Introduction
Human resources are one of the most important opportunities that helps companies to excel and can keep them in their position by encouraging employees to empower them and create job motivation in them. Encouraging, empowering and trying to improve human resources will help retain and motivate employees [1, 2]. Organizations need the self-efficacy of their human resources to align with environmental changes. Bandura [3] considers self-efficacy as a constructive power that helps to organize the cognitive, social, emotional and behavioral skills of humans in an effective way to achieve different goals. People’s performance, despite having previous knowledge, skills and achievements, cannot be a predictor of their future performance, rather, a person’s belief about the ability to perform activities is effective on his performance. Many people are aware of how to do things and the necessary skills to do them, but often they are not successful in the proper implementation of the skills [4]. Generalized anxiety disorder is a common and costly disorder that shows a chronic course in most cases, and According to the guidelines for the diagnosis of mental illnesses and statistics on the incidence rate, introduces this disorder as excessive and uncontrollable worry about various events that occurs on most days and at least for six months to continue and is characterized by symptoms such as restlessness, irritability, muscle cramps and sleep problems [5]. In the last decade, stress has been another critical issue whose effects have been noticed in organizations. One of the acute problems in organizations is stress or nervous pressure, which endangers the physical and mental health of employees and has imposed a lot of costs on organizations. There is stress in the lives of working people and it puts mental and physical pressure on them in different ways. Undoubtedly, stress exists in the life of all people who have a job and it puts psychological pressure on them in different ways. As a result, if a lot of work stress is imposed on a person, it affects his physical and mental health, which in turn has a destructive effect on both the person's performance in the organization and the quality of his family life [6]. A series of long-term stressors can cause anxiety and negative abnormalities in people's daily lives and ultimately psychological and physical problems, which will lead to a decrease in their level of performance and self-efficacy. Most people suffering from stress and anxiety face decreased job performance because they cannot control and manage their stress and anxiety effectively [7, 8, 9]. Research shows that with increasing stress and anxiety, coping skills, which are a crucial factor in maintaining mental health, are affected, and if a person cannot use these coping factors to control stress and anxiety, he faces many problems in the field of health and mental health. Considering that most experts in rehabilitation centers are working in treatment departments, the nature and essence of these environments are such that they inevitably impose tension and stress on employees [9-12]. Rehabilitation therapists are faced with a large number of clients and patients with different physical, movement, mental, and psychological conditions. The stress and anxiety caused by the long-term treatment process and the increasing pressure of patients and their companions to accelerate the recovery process and achieve treatment results always increases the psychological pressure on rehabilitation therapists, which in the long run increases the possibility of medical errors and leads to lack of self-efficacy and possibly malpractice in the treatment process of patients. Therefore, this research was conducted to investigate and estimate the relationship between anxiety and occupational stress with the self-efficacy of therapists in rehabilitation centers.

