See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/352961129

Effect of four weeks of integrated yoga intervention on perceived stress and

sleep quality among female nursing professionals working at a tertiary care
hospital: A pilot study

Article  in  Industrial Psychiatry Journal · January 2021

DOI: 10.4103/ipj.ipj_11_21

CITATIONS READS

2 95

3 authors, including:

Man singh Jat

All India Institute of Medical Sciences
2 PUBLICATIONS   2 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Man singh Jat on 30 November 2021.

The user has requested enhancement of the downloaded file.

[Downloaded free from http://www.industrialpsychiatry.org on Tuesday, November 30, 2021, IP: 14.139.245.2]

ORIGINAL ARTICLE

Effect of four weeks of integrated yoga

intervention on perceived stress and sleep quality
among female nursing professionals working at a
tertiary care hospital: A pilot study
Niranjan Parajuli,
Balaram Pradhan1,
Mansingh Jat
Centre for Integrative Medicine
and Research, AIIMS,
New Delhi, 1Division of Yoga
and Humanities, SVYASA,
Bengaluru, Karnataka, India
Address for correspondence:
Dr. Balaram Pradhan,
SVYASA Yoga University,
# No‑19, Eknath Bhavan,
Gavipuram Circle, KG Nagar
City, Bengaluru ‑ 560 019,
Karnataka, India.
E‑mail: balaramp13@gmail.com
A B S T R A C T
Background: Studies have reported that significant nursing professionals experience
tremendous stress which often affects their sleep quality leading to poor well‑being.
Yoga being a mind body intervention reported to improve sleep quality and reduce stress.
Aim: The present pilot study was designed to assess the effect of yoga on perceived
stress and sleep quality of the female nursing professionals working at tertiary care
hospital. Materials and Methods: Thirty‑three apparently healthy nursing staffs in the
age range of 30–60 years (mean age 40.60 ± 10.26) were recruited as participants
of the study, from a tertiary care hospital in Delhi. Participants were administered
perceived stress scale (PSS) and Pittsburgh sleep quality index (PSQI) before and after
the yoga intervention. Participants received 4 week of yoga intervention for 45 min/
day for 5 days a week. Results: There was a significant reduction on the postscores
of PSS (t = 5.86, P < 0.0001, paired t‑test) and PSQI (z = −4.38, P  < 0.0001,
Wilcoxon signed‑ranks test) in comparison to prescores. After the yoga intervention,
perceived stress reduced by 27.01% and the sleep quality improved by 38.68%.
Conclusion: The finding of the study suggests effectiveness of yoga in reduction of the
perceived stress and improvement of the quality of sleep of the nursing professional.
However, the present findings need to be confirmed with further studies with larger
sample size and robust research design.

Received: 15 January 2021

Revised: 29 April 2021
Accepted: 30 April 2021 Keywords: Nursing profession, sleep quality, stress, yoga
Published: 30 June 2021

N ursing professionals in India as well as throughout

the world experience high stress[1‑3] and poor sleep
quality.[4‑7] Negative consequences of stress and poor sleep
low quality of life.[12,13] Stress and poor sleep quality in
nurses’ even increases patient care errors.[14,15]

quality in the health of nursing professionals are well
established. Studies showed that stress and poor sleep
quality are positively associated with anxiety, depression,
fatigue, and confusion, and negatively associated with
attention, memory, and concentration of professional
nurses.[8‑11] High level of stress and poor sleep quality are
also correlated with increased physical health complications
such as hypertension, obesity, cardiovascular diseases, and
Access this article online
Quick Response Code:
The findings of scientific studies showed excessive
workload, professional conflicts, poor leadership
management style, inadequate pay, work shift pattern, and
emotional cost of caring are some of the causes of stress
and poor sleep quality in nursing professionals.[16‑19] In
addition, nurses are found neglecting their self‑care needs
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.

Website: www.industrialpsychiatry.org For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Parajuli N, Pradhan B, Jat M. Effect of four

weeks of integrated yoga intervention on perceived stress and sleep
DOI: 10.4103/ipj.ipj_11_21
quality among female nursing professionals working at a tertiary care
hospital: A pilot study. Int Psychiatry J 2021;30:136-40.

