioned.12,13 For example, researchers14 described the development of a web-based, cognitive–behavioral (CBT) intervention designed to prevent depression and anxiety in young people. As participants completed study modules over a 6-month period, depression and anxiety symptoms decreased significantly. Two other Internet interventions support the viability of this platform for helping individuals with depressive and anxiety symptoms.15,16 To date, the evidence suggests that computer-based interventions rival the benefits attainable by more traditional face-to-face interventions17,18 with the advantage of allowing patients to use the interventions at their own pace and with greater privacy. The use of an Internet platform enables the intervention to be deployed on a larger scale in a cost-efficient manner.19,20 Building upon previously successful behavioral interventions for stress in Navy recruits,8,9 the current study describes the feasibility of translating these earlier successful group facilitation interventions into a web-enhanced behavioral self-management program (WEB-SM) entitled “Stress Gym” designed for active duty military personnel. Use of a WEB-SM format has a number of advantages including (a) the ability to tailor content to the individual, (b) the ability to deploy a standardized intervention to a large number of individuals at little cost and at distance, and (c) the flexibility and anonymity of this mode of treatment delivery reduces time constraints and helps to preserve privacy. The purpose of the present study was to evaluate whether a web-based program about stress would be used and accepted by Navy members. Specifically we translated a group-facilitated intervention into a web-based format and assessed the qualitative experience of active duty military who were offered the opportunity to use “Stress Gym.” We examined the pre–post differences in stress among those who tried Stress Gym, and identified differential responses to Stress Gym on the basis of demographic characteristics such as rank, sex, ethnic/racial background, and history of deployment. METHODS Participants The study design was proof of concept to examine the feasibility of Navy members using Stress Gym. All active duty members at Naval Medical Center, Portsmouth, Virginia were invited to participate in the study. Participants were told about the opportunity to participate in the study by general invitation

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from the command master chief or a senior medical officer. All participation was anonymous thus no identifying information was obtained. A total of 396 Navy members logged into Stress Gym, read and signed the informed consent document, and agreed to participate. Of those who signed informed consent, 290 completed the screening questions and examined some of the modules. Complete data were available on 142 individuals who in addition to completing the screening questions and viewing the modules also provided demographic data and filled out the evaluation form. The sample of 142 is reported on below. The sample consisted of 24% officers and 76% enlisted sailors. Mean ages were 41.1 (SD = 9.2) and 29.5 (SD = 7.9), respectively. The officers ranged in rank from ensign (O-1) to captain (O-6) and the enlisted sailors ranged in rank from hospital recruit (E-1) to command master chief (E-9). There were 55% (n = 78) females and 45% (n = 64) males who completed the evaluation. The ethnic/racial background of the sample (valid %) consisted of 62.3% (n = 76) Caucasians, 20.5% (n = 25) African Americans, 9.0% (n = 11) Hispanics, 4.1% (n = 5) Asian Americans, 2.5% (n = 3) American Indians, and 1.6% (n = 2) other. There were 18 who did not indicate their ethnic/racial background. The ethnic/racial composition of this sample is consistent with the Navy’s overall racial/ethnic background mix. The average length of time in the Navy was 16.1 (SD = 8.3) years for the officers and 9.25 (SD = 7.4) years for the enlisted members. When asked whether they were deployed to or near a war zone before the study, 49.2% (n = 60) answered “yes” and 50.8% (n = 60) said “no.” There were 18 who did not indicate their deployment status. Intervention Stress Gym was designed to be delivered as an Internet-based intervention. The content for Stress Gym, however, was translated from a previously evaluated group intervention using a standardized manual.8,9 Each module was grounded in the theoretical underpinnings of Lazarus and Folkman’s11 model of cognitive appraisal and was written at an 8th grade level. The modules in Stress Gym are briefly described in Table I and focus on managing stress by developing an awareness of stress in interpersonal relationships, stress associated with dealing with specific health issues, and maladaptive responses to stress (e.g., altered sleep patterns, depressed affect, and alcohol use). A new user to Stress Gym is first presented with an overview of the program as well as a 14-item screener that helps to identify modules of relevance to the participant (i.e., individual tailoring). Examples of screening statements are: I am feeling overwhelmed; I am not getting enough sleep to feel rested; I am having difficulty balancing my life. The participants’ range of response was from “strongly agree” to “strongly disagree” for each of the statements. If a screening statement was endorsed the program would recommend that participants complete the respective modules containing relevant content to their concerns. This initial tailoring of the

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Stress Gym: Web-Based Program for Stress in a Military Setting TABLE I.

