***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: A common question in clinical consultations is : “ For this person , what are the likely effects of one treatment compared with another ? ” The central tenet of evidence based medicine is that this task is achieved by using the best evidence combined with consideration of that person 's individual needs.1 A further question then arises : “ What is the best evidence ? ” Two recent studies in the New Engl and Journal of Medicine have caused uproar in the research community by finding no difference in estimates of treatment effects between r and omised controlled trials and non-r and omised trials . The r and omised controlled trial and , especially , systematic review s of several of these trials are traditionally the gold st and ards for judging the benefits of treatments , mainly because it is conceptually easier to attribute any observed effect to the treatments being compared . The role of non-r and omised ( observational ) studies in evaluating treatments is contentious : deliberate choice of the treatment for each person implies that observed outcomes may be caused by differences among people being given the two treatments , rather than the treatments alone . Unrecognised confounding factors can always interfere with attempts to correct for identified differences between groups . These considerations have supported a hierarchy of evidence , with r and omised controlled trials and derivatives at the top , controlled The challenges of providing exemplary undergraduate nursing education can not be underestimated in an era when burnout and negative mood states predictably lead to alarming rates of academic as well as career attrition . While the multi-dimensional nature of this complex issue has been extensively eluci date d , few rational strategies exist to reverse a disheartening trend recognizable early in the educational process that subsequently threatens to undermine the future viability of quality healthcare . This controlled prospect i ve crossover study examined the impact of a 6-session Recreational Music-making ( RMM ) protocol on burnout and mood dimensions as well as Total Mood Disturbance ( TMD ) in first year associate level nursing students . A total of 75 first year associate degree nursing students from Allegany College of Maryl and ( ACM ) participated in a 6-session RMM protocol focusing on group support and stress reduction utilizing a specific group drumming protocol .  Burnout and mood dimensions were assessed with the Maslach Burnout Inventory and the Profile of Mood States respectively . Statistically significant reductions of multiple burnout and mood dimensions as well as TMD scores were noted . Potential annual cost savings for the typical associate degree nursing program ( $ 16,800 ) and acute care hospital ( $ 322,000 ) were projected by an independent economic analysis firm . A cost-effective 6-session RMM protocol reduces burnout and mood dimensions as well as TMD in associate degree nursing students RATIONALE Stress is known to increase drug craving , associated physiological arousal and risk of relapse in drug dependent individuals . However , it is unclear whether these responses are altered by recent frequency of drug use . The current study examined whether frequency of cocaine and alcohol abuse alters drug craving and associated arousal with laboratory exposure to stress and to drug related cues . METHODS Fifty-four recently abstinent treatment-seeking cocaine abusers who were part of a study on stress and drug craving were categorized into high- and low-frequency users on the basis of their recent cocaine use . The high use cocaine group also consumed significantly more alcohol than the low use cocaine group . Participants were exposed to a brief 5-min guided imagery procedure that involved imagining a recent personal stressful situation , a personal drug-related situation and a neutral-relaxing situation , one imagery session on separate days presented in r and om order .  Subjective ( craving and anxiety ) , cardiovascular ( heart rate , systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) ) and biochemical ( adrenocorticotropic hormone ( ACTH ) , cortisol , prolactin ) measures were assessed . RESULTS High-frequency abusers demonstrated a significantly greater drug craving , anxiety and associated cardiovascular and hypothalamic-pituitary-adrenal ( HPA ) response to both stress and drug-cue exposure as compared to low-frequency abusers . CONCLUSIONS Increased frequency of recent cocaine and alcohol use is associated with an enhanced stress and cue-induced drug craving and arousal response that appears to be similar to the effects of cocaine , and one that may increase the vulnerability to drug-seeking behavior and relapse in drug dependent individuals A quasi-experimental pre- , post-test , follow-up and control group design was used to investigate the effect of psychological and educational counselling in reducing  anxiety in nursing students . The research study used method ological triangulation , involving the use of structured data collection techniques such as st and ardized question naires and semi-structured focus groups . Focus groups were used to provide greater insight regarding the student 's opinions . The sample consisted of 100 second- and fourth-year baccalaureate nursing students from the Faculty of Nursing at Shiraz University