136 © 2021 Industrial Psychiatry Journal | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.industrialpsychiatry.org on Tuesday, November 30, 2021, IP: 14.139.245.2]
Parajuli, et al.: Yoga for nursing professionals
when they are devoted to patient care.[20] Abandonment of
self‑care increases stress, reduces quality of life, deteriorates
physical and psychological health of nurses as well as
increases the health care cost.[21] It also compromises the
patients care quality.[21] The present study also showed that
stress negatively affects self‑care in nurses.[22] Therefore,
hospital managements are required to improve nurses’
working environment and promote practices that nurture
self‑care in nurses, reduce their stress and improve sleep
quality. Fostering self‑care, improving sleep quality and
helping to manage stress can enhance nurses’ physical and
psychological health, can minimize patient care errors and
health‑care cost of an institution.
Yoga is a practice to enhance self‑care, coping strategies
and sleep quality, and to reduce work stress of nurses.[23‑25]
A randomized, control, pilot‑study conducted in 40
nurses showed that yoga significantly improves self‑care
and mindfulness, and significantly reduces emotional
exhaustion. [26] Another randomized control study
conducted in nurses with chronic low back pain showed
that yoga is an efficient intervention to improve their
physical, psychological, and social health spheres of quality
of life compared to physical exercise.[27] Even a systematic
review reported yoga as an effective technique to manage
the stress of health workers. [28] Yoga also improves
nurses’ problem‑solving ability and ability to focus on
patients’ needs.[29] In addition, mindfulness meditation and
mindfulness‑based stress reduction techniques were found
effective in improving general health, sense of coherence,
coping ability, life satisfaction, relaxation, mental well‑being
and job satisfaction as well as reducing stress, anxiety,
depression, burnout of professional nurses.[30‑33]
Studies to assess the effect of yoga on stress and sleep
quality of nursing professionals are rare, one study
conducted in Chinese nurses reported 6 months of yoga
intervention improves nurses sleep quality and reduces
work stress.[24] Further studies are required to support
the effect of yoga on stress and sleep quality of nursing
professionals. Literature review showed no study to assess
the effect of yoga on perceived stress and sleep quality in
India. Therefore, the present pilot study was designed to
assess the effectiveness of 4 weeks of yoga on perceived
stress and sleep quality among the nursing professionals
working at a tertiary care hospital.
MATERIALS AND METHODS
Convenient sample of 33 apparently healthy female nursing
professionals within the age range of 30–60 years (mean
age 40.60 ± 10.26), working at a tertiary care hospital in
New Delhi were recruited as the participants for the present
Industrial Psychiatry Journal 
study. Registered Direct Care Giving nursing professionals’
and those who were willing to participate were included
in the study. Whereas those nursing professionals who
were diagnosed with severe musculoskeletal, neurological
or psychiatric illness, those who had recent surgical
intervention and those who were practicing yoga on a
regular basis were excluded from the study. The design
of the study was a single group pre‑post. Patients were
assessed on baseline and after the 4 weeks of intervention.
The study was approved by a project Evaluation Committee
of Directorate of Distance Education, SVYASA deemed
to be University, Bengaluru, Karnataka, India. Verbal
informed consent was obtained from the nursing
professionals before the study, after explanations of the
nature of the study in detail.
Intervention
45 min of group yoga was given for 6 days a week
for 4 weeks. 45 min of yoga intervention includes
Sukshma Vyayama (Joints loosening) breathing exercise,
asanas (postures), pranayamas and deep relaxation
technique. Yoga intervention was given by an academically
trained yoga therapist. Practices mentioned in Table 1 were
repeated throughout the intervention period.
Assessments
Perceived stress
Perceived stress was assessed using the perceived stress
scale (PSS). PSS is a self‑reported 10‑item questionnaire to
assess perception of stress in one’s day‑to‑day life.[34] PSS is
easy‑to‑use questionnaire with well‑established psychometric
property.[35] Each item of PSS is rated on 5 points scales
from 0 (never) to 4 (very often). Each item of PSS is rated on
5‑point scale from 0 (never) to 4 (very often). The possible
score ranges from 0 to 40. The total score is obtained by
reversing the responses for the positively state items (4, 5,
7, and 8) and summing scores across all the scales items.[34]
PSS score ranging from 0 to 13 would be considered low
stress; score ranging from 14 to 26 would be considered to
be moderate stress; and score ranging from 27 to 40 would
be considered to be high stress.[36]
Sleep quality
Sleep quality was assessed using the Pittsburgh sleep quality
index (PSQI) is a self‑rated questionnaire to measure
the quality of sleep and sleep disturbance over 1 month.
PSQI contains 19 items and generates scores of seven
components: subjective sleep quality, sleep latency, sleep
duration, habitual sleep efficiency, sleep disturbances, use of
sleeping medications, and daytime dysfunction.[37] PSQI has
internal consistency and reliability coefficient (Cronbach’s
alpha) 0.83 and test‑retest reliability 0.87.[38] PSQI has
diagnostic sensitivity of 89.6% and specificity of 86.5%.[37]
Each item is rated in four point scales: 0 (not during the
137 Volume 30 | Issue 1 | January-June 2021
[Downloaded free from http://www.industrialpsychiatry.org on Tuesday, November 30, 2021, IP: 14.139.245.2]