Description of Modules in Stress Gym

Module 1 (Stress and Emotionality) Participants receive didactic content regarding the interplay between stress and emotions and why awareness of each is important to mental health and daily functioning.25–27 Users of this module are instructed in the methods of recording their emotionality and stress levels using a graphing system. Module 2 (Reacting to Stress) Specific methods of stress reduction are described and participants are instructed in methods of implementing these strategies.28–30 Examples include: deep breathing, counting, creating a picture or visualization, and using mental mnemonics. Module 3 (Sleep) Participants focus on how work assignments and stress can interfere with sleep. Users identify behavioral strategies that help to obtain adequate rest such as: going to bed at a regular time each night, refraining from exercising late in the evening, and refraining from alcohol for inducing sleep.31,32 Module 4 (Problem Solving) Users learn structured approaches to problem solving with opportunities to practice their new skills with predefined examples as well as with personally relevant situations of their choosing. Structured problem solving includes brainstorming possible solutions, refining options, weighing the advantages and disadvantages of potential solutions, and selecting a plan. Implementing the plan and revising it on the basis of feedback are also encouraged.33–36 Module 5 (Change Your Thinking) Thinking may not be optimally clear and broad under conditions of stress. Maladaptive forms of thinking are described, such as ignoring the positives and focusing on the negatives, either–or thinking, overgeneralization, perceiving that others are more successful, “should” statements, and mislabeling—all leading to depression. Linkages between maladaptive thinking styles and depression are described and the module identifies methods of (a) localizing maladaptive thinking, and (b) approaches to challenging and modifying such patterns.37,38 Module 6 (Belonging) Increasing a sense of belonging has significant effects on the psychological and social well-being of an individual.39,40 This module provides behavioral strategies to help individuals gain a stronger sense of interpersonal relatedness (e.g., greeting at least one new individual each day, finding and sharing something in common with other individuals, complimenting others and avoiding criticizing, asking for help, actively listening when in a conversation, and taking pride in successes).39–42 Module 7 (Relationships) Issues are addressed that may be present in current relationships or unresolved issues in past relationships.41,42 Strategies are offered to build healthy and satisfying relationships, improve communication, and subsequently approaches to maintaining meaningful and fulfilling relationships over the long term. Module 8 (Teamwork) The importance of team cohesion is emphasized in the context of social support.43 Participants review the 12 pledges of teamwork and attempt to fulfill one or more of these pledges each day.44 Several examples of strategies include: “We expect the truth. We will not lie to ourselves or to others.” “We will keep our word. We will say what we mean and mean what we say. We will trust the word of others.”43,44 Module 9 (Balance) Trainings are offered in finding and keeping balance in one’s life. It examines the competing demands of deployment, work, or recovery, and the demands of family. Strategies are provided to assist in maintaining a balance between needs and competing/conflicting demands.6

intervention guides the user to areas of the website holding information of most immediate importance.

scale ranging between “strongly disagree” to “strongly agree.” Items are listed by category in Table III.

Measures The purpose of this intervention was to assess whether active duty military personnel would accept and use a WEB-SM program for the management of stress. The assessment measures used in this study therefore captured information regarding the adequacy of the WEB-SM programs user interface, its utility as an intervention, and the feasibility and satisfaction of the intervention within the intended population.