Materials and Methods
This research was conducted cross-sectionally and with a practical purpose using a descriptive survey method. The statistical population of the research included all rehabilitation therapists of Tehran City in 2022, and the sample size was determined by a multi-stage classification method. After determining the sample size using the multi-stage classification sampling method, Tehran City was divided into east, west, south, and north regions. Based on the statistics of the medical system, public and private hospital centers with rehabilitation departments were identified in each region. Then the required number of centers as a class is selected randomly from each region and then from each center, a maximum of 2 people from the rehabilitation staff (including physiotherapists, audiologists, occupational therapists, speech therapists, and optometrists) working in that center are randomly selected. As a sample, they completed the questionnaires in the presence of the researcher, and on the same day, the scores obtained from each sample were entered into the computer and data analysis software, and finally 122 people were identified. To collect the background of the research, the method of field and library studies was used, and to collect the required data, standard questionnaires whose validity and reliability have been confirmed in previous studies were used. The questionnaires include the following items:
Beck's anxiety questionnaire is a questionnaire to measure the intensity of anxiety in teenagers and adults, and by completing it, people evaluate their anxiety level. This is a 21-item questionnaire in which people choose their level of anxiety by answering one of the four options of each question. This questionnaire has high reliability. Its internal consistency coefficient is 0.92, its reliability is 0.75 with a one-week interval, and the correlation of its items varies from 0.30 to 0.76. Five types of validity of content, concurrent, construct, diagnostic, and factor have been measured for this test, which all indicate the high efficiency of this tool in measuring the intensity of anxiety. This questionnaire is a 21-question scale in which the subject chooses one of the four options that indicate the intensity of anxiety in each subject. The four options of each question are scored in a four-part spectrum from 0 to 3. Each test item describes one of the common symptoms of anxiety (mental, physical, and panic symptoms). Therefore, the score of this questionnaire is in the range of 0 to 63. A score less than 9 is a sign of no anxiety, 21-11 is a sign of mild anxiety, 21-31 is a sign of moderate anxiety, and 31 or more is a sign of severe anxiety [13]. 
Beck's anxiety questionnaire has been standardized by Kaviani and Mousavi in Iran, thus 1513 men and women in different gender groups in Tehran filled this test through random cluster sampling. Also, 261 patients with anxiety referred to medical centers and clinics participated in this study. Statistical analysis was performed to obtain an internal consistency coefficient and analysis of materials. To obtain the final test re-test coefficient, 112 previously tested subjects from the normal population completed the test again within one month from the first stage. Also, to obtain the validity coefficient, 151 patients with clinical anxiety were clinically interviewed and in parallel, two evaluators evaluated the level of anxiety of the people based on a quantitative rating of 0-10. The results showed that the desired test has good validity (r=0.72, P<0.001), reliability (r=0.83, P<0.001), and internal consistency (alpha=0.92) [14].
2) Osipow and Spokane created the Osipow occupational stress questionnaire to assess individual stress in the work environment [15]. Osipow job stress scale is used to investigate and measure job stress caused by job roles. The Osipow job stress test aims to determine the intensity and difference in the intensity of the stress caused by the job role in different organizational employees.

Aspects and elements of occupational stress questionnaire
1) The role load dimension: Examines the person’s situation in relation to the demands of the work environment. 2) The dimension of role incompetence: Evaluates the appropriateness of a person’s skills, education and educational and experience characteristics with the needs of the work environment. 3) Dimension of role duality: Evaluates the individual’s awareness of priorities, expectations of the work environment and evaluation criteria. 4) Dimension of role scope: It evaluates the conflicts that a person has in terms of work conscience and the role that is expected of her in the work environment. 5) Responsibility dimension: It measures the individual’s sense of responsibility in terms of the efficiency and well-being of others in the work environment. 6) The physical environment dimension: Examines the unfavorable physical conditions of the work environment to which a person is exposed.
The Osipow job stress scale consists of 60 statements and the scoring of the Osipow job stress scale is based on a 5-point Likert scale between one (never) and five (most of the time). In the job stress questionnaire, the lower the score a person gets, the less stress he has. The Osipow-Spokan questionnaire aims to measure the level of occupational stress of people and compare the occupational stress levels of different research groups. During the Sharifian et al.'s research, the content validity of this questionnaire was reported to be very favorable, its reliability was calculated at a satisfactory level by the re-test method, and its Cronbach's α coefficient was also calculated and reported as 98.00 [16].  