Parajuli, et al.: Yoga for nursing professionals

Table 1: Yoga module for professional nurses

Practices Rounds Durations (min)
Sukshma Vyayama (joints loosening) 10
Padanguli Namana (toes bending) 5
Gulpha Namana (ankles stretch) 5
Gulpha Chakra (ankles rotation) 5
Janu Namana (knees bending) 5
Purna Titali (butterfly) 5
Mushtika Bandhana (loosening of fingers) 5
Manibandha Naman (wrists stretch) 5
Kehuni Naman (elbows stretch) 5
Skandha Chakra (shoulders rotation) 5
Greeva Sanchalana and Greeva Chakra (neck bending and rotation) 5 each
Breathing exercises 10
Hands in and out breathing 5
Ankle stretch breathing 5
Tiger breathing 5
Alternate legs raising breathing 10
Yoga Asanas 10
Ardhakatichakrasana 1
Padahastasana 1
Ardha Chakrasana 1
Vakrasana 1
Bhujangasana 1
Salabhasana 1
Udarakarsanasana 1
Setubandhasana 1
Pranayamas 5
Kapalbhati 2
Nadisuddhi 9
Bhramari 9
DRT 10
DRT Deep relaxation technique

past month), to 3 (three or more times a week) for items
1–8 and 0 (very good) to 3 (very bad) for item number 9.
The seven component scores are added to obtain a global
score ranging from 0 to 21 and global score 5 or greater
indicates worse sleep quality.[39]
Statistical analysis
Statistical analysis was performed using IBM statistics
Statistical Package for the Social Sciences (SPSS) using
Version 19.0., (Armonk, NY: IBM Corp.). Data were
found to be normally distributed for PSS and were not
found to be normally distributed for PSQI when tested
with Shapiro–Wilk test. Hence, paired t‑test was used to
analyze PSS scores and Wilcoxon signed‑ranks test was
used to analyze the PSQI scores, respectively. All statistical
analysis was computed with two‑tailed.
RESULTS
P < 0.0001, Wilcoxon signed‑ranks test) in comparison with
prescores. Cohen’s d for PSS is 0.69 and for PSQI is 0.63 which
indicates moderate effect size. Yoga reduces the perceived
stress by 27.01% and improves the quality of sleep by 38.68%.
The study suggests yoga helps to reduce the perceived stress
and improve the sleep quality of the nursing professionals.
Mean pre‑ and post‑scores of PSS and PSQI, Cohen’s d as
well as t score and z scores are illustrated in Table 2.
DISCUSSION
The present study was designed to assess the effect
of the integrated yoga module in the perceived stress
and sleep quality among nursing professionals working
at a tertiary care hospital. The finding of the study
indicated the significant reduction in the perceived stress
and improvement in the sleep quality of the nursing
professionals after integrative yoga intervention.