Stress Gym Open-Ended Qualitative Evaluation

Stress Gym Feasibility Questionnaire

This questionnaire assessed the following perceptions of individuals using the site: (a) the user interface, (b) the utility of the site, (c) the feasibility of using such a site, and (d) the satisfaction of using Stress Gym in active duty Navy personnel. The questionnaire consisted of 16 statements to which participants were asked to respond based upon a 5-point Likert-type

Participants were provided with the opportunity to complete a series of open-ended questions regarding their experiences with Stress Gym. These questions focused upon both the positive and negative aspects of the program. Participants were told that their responses to these questions would be used to help refine the program for future participants. Impact on Perceived Stress While the intent of this study was to assess the feasibility of deploying Stress Gym in a military environment and not to evaluate the efficacy of Stress Gym in reducing mental illness, a single analog scale of the participants’ perceived stress was assessed both before and following the use of Stress Gym. This numeric rating scale of stress (NRS) offered the following response options: “1” (no stress) to “10” (extreme stress). Single NRS’s

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of this nature are extensively used to measure acute perceptions of symptom intensity in a variety of health conditions.21–23 Demographic and Descriptive Data Demographic and descriptive data such as gender, age, and racial/ethic background were collected to assess differential responses to Stress Gym based upon demographic factors. Questions such as rank/rate in the Navy, years in the Navy, deployment to or near a war zone, and length of time deployed before the study were also collected. The questionnaire to evaluate the website took approximately 3 minutes to complete. Procedures Participants gained access to the secure website containing Stress Gym via an invitation code provided by the command master chief or a senior medical officer to protect the program from use by unintended others. All participants completed an online consent form after which, if they agreed to participate, the program took them to a page where they could create a unique identification code known only by them allowing anonymous access to Stress Gym. No names or e-mail addresses were part of study participation. The study and protocol was approved by a university and two military institutional review boards, which approved the study for protection of human subjects. The Stress Gym content is best suited for users who are experiencing early onset and/or mild stress symptoms. Participants with more serious mental health symptoms are introduced to content of Stress Gym on the home page and provided with the opportunity to access more intensive and more traditional mental health services. All participants were offered the opportunity to complete the screening questions, which are based on the content contained in the nine modules. Navigation through Stress Gym was simplified by allowing participants to move to any module simply by selecting the desired module in the navigation bar. Module navigation comprised scrolling or selecting for advancing through simple interactive web-pages. Each module offered options for information, opportunities such as writing responses in logs, or graphing symptom levels (e.g., stress). Stress Gym also included animation and interactive exercises. Responses were maintained in the program and were accessible each time the participant accessed the program. Upon completing any or all of the modules, participants were encouraged to complete the evaluation questionnaire and then log off. Data Analysis Preliminary data analysis included the preparation of summary and contingency tables as well as bar graphs for categorical information, and summary statistics (means, medians, ranges, standard deviations, and histograms) for continuous variables. All variables were examined for aberrant or miscoded values. Descriptive statistics were used to characterize evaluative comments and c2 was used to determine whether user interface, utility, feasibility, and satisfaction with

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Stress Gym were influenced by demographic or background variables, such as deployment, and the amount of stress. A p value of 0.05 or less was set a priori to determine statistical significance in these group comparisons. Paired t-tests were used to compare changes in perceived stress within individuals across two points in time and Pearson correlation was used to evaluate the association between the amount of time logged onto the website and the number of modules completed with change in perceived stress. RESULTS Module Use Based on Screening Assessment Use of the screener resulted in the following modules being the most frequently recommended: stress and emotion, sleeping, balance, and reacting to stress. The teamwork module was the least frequently recommended module. For a complete breakdown of the screen tailoring of Stress Gym see Table II. Stress Gym Feasibility Questionnaire Based upon preliminary descriptive analyses of these 16 items, none of the program evaluation questions demonstrated significant differences based upon demographic characteristics (i.e., rank, ethnic/racial backgrounds, or sex). Program evaluation data were therefore examined using the total sample. Overall, the majority of military personnel who tried Stress Gym provided positive ratings across all evaluative categories; that is, they found the user interface acceptable and easy to navigate, the approaches to stress management were useful, and satisfaction with the program was high. Table III displays the actual evaluation items and the range of response ratings for each item. The average participant completing the Feasibility Questionnaire remained logged into Stress Gym for 17:51 (SD = 35:41) minutes. Changes in Perceived Stress via Stress Gym The NRS rating of perceived stress demonstrated a significant reduction in stress intensity from baseline to post website use. Significant differences were noted for both officers and enlisted members using paired t-test before and after using Stress Gym (see Figure 1). Baseline differences in perceived stress between officers and enlisted members were not TABLE II. Percentage of Participants Guided to Each Module Based Upon Tailoring from the Screener (N = 142) Modules

Percentage

N

Stress and Emotion Sleeping Balance Reacting to Stress Problem Solving Changing Your Thinking Relationships Belonging Teamwork

55.5 53.6 47.5 47.5 37.2 36.5 35.1 31.1 26.6

79 76 67 67 53 52 50 44 38

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Stress Gym: Web-Based Program for Stress in a Military Setting TABLE III.