Riggs and Knight job self-efficacy questionnaire (1994)
Riggs and Knight created the Riggs and Knight job self-efficacy questionnaire, which has 31 questions in four components to measure individual self-efficacy beliefs, individual outcome expectations, collective efficacy beliefs, and collective outcome expectations. The items are designed based on theoretical definitions (Bandura, 1977; 1986) in all four structures and characteristics of these beliefs in the respondents' work environment. The reliability of this scale was reported between 0.85 and 0.88 in the studies of Riggs. Cronbach's α reliability for individual self-efficacy beliefs is 0.86, the expectation of individual consequences is 0.88, collective efficacy beliefs is 0.88, the expectation of collective consequences is 0.85, and the internal correlation between subscales is between 0.06 and 0.56 [17]. This questionnaire was translated and validated for the first time in Iran by Saei (2018) [18]. Also, in the research of Najarasl (2019), the confirmatory factor analysis method was used to determine the validity of the questionnaire, and the comparative fit indices and the squared error of approximation index were obtained as 0.70 and 0.90, which are acceptable [19]. In the research of Mareshian et al., the reliability coefficients of this questionnaire were calculated using two methods, Cronbach's α and halving, and the coefficients were 0.53 and 0.57, respectively. The scoring of the questionnaire is based on the Likert scale. Each item has a five-point response from 1 completely disagree to 5 completely agree. The reverse questions of this questionnaire are 2, 3, 4, 6, 8, 10, 12, 14, 17, 20, 21, 23, 24, 25, 28, and 30, which are completely against 5 to completely agree 1. The minimum and maximum score of each person in this test is 31 and 155, respectively [20]. After extracting the data, their analysis was done by SPSS software, version 26 at two descriptive and analytical levels. At the descriptive level, indicators, such as Mean±SD, and median, were used, and in the analytical statistics section, Pearson's correlation coefficient test was used to examine the relationship between qualitative variables, and analysis of variance (ANOVA) was used to examine self-efficacy, stress, and anxiety between different rehabilitation disciplines in quantitative variables. We also used the chi-square method to examine the two qualitative variables of stress and anxiety.

Results
According to Table 1, the sample population included 60 men (49.2%) and 62 women (50.8%).


The mean age is 35.02±6.51 and the age range is between 25 and 56 years. The largest number of participants was from region 12 with 27 people (13.9%). A total of 62 people (50.8%) from the government center, 16 people (13.1%) from the charity center, and 44 people (36.1%) from the private center participated in the plan. The specialty of the sample included 51 physiotherapy (48.1%), 13 occupational therapy (10.7%), 21 optometry (17.2%), 26 audiometry (21.3%) and 11 speech therapy (9%). The mean work experience was 11.6 years with a standard deviation of 5.64 and the age range was 28 to 56 years. In examining the amount of job stress and its six dimensions according to Table 2, the mean score of the workload dimension was 27.78±4.97, the mean score of incompetence was 33.57±4.57, the mean ambivalence was 3.9 31.8±31.8, the mean range score was 27.66±3.14, the mean responsibility score was 24.26±4.32, the mean physical environment score was 15.47±5.45, and the mean job stress score was equal to 160.54±17.7 with a range of 131 to 214.


According to the results, the mean anxiety score was 25.27±4.37 with a range of 21 to 45.
According to Table 3 and self-efficacy level and its four dimensions in therapists, the following results were obtained:


The mean score of individual self-efficacy beliefs was equal to 40.41±4.87, the mean score of collective outcome expectation was 23.25±2.66, the mean score of individual outcome expectation was 26.8±4.96, the mean collective efficacy belief was equal to 23.61±3.69 and the overall self-efficacy score of the questionnaire was equal to 114.07±11.92 with a range of 75 to 142. According to the results of the present study, in Table 4, a statistically significant relationship was observed between the anxiety score and the self-efficacy score, for one-unit increase in a person's anxiety score, the self-efficacy score decreases 0.424 times.