There was a significant reduction on the postscores of This finding of the present study was supported by the
PSS (t = 5.86, P < 0.0001, paired t‑test) and PSQI (z = ‒4.38, outcomes of previous studies which demonstrated yoga

Volume 30 | Issue 1 | January-June 2021 138 Industrial Psychiatry Journal

[Downloaded free from http://www.industrialpsychiatry.org on Tuesday, November 30, 2021, IP: 14.139.245.2]
Parajuli, et al.: Yoga for nursing professionals
Table  2: Mean±standard deviation, t score and Z score of perceived stress scale and Pittsburg sleep
quality index before and after yoga intervention, and Cohen’s d
Variables Mean±SD
Pre Post
PSS score 15.82±6.67 11.55±5.62***
PSQI score 5.09±3.48 3.23±2.74***
***P<0.001. PSS Perceived stress scale; PSQI Pittsburg sleep quality index
intervention significantly reduced work stress, anxiety,
muscle fatigue and emotional exhaustion, and enhanced
the quality of sleep, self‑care, coping skills, and sense
of well‑being of nursing professionals.[24,40,41] However,
the possible mechanism of reduction of stress and
improvement in the quality of sleep after yoga intervention
is not yet understood clearly. A previous study had shown
that yoga reduced the sympathetic nerves activities,
increases parasympathetic activities and balances autonomic
nervous system reactivity. [42] Another study showed
that yoga increased the secretion of a neurotransmitter
called gamma‑amino butyric acid (GABA). [43] Thus,
increase in parasympathetic nerve activities, reduction of
sympathetic nerve activities, and secretion of the inhibitory
neurotransmitters such as GABA after yoga practice could
be the possible mechanism for reduction of the perceived
stress and improvement of the sleep quality. Increase in
positive affect and self‑compassion as well as inhibition
of the posterior hypothalamus and salivary cortisol after
yoga practice can also play an important role in reduction
of stress.[44]
The finding of the present study advocated yoga module
is effective in reducing perceived stress and improving
sleep quality of nursing professionals; however, further
study is required to conform to the present finding.
Based on the present finding, health agencies and hospital
managements can design the integrated yoga program for
nursing professionals to improve their overall well‑being
and enhance patients care. In addition, based on the current
research outcome, medical professionals can encourage
patients at risk of getting stress‑related disorders to practice
yoga on a regular basis to minimize the stress, improve
the sleep quality and prevent serious physiological and
psychological complications. Furthermore, corporations
and other organizations also can incorporate yoga on their
daily schedule to enhance employees’ psychological health
and to minimize health care burden.
The limitations of the present study are small sample size,
lack of control group, and use of self‑report measures
to assess stress and sleep quality. These limitations can
be addressed in future research by incorporating large
sample size and robust research design. Three arm
randomized control trials can be conducted including
Industrial Psychiatry Journal 
Percentage changes t score and Z scores Cohen’s d
−27.01 t=−5.49 0.69
−38.68 Z=−4.38 0.63
groups performing yoga and physical exercise and a group
without intervention. Studies also can be conducted using
biomarkers of stress such as serum or salivary cortisol as
well as electroencephalography. In addition, future studies
to evaluate the effect of yoga on nursing professionals’
overall health as well as patients’ care could quantify the
actual benefit of yoga.
CONCLUSION
The finding of the present study suggested integrative yoga
intervention significantly reduced the perceived stress and
improved the sleep quality of the nursing professional.
Therefore, yoga can be cost‑effective tools to manage
the stress and improve the quality of sleep of the nursing