of Medical Sciences , Iran . They were r and omly assigned to either an experimental group ( n = 50 ) or a control group ( n = 50 ) . The experimental group received a 12-week intervention programme . Quantitative analysis of data was undertaken using t-test and analysis of variance for repeated measures to test differences between and within groups . The results indicated that from pre- to post-test there was no statistically significant reduction in anxiety between groups , but there was a statistically significant reduction in anxiety after one semester ( in the follow-up ) . Student self-esteem was increased significantly from pre- to post-test . This increase was statistically significant and remained the same in follow-up . A statistically significant difference was seen in the student grade point average from pre-test to follow-up in the experimental group but not for the control group . The implementation of an intervention programme reduced their anxiety , increased their self-esteem and improved their grade point average over time This study sought to develop a stress management program based on the arousal-attribution stress model and to evaluate the effectiveness of the program in reducing anxiety and depression experienced by nursing students . Forty-two sophomore and 34 senior nursing students in a private , sectarian , liberal arts college were r and omly assigned to experimental and control groups . All subjects were given pre- and posttests consisting of the State form of the State-Trait Anxiety Inventory and the Institute for Personality and Ability Testing Depression Scale . Posttest analysis indicated that the experimental group had significantly lower anxiety and depression than the control group ( p less than .05 ) . These results support the use of the arousal-attribution stress model as a theoretical framework for stress management training The double-blind r and omized controlled trial ( RCT ) is accepted by medicine as objective scientific methodology that , when ideally performed , produces knowledge untainted by bias . The validity of the RCT rests not just on theoretical arguments , but also on the discrepancy between the RCT and less rigorous evidence ( the difference is sometimes considered an objective measure of bias ) . A brief overview of historical and recent developments in " the discrepancy argument " is presented . The article then examines the possibility that some of this " deviation from truth " may be the result of artifacts introduced by the masked RCT itself . Can an " unbiased " method produce bias ? Among the experiments examined are those that augment the method ological stringency of a normal RCT in order to render the experiment less susceptible to subversion by the mind . This methodology , a hypothetical " platinum " st and ard , can be used to judge the " gold " st and ard . The concealment in a placebo-controlled RCT seems capable of generating a " masking bias . " Other potential biases , such as " investigator self- selection , " " preference , " and " consent " are also briefly discussed . Such potential distortions indicate that the double-blind RCT may not be objective in the realist sense , but rather is objective in a " softer " disciplinary sense . Some " facts " may not exist independent of the apparatus of their production This study examined the effectiveness of audiotaped imagery in reducing anxiety and improving test performance among first-year nursing students . Volunteer subjects were r and omly assigned to three groups , imagery-only , imagery/relaxation , and a no-treatment control group .  Pottest state anxiety scores in these groups were significantly lower ( p = .001 ) than in the no-treatment control group . Test performance did not differ significantly ( p = .067 ) . Subjects using the audiotaped imagery reported an increased sense of well-being , improved ability to sleep , greater energy , and improved self-confidence This article describes a natural experiment that overcomes a number of method ological problems inherent in previous studies of occupational stress and strengthens evidence for the causal role of the work setting in influencing mental health and well-being . Student nurses ( N = 164 ) were r and omly assigned to one of four possible combinations of ward types such that two factors — type of nursing ( medical/surgical ) and sex of patients (male/female)—were systematic all y varied with counterbalancing of order effects . Self-reported levels of affective symptoms and perceptions of the work environment , together with independent data on sickness/absence , performance , and the objective work environment , were recorded longitudinally over the two ward periods . Within-subjects analyses showed significant differences between medical and surgical wards in affective symptoms and in perceived and objective measures of the work environment . Male and female wards differed primarily in the perceived environment , work satisfaction , and performance . Correlational analyses were used to examine the relationships between different types of measures . Further analysis of the main effects , with control for covariance , indicated that the perceived work environment contributed to the observed differences in affective distress between medical and surgical wards , while mitigating differences between male and female wards . In spite of extensive research , the causal