In other words, an inverse statistical relationship was observed (P<0.001). This significant inverse relationship between the anxiety score with the dimensions of individual outcome expectation and collective efficacy beliefs was also found, but the relationship between anxiety and the dimension of collective outcome expectation was not significant. Based on the analyzes of Table 4, a statistically significant relationship was observed between the stress score and the individual's self-efficacy score in such a way that for an increase of one unit in the individual's stress score, the self-efficacy score decreases by 0.403 times. In other words, an inverse statistical relationship was observed (P<0.001). This significant inverse relationship was found between the stress score and all dimensions except the dimension of collective outcome expectation. Also, based on the results, a significant statistical relationship was observed between the anxiety score and the individual's stress score, for a one-unit increase in the individual's anxiety score, the stress score increased 0.606 times. In other words, a direct statistical relationship was observed (P<0.001). This significant direct relationship between the anxiety score and all dimensions was also found. A statistically significant relationship was observed between the self-efficacy score and the person's age and sex. For a one-year increase in a person's age, the self-efficacy score increases by 0.213 times, and for one year of work experience, the self-efficacy score increases by 0.247 times. Also, a statistically significant relationship was observed between the stress score and the age and gender of the person, for increasing one year of age, the stress score decreases 0.185 times, and for increasing one year of work experience, the stress score decreases 0.189 times. Also, according to the data, no significant relationship was observed between anxiety and demographic variables (age and work experience). The mean of three scores for male and female participants did not show a statistically significant difference (P<0.05).
 However, the mean score of anxiety and stress of employees working in private centers was lower than others (P=0.002 and P<0.001). Also, the mean self-efficacy score of the employees working in the charity center was higher than the others. This statistical difference between the groups is significant (P<0.001). According to Table 5, the mean anxiety score of the employees working in the audiometry department was lower than the others and was equal to 23.58±2.1, while the anxiety of the optometrists was higher than the others and was equal to 25.9±5.32.