professional, which can lead to the improvement in overall
health of nurses and reduction in patient care errors. Based
on the finding of the present pilot study, further studies can
be conducted with larger sample size and robust research
design.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Bhatia N, Kishore J, Jiloha R. Occupational stress amongst
nurses from two tertiary care hospitals in Delhi. Australas
Med J 2010;3:731‑8.
2. Chatzigianni  D, Tsounis  A, Markopoulos  N, Sarafis  P.
Occupational stress experienced by nurses working in a
Greek regional hospital: A cross‑sectional study. Iran J Nurs
Midwifery Res 2018;23:450‑7.
3. Maharaj S, Lees T, Lal S. Prevalence and risk factors of
depression, anxiety, and stress in a cohort of Australian
nurses. Int J Environ Res Public Health 2018;16:61.
4. Bagheri  H, Shahabi  Z, Ebrahimi  H, Alaeenejad  F. The
association between quality of sleep and health‑related
quality of life in nurses. J Hayat 2007;12:13‑20.
5. Hasson D, Gustavsson P. Declining sleep quality among
nurses: A population‑based four‑year longitudinal study on
the transition from nursing education to working life. PLoS
One 2010;5:e14265.
6. Lin SL, Huang CY, Shiu SP, Yeh SH. Effects of yoga on
stress, stress adaption, and heart rate variability among
mental health professionals – A randomized controlled trial.
Worldviews Evid Based Nurs 2015;12:236‑45.
139 Volume 30 | Issue 1 | January-June 2021
[Downloaded free from http://www.industrialpsychiatry.org on Tuesday, November 30, 2021, IP: 14.139.245.2]
Parajuli, et al.: Yoga for nursing professionals
7. Chien PL, Su HF, Hsieh PC, Siao RY, Ling PY, Jou HJ. Sleep
quality among female hospital staff nurses. Sleep Disord
2013;2013:283490.
8. Allan JL, Farquharson B, Johnston DW, Jones MC,
Choudhary CJ, Johnston M. Stress in telephone helpline
nurses is associated with failures of concentration, attention
and memory, and with more conservative referral decisions.
Br J Psychol 2014;105:200‑13.
9. Mark G, Smith AP. Occupational stress, job characteristics,
coping, and the mental health of nurses. Br J Health Psychol
2012;17:505‑21.
10. Kunert K, King ML, Kolkhorst FW. Fatigue and sleep quality in
nurses. J Psychosoc Nurs Ment Health Serv 2007;45:30‑7.
11. Pilcher JJ, Ginter DR, Sadowsky B. Sleep quality versus
sleep quantity: Relationships between sleep and measures
of health, well‑being and sleepiness in college students.
J Psychosom Res 1997;42:583‑96.
12. Kane PP. Stress causing psychosomatic illness among nurses.
Indian J Occup Environ Med 2009;13:28‑32.
13. Shao MF, Chou YC, Yeh MY, Tzeng WC. Sleep quality and
quality of life in female shift‑working nurses. J Adv Nurs
2010;66:1565‑72.
14. Khamisa N, Oldenburg B, Peltzer K, Ilic D. Work related
stress, burnout, job satisfaction and general health of nurses.
Int J Environ Res Public Health 2015;12:652‑66.
15. Johnson AL, Jung L, Song Y, Brown KC, Weaver MT,
Richards KC. Sleep deprivation and error in nurses who work
the night shift. J Nurs Adm 2014;44:17‑22.
16. Adib‑Hajbaghery  M, Khamechian  M, Alavi  NM. Nurses’
perception of occupational stress and its influencing
factors: A qualitative study. Iran J Nurs Midwifery Res
2012;17:352‑9.
17. Sharma P, Davey A, Davey S, Shukla A, Shrivastava K,
Bansal R. Occupational stress among staff nurses: Controlling
the risk to health. Indian J Occup Environ Med 2014;18:52‑6.
18. McVicar A. Workplace stress in nursing: A literature review.
J Adv Nurs 2003;44:633‑42.
19. Oommen H, Wright M, Maijala H. Stress‑promoting and
stress‑relieving factors among nurses in rural India: A case
study. Divers Equal Health Care 2010;7:189-200.
20. Lombardo B, Eyre C. Compassion fatigue: A nurse’s primer.
Online J Issues Nurs 2011;16:3.
21. Richard AA, Shea K. Delineation of self‑care and associated
concepts. J Nurs Scholarsh 2011;43:255‑64.
22. Nahm ES, Warren J, Zhu S, An M, Brown J. Nurses’ self‑care