Stress Gym Feasibility Evaluation Questionnaire: Participant Responses by Category (N = 142) SD % (n)a

D % (n)

N % (n)

A % (n)

SA % (n)

Stress Gym opening page was immediately engaging. Organization of the opening pages was logical. I was able to navigate through the program easily. I like the animation that is in the program. The clipart was consistent with the content.

1.5 (2) 0.7 (1) 1.5 (2) 2.3 (3) 1.5 (2)

5.3 (7) 3.8 (5) 0.8 (1) 3.8 (5) 3.0 (4)

26.3 (35) 11.3 (15) 14.5 (19) 34.8 (46) 25.6 (46)

55.6 (74) 69.9 (93) 61.1 (80) 46.2 (61) 57.1 (61)

11.3 (15) 14.3 (19) 22.1 (29) 12.9 (17) 12.8 (17)

3.7 3.9 4.0 3.6 3.8

(0.80) (0.69) (0.73) (0.84) (0.77)

Utility Items The screening questions helped me start with the most relevant modules. The modules within Stress Gym were the important areas for me to explore. I like the option to maintain a log of my thoughts and feelings in my life. Stress Gym gave me direction to seek additional help if I need it. Stress Gym helped me to understand how I respond to stress. I learned new strategies for managing my stress.

1.5 (2) 1.5 (2) 3.0 (4) 3.8 (5) 6.1 (8) 6.1 (8)

3.8 (5) 4.6 (6) 9.1 (12) 4.5 (6) 3.8 (5) 4.5 (6)

18.0 (24) 18.3 (24) 31.8 (42) 28.8 (38) 20.6 (27) 28.0 (37)

59.4 (79) 64.9 (85) 46.2 (61) 50.0 (66) 58.8 (77) 47.0 (62)

17.3 (23) 10.7 (14) 9.9 (13) 12.9 (17) 10.7 (14) 14.4 (19)

3.9 3.8 3.5 3.6 3.6 3.6

(0.79) (0.76) (0.99) (0.90) (0.95) (0.99)

Feasibility and Satisfaction Items I like the design of the program. I will use Stress Gym again to help myself. I would recommend Stress Gym to my shipmates. Stress Gym would be helpful to my family. Stress Gym was easy to use with my work schedule.

2.3 (3) 6.1 (8) 4.5 (6) 4.6 (6) 3.1 (4)

3.8 (5) 6.8 (9) 2.3 (3) 9.2 (12) 3.1 (4)

30.5 (40) 34.8 (46) 26.5 (35) 32.8 (43) 24.4 (32)

48.1 (63) 40.9 (54) 48.5 (64) 41.2 (54) 55.7 (73)

15.3 (20) 11.4 (15) 18.2 (24) 12.2 (16) 13.7 (18)

3.7 3.5 3.7 3.5 3.7

(0.86) (0.99) (0.94) (0.98) (0.85)

User Interface Items

Mean (Std. Dev.)

SD, strongly disagree; D, disagree; N, neutral; A, agree; SA, strongly agree; (SD = 1 to SA = 5). c2 results: no significant differences in each evaluation item and males vs. females, officers vs. enlisted, ethnic/racial background, and deployment vs. not deployed before the study. a Not all participants respond to every item.

(2) positive statements about the quantity of stress-related information, (3) positive statements regarding the availability of information on sleep, (4) positive statements about the availability of information on reacting to stress, (5) positive statements about the availability of information on changing thinking patterns, (6) positive statements about the availability of information on belonging and relationships, and (7) positive statements about the brevity and “digestibility” of the modules. There were no open-ended negative comments specifically regarding Stress Gym; however, several participants reported that they were not the type of person who got stressed or reported that they already know how to deal with stress.

