High levels of stress are common for nursing students and nursing professionals (American Nurses Association, 2020). Prolonged stress is exhausting, often leading to burnout, depersonalization, deterioration of health, or leaving the profession altogether. Nursing students focus much of their attention on helping clients cope with illness but are given inadequate experiential training in self-care skills to cope effectively with their own stress.
Mindfulness, a skill that involves a heightened, nonjudgmental awareness and attention to the present moment (Kabat-Zinn, 2006), has been shown to be effective in reducing stress levels for a wide variety of populations, including nurses and nursing students (Janssen et al., 2018; van der Riet et al., 2018). The technique can be taught online, which enhances accessibility and feasibility (Jayawardene et al., 2017). This research brief details an online mindfulness-based intervention for nursing students, which took place in fall 2019.
Based on a review of 23 articles on mindfulness interventions, there is high heterogeneity in the intervention across studies in terms of overall length, dosage (requirement per day/week), and delivery (e.g., online, via CDs, application-based), with moderate effect sizes for shorter or medium-length interventions (two to eight weeks) versus longer interventions (Heber et al., 2017). Common to all studies reviewed is an element of experiential learning, that is, practicing the skill (Gilmartin et al., 2017). Another critical characteristic of mindfulness-based interventions is personal reflection in a group (Jayawardene et al., 2017). Moderate effect sizes for stress reduction, as a result of mindfulness training, are similar across the meta-analyses (g = .43 to .54), but with high heterogeneity (I2 = 64.96 to 85.18). This heterogeneity indicates variability in the studies’ results but decreases significantly after removing low-quality studies (I2 = 35.44 to 69.41).
Two theoretical frameworks underpin this study: the theory of positive reappraisal (Lazarus & Folkman, 1984) and the theory of experiential learning (Kolb, 1993). The theory of positive reappraisal describes the process by which stress can be ameliorated using cognitive reappraisal. Attentional broadening (Garland et al., 2009) and metacognitive awareness, afforded by the practice of mindfulness, are mechanisms for cognitive reappraisal. Kolb’s theory of experiential learning guided the design of the intervention to support acquisition of a new and embodied skill by students through practice and guided reflection.
This pilot study examined whether undergraduate nursing students at a community college in Ontario, Canada, experience a decrease in perceived levels of stress and an increase in mindfulness after experientially learning the self-care skill of mindfulness practice through a brief, guided, group-based online program. Two research questions were asked: 1) Does online mindfulness meditation training decrease nursing students’ stress level? 2) Does online mindfulness meditation training increase students’ mindfulness?
This study received full approval by the research ethics board at the college. The researcher was not involved in teaching the course and had no influence on students’ grades or willing participation. To protect confidentiality, students used a unique identifier in SoGoSurvey©, and no identifiable information was collected.
The design involved an online mindfulness training program embedded in a nursing theory course and offered to undergraduate nursing students. Recruitment was through convenience sampling. All students (110) were invited to participate. Students’ perceived stress and levels of mindfulness were assessed pre- and postintervention and at four weeks follow-up and compared using descriptive and inferential statistical analysis. Outcomes were measured using SoGoSurvey and completed online.
This five-week mindfulness training program included a psycho-education component using material on the learning management system, material embedded within the meditations, and engagement in the meditation practice. Students used the applications Headspace© and Smiling Mind© and each day chose from a repository of free meditations on both apps. Students engaged in mindfulness practice five to 10 minutes per day, for an ideal total of 21 times over the five-week period. Students blogged weekly in response to specific guided questions, reflecting on their practice and challenges. The author of this project, as well as a mindfulness expert, also interacted with students, offering guidance, reminders, motivation, and feedback through announcements, comments, and private messages.
Stress was measured using the widely accepted Perceived Stress Scale (PSS-10), which demonstrates strong internal reliability (>.70; Cohen & Williamson, 1988) and construct validity (α = .83) among a representative college sample (Roberti et al., 2006). Mindfulness was measured using the Five Facet Mindfulness Questionnaire, considered a synthesis of several of the most widely used mindfulness scales, based on a factor analysis of each (Janssen et al., 2018). It demonstrates strong reliability (Gu et al., 2016) and was found to have the highest ratings in terms of “internal consistency and construct validation by hypothesis testing” (Park et al., 2013). The shorter 15-item scale was used in this study as it has good convergent validity with the longer version (Gu et al., 2016) and reduced participant burden. Baer et al. (2012) found internal consistency between the subscales was adequate despite the abbreviation of items (α = .80 to .85).