behaviors related to weight and stress. Nurs Outlook
2012;60:e23‑31.
23. Crane PJ, Ward SF. Self‑healing and self‑care for nurses.
AORN J 2016;104:386‑400.
24. Fang R, Li X. A regular yoga intervention for staff nurse sleep
quality and work stress: A randomised controlled trial. J Clin
Nurs 2015;24:3374‑9.
25. Mehrabi T, Azadi F, Pahlavanzadeh S, Meghdadi N. The
effect of yoga on coping strategies among intensive care unit
nurses. Iran J Nurs Midwifery Res 2012;17:421‑4.
26. Alexander GK, Rollins K, Walker D, Wong L, Pennings J.
Yoga for self‑care and burnout prevention among nurses.
Workplace Health Saf 2015;63:462‑70.
27. Patil NJ, Nagaratna R, Tekur P, Manohar PV, Bhargav H,
Patil D. A randomized trial comparing effect of yoga and
exercises on quality of life in among nursing population with
chronic low back pain. Int J Yoga 2018;11:208‑14.
Volume 30 | Issue 1 | January-June 2021 140
View publication stats
28. Cocchiara RA, Peruzzo M, Mannocci A, Ottolenghi L, Villari P,
Polimeni A, et al. The use of yoga to manage stress and
burnout in healthcare workers: A systematic review. J Clin
Med 2019;8:284.
29. Raingruber B, Robinson C. The effectiveness of Tai Chi,
yoga, meditation, and Reiki healing sessions in promoting
health and enhancing problem solving abilities of registered
nurses. Issues Ment Health Nurs 2007;28:1141‑55.
30. Ando M, Natsume T, Kukihara H, Shibata H, Ito S. Efficacy
of mindfulness‑based editation therapy on the sense of
coherence and mental health of nurses. Health (Irvine)
2011;3:118‑22.
31. van der Riet P, Levett‑Jones T, Aquino‑Russell C. The
effectiveness of mindfulness meditation for nurses and
nursing students: An integrated literature review. Nurse Educ
Today 2018;65:201‑11.
32. Smith SA. Mindfulness‑based stress reduction: An
intervention to enhance the effectiveness of nurses’ coping
with work‑related stress. Int J Nurs Knowl 2014;25:119‑30.
33. Ghawadra SF, Abdullah KL, Choo WY, Phang CK.
Mindfulness‑based stress reduction for psychological
distress among nurses: A systematic review. J Clin Nurs
2019;28:3747‑58.
34. Cohen S, Kamararck T, Mermelstein R. A global measure of
perceived stress. J Health Soc Behav 1983;24:385-96.
35. Lee EH. Review of the psychometric evidence of the
perceived stress scale. Asian Nurs Res (Korean Soc Nurs Sci)
2012;6:121‑7.
36. Cohen  S, Janicki‑Deverts  D. Who’s stressed? Distributions
of psychological stress in the United States in probability
samples from 1983, 2006, and 20091. J Appl Soc Psychol
2012;42:1320‑34.
37. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR,
Kupfer DJ. The Pittsburgh sleep quality index: A new
instrument for psychiatric practice and research. Psychiatry
Res 1989;28:193‑213.
38. Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen F.
Test‑retest reliability and validity of the Pittsburgh Sleep
Quality Index in primary insomnia. J Psychosom Res
2002;53:737‑40.
39. Buysse DJ, Hall ML, Strollo PJ, Kamarck TW, Owens J,
Lee L, et al. Relationships between the Pittsburgh Sleep
Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and
clinical/polysomnographic measures in a community sample.
J Clin Sleep Med 2008;4:563‑71.
40. Anderson R, Mammen K, Paul P, Pletch A, Pulia K. Using
yoga Nidra to improve stress in psychiatric nurses in a pilot
study. J Altern Complement Med 2017;23:494‑5.
41. Beddoe AE, Murphy SO. Does mindfulness decrease stress
and foster empathy among nursing students? J Nurs Educ
2004;43:305‑12.
42. Vempati RP, Telles S. Yoga‑based guided relaxation reduces
sympathetic activity judged from baseline levels. Psychol Rep
2002;90:487‑94.
43. Streeter CC, Jensen JE, Perlmutter RM, Cabral HJ, Tian H,
Terhune DB, et al. Yoga asana sessions increase brain
GABA levels: A pilot study. J Altern Complement Med
2007;13:419‑26.
44. Riley KE, Park CL. How does yoga reduce stress? A systematic
review of mechanisms of change and guide to future inquiry.
Health Psychol Rev 2015;9:379‑96.
Industrial Psychiatry Journal