FIGURE 1. Perceived stress levels of officers and enlisted before and after completing Stress Gym.

significantly different (t-test [116] = 1.50, p = NS). There was a small nonsignificant correlation (r = 0.10) between the amount of time they were on the website with their perceived stress scores after completing Stress Gym. However, there was a positive significant correlation (r = 0.21, p = 0.027) between the number of modules completed and the decrease in perceived stress scores after completing the program. Stress Gym Open-Ended Qualitative Evaluation A total of 46 participants provided open-ended written responses regarding aspects of Stress Gym which they “liked.” Themes contained within these responses included the following: (1) statements expressing a globally positive reaction,

DISCUSSION This study builds upon our previous research8–10 involving Navy recruits by translating a previously successful self-help intervention into a web-enhanced format. The current study tested the feasibility and utility of the new web-based “Stress Gym” intervention in active duty Navy members and found it to be well-received in this new military sample. The individualized tailoring questions in the screener tended to identify the modules on stress and emotion, sleeping, balance, and reacting to stress to be of most relevance for both officers and enlisted members. The least frequently recommended module was teamwork; a somewhat expected finding given that the Navy emphasizes the importance of teamwork in the workplace. The results of the 16-item Feasibility Questionnaire were encouraging. It was clear that the participants found Stress Gym easy to navigate, logical, facilitated completion of relevant modules, and covered important areas. The positive

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response to Stress Gym by participants suggests that it does not suffer from some of the criticisms of Internet interventions such as lack of engaging content and relevance.14,24 It was noteworthy that there were no statistically significant c2 differences in the evaluation of Stress Gym on the basis of sex, rank, and status, or whether participants had been deployed to or near a war zone or not. This lack of differences suggests that Stress Gym is found to be a useful tool for Navy personnel generally and is not limited to a specific subgroup—a finding that supports potential utility of Stress Gym for broader deployment. Additionally, although written at an 8th grade reading level so as to reach the broadest possible range of educational background, the respondents were not put off by the simplicity of the content presentation. This finding is consistent with our face-to-face clinical experience where simple strategies appear to assist patients the most in managing stressful conditions. Individuals under considerable stress or developing depressive symptoms are often unable to incorporate complicated processes and instructions. Data from this study suggest that perceived stress diminishes even during the relatively short time frame in which the program is being used. In addition, there was a significant correlation with the number of modules used and a decrease in perceived stress. It is not known, however, whether this significant decrease in perceived stress is sustainable and would need to be evaluated in a future study of efficacy or effectiveness. In actual practice, Stress Gym would have unlimited login opportunities thus allowing for the management of stress over long time frames. Several limitations existed in this study. There were a sizable number of individuals who logged into the study but failed to complete the evaluation questionnaire at the end. We suspect that this discrepancy was in part due to a programming limitation that allowed for an evaluation reminder to appear if the “log-off” button was selected but not if the “close” button was used. We suspect many participants closed out the program by using the close button instead of logging off. The evaluation questionnaire was a self-report of the helpfulness of the website and their change in perceived stress before and after completing Stress Gym. The inherent limitations of selfreport are noted. Another possible limitation was not having an incentive to complete the program given the heavy workload of active duty personnel. Since the website was completely anonymous, it was not possible to provide an incentive and the military limits the use of providing a research incentive to personnel. Despite these limitations, it was encouraging to see so many individuals agreeing to evaluate the site. In conclusion, Stress Gym demonstrated feasibility with Naval members, thus the results supplied data that can be used in preparation for clinical trials testing Stress Gym’s effectiveness in stress reduction, depression risk reduction, and improving coping strategies. Underway is a study examining the effectiveness of an adapted version of Stress for Wounded

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Warriors addressing such symptoms of PTSD, depression, anger, and anxiety. If Stress Gym continues to demonstrate effectiveness, it may warrant broader adaptation within the military or in the general population in a variety of contexts in which people need to learn stress management strategies to manage life situations and prevent more serious physical and psychological concerns. ACKNOWLEDGMENTS The authors extend appreciation to Naval Medical Center, Portsmouth, Office of the Vice President for Research, the School of Nursing, University of Michigan, and Gary Gatien, project manager for their support of this research project. The Department of Defense, TriService Nursing Research Program sponsored this research (TSNRP N04-014, MDA-905-04-TS04) at the Uniformed Services University of the Health Sciences.

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