role of the work environment in influencing mental health and well-being has not yet been adequately demonstrated . The difficulties in resolving this important issue are primarily method ological , and several recent papers have emphasized the limitations The view is widely held that experimental methods ( r and omised controlled trials ) are the " gold st and ard " for evaluation and that observational methods ( cohort and case control studies ) have little or no value . This ignores the limitations of r and omised trials , which may prove unnecessary , inappropriate , impossible , or inadequate . Many of the problems of conducting r and omised trials could often , in theory , be overcome , but the practical implication s for research ers and funding bodies mean that this is often not possible . The false conflict between those who advocate r and omised trials in all situations and those who believe observational data provide sufficient evidence needs to be replaced with mutual recognition of the complementary roles of the two approaches . Research ers should be united in their quest for scientific rigour in evaluation , regardless of the method used The purpose of this study was to investigate the effects of a 5-week stress management program for 40 junior baccalaureate nursing students . A quasi-experimental pretest-posttest control group design was used . The stress management group included training sessions using cognitive modification techniques and Stroebel 's Quieting Response ( QR ) augmented with biofeedback techniques for self-relaxation . A significant reduction of state anxiety ( P < .001 ) was reported on the State-Trait Anxiety Inventory ( STAI ) by the experimental groups , while the state anxiety of the control groups remained relatively unchanged . There were no significant changes in trait anxiety scores . Urinary potassium excretion was measured as an index of the adrenal stress response . Findings revealed no statistically significant correlation between potassium excretion and scores on the STAI . These results support the benefits of integrating a stress management program into curricula for nursing students BACKGROUND Nurses ' occupational stress decreases job satisfaction , increases turnover rate , and reduces nursing quality . At different workplaces nurses are confronted with different work tasks , working conditions and hence different sources of stress . OBJECTIVES The purpose of this study was to explore what factors contribute to work-related stress among Icel and ic nurses working within and outside the hospital environment . DESIGN The study used a cross-sectional survey design . SETTING S AND PARTICIPANTS The study population was composed of all working nurses registered at the Icel and ic Nurses ' Association ( INA ) . Approximately 95 % ( N=2,234 ) of Icel and ic nurses are members of the INA . Question naires were posted to 522 ( 23.4 % ) r and omly selected participants . The response rate was 42 % ( N=219 ) , representing 9.8 % of the population . Data was analyzed from 206 nurses ; 35 % worked outside the hospital setting and 65 % were hospital based . METHODS Data was gathered on demographic information and indicators of working conditions , occupational stress , workload , and job satisfaction . A stepwise , multiple linear regression model was employed to calculate significant predictors of occupational stress . RESULTS The findings suggest that the strenuous conditions of Icel and ic nurses are felt more severely among hospital nurses than among nurses working outside hospital setting s. The study identified which sources of occupational stress are specific to each of the two groups . CONCLUSIONS The study found several factors that contribute to work-related stress . These findings can be used to guide preventive measures to diminish occupational stress among Icel and ic nurses BACKGROUND It is well-established that stress is likely to contribute to attrition in nursing students . Attrition from nursing programmes and retention of nurses in the profession are international concerns and steps are currently being taken in the United Kingdom to tackle these issues . AIM The aim of this study was to investigate prospect ively the determinants of , and relationships among , stress , burnout and attrition in nursing students . METHOD A longitudinal design involving a complete cohort of nursing students was employed , using a battery of instruments to measure personality , intelligence , psychological morbidity , stress , coping and burnout . Data were gathered on entry , at 12 and 24 months , and at the end of the nursing programme . FINDINGS Students experienced increasing levels of stress and use of negative coping mechanisms as the programme progressed and psychological morbidity increased . Positive aspects of personality were more likely to lead to aspects of burnout , and personality was a more important indicator of attrition than cognitive ability . CONCLUSIONS Stress , burnout and attrition may not be directly linked . Personality factors at 
    Output:
    
RESULTS The most effective interventions provided skills for coping with stressful situations ( typically relaxation ) and skills for changing maladaptive cognitions .
Interventions which promoted skills to reduce the intensity or number of stressors were also successful .
In most cases , stress interventions did not improve academic performance .