Results
In relation to the first hypothesis, which looked at perceptions of mood, the treatment group demonstrated significant decreases in both state anxiety (t=2.4, p=.009) and trait anxiety (t=1.7, p=.04). The General Well Being Scale was used to measure subjects perception of overall health. Subjects in the treatment group reported significantly decreased levels of anxiety (t=2.8, p=.003) and depression (t=2.0, p=.024), as well as significantly increased feelings of emotional control (t=1.9 p=.029) and positive affect (t=1.9, p=.029) when compared with the control group. No significant differences were observed for the subscales of anger, confusion or fatigue.
 
For the second hypothesis, which looked at sleep disturbances and fatigue, a significant decrease in perceived sleep disturbances was noted for subjects in the treatment group, working 12-hour shifts (t=2.9, p=.005); no differences in perceptions of sleep disturbances were noted in subjects working eight-hour shifts. The Multidimensional Fatigue Inventory was used as a measure of the dimensions of general fatigue, physical fatigue, mental fatigue, reduced motivation, and reduced activity. For each of these subscales, no significant differences were noted between the control and treatment groups.

As noted previously, there is limited data looking at the effect of massage on organizational outcomes. For this study, the organizational outcomes of job satisfaction, absenteeism and work-related illness were evaluated. In relation to job satisfaction, subjects completed the Index of Work Satisfaction (IWS) prior to, and at the end of, the study. Results demonstrate that prior to beginning the study, IWS scores were higher for the control group (IWS=14.4) than for the treatment group (IWS=13.1). Upon completion of the study, IWS scores were consistent for the treatment group (IWS=13.4), while the control group demonstrated a decrease in scores (IWS= 2.7). Chi-square analysis of absenteeism showed no differences between the treatment group and control group (p=0.7). 
During the three months in which the study was conducted, there was only one work-related injury reported among the subjects enrolled. Therefore, it is not possible to draw inferences on the effect of WSAM on work-related injuries.

Discussion
The intent of this study was to investigate the effect of WSAM on selected psychological and organizational outcomes associated with job stress. Previous reports indicated that health-care workers were at risk for musculoskelatal problems, which result in work-related injuries and psychological problems, such as increased anxiety and depression, from increased job stress.17,4,2 Downsizing, shorter patient stays, restructuring, and layoffs add to the stress in health-care environments. Employees responsible for providing health care are, therefore, at a greater risk for illness. Health-care organizations face problems of reduced productivity, absenteeism, accidents and injuries.
 
Results of this study demonstrate the beneficial effects of WSAM. Subjects in the experimental group exhibited improved general well-being, as evidenced by decreased anxiety and depression, as well as increased emotional control and overall well-being. In addition, participants reported a decrease in general sleep disturbances.
 
Although no improvement in employee job satisfaction was noted, subjects in the treatment group maintained their pre-study level of job satisfaction, while subjects in the control group demonstrated a decrease in their level of job satisfaction. This may be explained in part by increases in patient acuity and hospital census, as well as decreases in staffing that occurred during the course of this study. An increase in job stress, as well as a decrease in job satisfaction, is consistent with these changes. Subjects in the treatment group may have perceived less job stress as a result of WSAM and, therefore, did not exhibit a decrease in job satisfaction. 

Implications for future research include the need to look at the effect of WSAM on absenteeism and work-related injuries over a longer period of time and with a larger sample size. Additional research is also necessary to examine the association between health-care workers, WSAM and patient care delivery. Given the beneficial responses found, it is possible that these favorable outcomes might lead to improved patient care and patient care outcomes. 

Partial funding for this study was received from the American Massage Therapy Association Foundation and Sigma Theta Tau, Zeta Eta Chapter.

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Margaret Hodge, EdD, RN; Carol Robinson, MPH, RN; Judie Boehmer, MSN, RN; Sally Klein, MSN, RN; and Sue Ullrich, EdD, RN are on the staff of the University of CaliforniaDavis Medical Center, 2315 Stockton Blvd., Sacramento, CA 95817. Contact: peggy.hodge@ucdmc.ucdavis.edu.

The authors would like to thank the following massage therapists, whose knowledge and expertise made this study possible. They are: Noma Wilson, Lani Richardson, Stephanie Dollar, Dodi Glass, Sylvia and Richard Christianson, and Jim Farquhar.