Sixty students (n = 60) participated in both the pretest and the posttest with matching unique identifiers. Most participants (75 percent) were women (n = 45). The majority were in the 20 to 30 years of age category (n = 44), with the remainder aged 31 to 50 years (n = 16). Of the 60 students, 29 participated in the four-week follow-up testing.
Mean pretest PSS-10 scores were high (M = 20.42, SD = 5.42) as compared with norms according to a poll in the United States (Cohen & Williamson, 1988). Five Facet Mindfulness Questionnaire scores were similar to preintervention scores found by Gu et al. (2016) in their research (M = 47.6, SD = 7.48). Using random intercept linear regression models, changes in stress and mindfulness between pretest, posttest, and follow-up were analyzed using time as the independent variable. Although mean stress scores lowered, the change was not statistically significant, either at posttest (M = −1.02, SE = .805, p = .207) or follow-up (M = −1.448, SE = 1.193, p = .225). The increase in mindfulness was significant at posttest (M = 3, SE = .846, p = .000) and was maintained at follow-up (M = 3.034, SE = 1.209, p = .012).
Twenty-eight percent of students reported completing ≤20 sessions (n = 17); 72 percent completed ≥21 sessions (n = 43). A significant difference in both stress and mindfulness was noted at posttest for those who were strongly adherent (≥21 sessions). The decrease in stress was mildly significant at the p ≤ .10 level (M = −1.678, SE = .944, p = .075); the increase in mindfulness was highly significant at the p ≤ .001 level (M = 3.752, SE = 1.044, p = .000). This breakdown of the sample by adherence level was not done at follow-up because of the smaller sample size.
Stress decreased more for older participants than for younger participants, and this was mildly statistically significant (M = −3.278, SE = 1.897, p = .084). There were no significant differences in change in mindfulness between the two age categories as compared with pretest. Although pretest stress was significantly higher for women than men (M = 3.045, SE = 1.510, p = .044), gender did not have a statistically significant effect on the change in stress or mindfulness. Follow-up data were not analyzed with age or gender as interaction variables because the sample size was not sufficient to yield meaningful data.
Although PSS-10 scores did not decrease significantly, there was a statistically significant negative correlation between the change observed in stress and mindfulness. The strength of this correlation was moderate (−.572, p ≤ .0001). Larger increases in mindfulness were associated with larger decreases in stress.
DISCUSSION AND CONCLUSION
The statistically significant negative correlation between mindfulness and stress was expected according to the theory of cognitive reappraisal. Attentional broadening as a result of greater mindfulness was associated with a decrease in stress in this sample. Results of the linear regression model with the interaction of adherence suggest that the intervention may have been too abbreviated to demonstrate a significant decrease in stress. Participants with higher levels of adherence had a greater decrease in stress and a greater increase in mindfulness. The baseline higher-than-average stress scores may also point to the need for a more sustained intervention. The pretest mean of 20.42 (SD = 5.42) for the participating nursing students indicates a significantly more stressed population, which may require a higher dose of the intervention to demonstrate more significant reduction in stress. In addition, this suggests an even greater need to educate students on self-care strategies such as mindfulness.
The finding that older students responded more with decreased stress and increased mindfulness may be due to increased capacity for reflection and metacognition with respect to coping with stress. Reflection and metacognition are key elements of experiential learning, specifically the phases of reflective observation and abstract conceptualization (Kolb, 1993). Younger students may need more guidance to draw on life experiences, increase their self-awareness, and conceptualize the ways in which mindfulness affects their thought processes and emotions.
This highly feasible experiential intervention can be replicated easily in other nursing programs. It fits especially well in a course that focuses on role transition or on the nurse-client therapeutic relationship as the therapeutic use of self requires the nurse to have effective stress management skills. Based on these results and the comparison with current literature, an online mindfulness intervention for nursing students lasting six to eight weeks is recommended, and ongoing research is necessary. The online platform can be a form of support that is easily accessible to students. Elements of reflection and group interaction should be retained to promote experiential learning and evaluated qualitatively.
Sample size is a limitation in this study; it may have been too small for reduction in stress to reach statistical significance. Also, a history bias likely masked some of the results on stress. Posttest and follow-up measurements were taken at much more stressful points in the semester than the pretest data. It is hypothesized that stress scores could have increased, perhaps significantly, in the absence of this intervention. A design with randomization to an intervention or control group would best mitigate this bias in a future study.
Nursing students engaged in the online mindfulness intervention experienced a decrease in perceived stress and an increase in mindfulness. This pilot study supports the effectiveness and feasibility of learning mindfulness online through principles of experiential learning. Future studies are recommended.
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