The mean stress score of the employees working in the audiometry department is lower than the others and is equal to 148.12±14.02 and the highest score belongs to the occupational therapy group equal to 167.54±13.02. The mean score of self-efficacies for the audiometry group is the highest and equal to 119.23±10.22, and the lowest for the occupational therapy group is 103.46±11.21.
In this study, the relationship between anxiety and occupational stress with the self-efficacy of rehabilitation therapists in Tehran in 2011 was discussed and investigated. This study found a statistically significant relationship between the anxiety score and the individual's self-efficacy score so that for one unit increase in the individual's anxiety score, the self-efficacy score decreases 0.424 times. It seems that the lack of anxiety and stress in audiologists is due to the nature of their job and the absence of job role conflict, a quiet environment without noise and acoustics, which is necessary for their job, which is in addition to the individual treatment of each patient and a lot of concentration, and allocating separate appointments to diagnose each person's illness has also helped a lot to increase their self-efficacy. These results were consistent with the results of Khaleghi et al.'s study [21], in which a negative relationship was observed between self-efficacy and exam anxiety (-0.532).
The results of the path analysis showed that learning styles have a predictive role on test anxiety with the mediation of self-efficacy. That is, as the students’ learning increases, the students’ academic self-efficacy increases, and with the increase of the academic self-efficacy, the students’ test anxiety decreases and vice versa. Also, the results of the present study were consistent with the findings of Mercader-Rubio et al. [22], which show a positive correlation between the dimensions of emotional intelligence (attention, clarity, and regulation) and physical anxiety, cognitive anxiety, and self-efficacy. In the present study, a statistically significant relationship was observed between the anxiety score and the individual's stress score in such a way that for an increase of one unit in the individual's anxiety score, the stress score also increases by 0.606 times. Based on our observations, a large number of clients in the optometry profession, many questions and answers between the therapist and the patient to achieve a more correct diagnosis, the multitude of diagnostic methods and devices, the large number of clients, especially in government centers, have increased their anxiety and as a result, with the increase of anxiety and work pressure, psychological changes related to that stress also increased. This result was consistent with the results of Sharma et al. [23] and Shoji et al. [24], in which the results showed that mindfulness has a positive relationship with self-efficacy, while it has a negative relationship with anxiety, stress, and depression. In addition, self-efficacy had a negative relationship with anxiety, stress, and depression. According to the results of the mediation analysis, the role of self-efficacy as a partial mediator in the relationship between mindfulness, stress, depression, and anxiety is consistent. Regarding the high occupational stress in the occupational therapy group, it seems that the complex conditions and characteristics of the referring patients, including a wide range of physical, mental, and psychological diseases and neurological disorders, along with the expectations of the patient and his family to speed up recovery and the treatment, slowness and time-consuming recovery in patients of this rehabilitation spectrum and the need for occupational therapists to have a lot of patience in dealing with patients and their families cause an excessive increase in stress and consequently decrease the self-efficacy of occupational therapists due to the slowness of the recovery process and doubt in their ability. It is about the success rate of the therapeutic activities they do. In the present study, the self-efficacy score increases by 0.213 times for a one-year increase in a person's age, and for a one-year increase in a person's work experience, the self-efficacy score also increases by 0.247 times. It seems that people who have more work experience in the field of rehabilitation treatment have the power to use their abilities and skills better when dealing with different patients, and with increasing experience, the belief that they can handle various obstacles and challenges also increases. Also, a statistically significant relationship was observed between the stress score and the person's age and sex, in such a way that the stress score decreases by 0.185 times for every one-year increase in the person's age, and the stress score decreases by 0.189 times for the increase of one year of the person's work experience. The increasing age of rehabilitation therapists gives them the ability to face stress, and the experiences gained over the years of activity develop the ability to adapt and react appropriately to the conditions and characteristics of the work environment and different patients, and the ability to manage stress in them. It distinguishes people who have less work history. These results are consistent with the results of Khamsa et al. [25] of nurses suffer from depression, (21.6%) from anxiety, and (47.6%) from stress, and the results of the research showed a significant relationship between anxiety, stress, and marital status of nurses (P<0.05). In addition, the relationship between the level of depression, stress and gender was also significant (P<0.05). Based on this, the destruction of therapists' morale can directly affect their performance and efficiency. In other words, high self-efficacy plays an effective role in curbing and reducing anxiety and situational stress and can have a great effect in promoting mental health, and therapists and preventing negative and destructive personal and social effects caused by stress and anxiety. Therefore, creating ways to increase self-efficacy can partially prevent people from suffering from psychological problems and increase their ability to adapt to the environment. This research provides information on the amount of occupational stress, self-efficacy, and psychological problems of stress, anxiety, and depression of rehabilitation therapists in Tehran City, to the practitioners and managers, planners, educational researchers, and psychologists, emphasizing the importance that high self-efficacy can protect a person against stress. Make a job more resistant and adaptable and thus increase well-being. Considering the importance of self-efficacy in people's sense of empowerment and its impact on the way of thinking, making decisions, and how to face stress, managers of various organizations, especially rehabilitation, due to the high sensitivity of work and high job stress, to have employees who are free from psychological problems can strengthen self-efficacy beliefs in their employees.

Conclusion
The results of the present study showed that occupational stress and anxiety had an effect on therapists’ self-efficacy and had a significant and inverse relationship, so that as stress and anxiety increase, therapists’ self-efficacy decreases and vice versa, which destroys therapists’ morale and decreases It affects their performance and efficiency. Considering the importance of self-efficacy in people’s sense of empowerment and its impact on decision-making thinking and how to deal with stress and subsequent anxiety caused by rehabilitation therapy activities, it is necessary for related managers to reduce stress and anxiety and consequently increase self-efficacy and performance efficiency. Therapists should think of a solution.

Ethical Considerations
Compliance with ethical guidelines
The Ethics Committee of Iran University of Medical Sciences, (IUMS) approved the study protocol (Code: IR.IUMS.REC.1401.55). Informed consent was obtained from all the participants after they were provided with details of the study protocol.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization: All authors; study design: Mohammad Kamali, Seyed Hassan Saneii and Mahtab Roohi-Azizi; Data collection and writing the initial draft: Eisa Sheikhi; Data analysis and interpretation: Seyed Hassan Saneii; Review, editing and final approval: Mahtab Roohi-Azizi.

Conflict of interest
The authors declared no conflict of interest.

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