Implementing Meditation Strategies to Improve Self-Care Management Among Undergraduate Nursing Students
Abstract
Problem: Nursing school curriculum does not address self-care behaviors or practices.
Background: New baccalaureate essentials require curriculum developments to support personal development.
Method: A descriptive pretest/posttest design was used to evaluate the impact of incorporating 5-min guided mediations throughout the curriculum on student stress.
Results: Stress scores posttest indicated lower scores than reported in other literature regarding nursing students with scores ranging from 11 to 40. Statistical significance was also found related to behaviors of physical activity and creative relaxation activities.
Conclusion: Intentional interventions to support student development of self-care strategies are needed in the baccalaureate program.
1. Introduction
The adoption of new baccalaureate essentials by the American Association of Colleges of Nursing [1] requires nursing programs to address personal and professional development topics within the curriculum. To address these requirements, education centered on self-management strategies such as mindfulness and meditation in the baccalaureate curriculum is important to address the physical and emotional needs essential for personal and professional well-being [2]. In addition, self-management strategies address the negative impact on mental health and academic performance due to the nursing school curriculum’s rigor. According to Onieva-Zafra et al. [3], 47.92% of nursing students experienced a moderate level of perceived stress and 25% of nursing students perceived a high degree of stress at a Spanish university. Factors impacting stress management include social considerations, culture, mental health disorders, and inadequate coping strategies [3].
Evidence supports the practice of regular mindfulness meditation to promote positive physiological and psychological outcomes [3, 4]. Mindfulness is a nonjudgmental self-awareness practice that can decrease blood pressure, improve stress management, and reduce cortisol levels [4]. With proposed revisions to nursing curriculums, as well as literature suggesting self-care practice benefits, it is expected that intentional implementation of mindfulness practice into the nursing curriculum will increase student-led self-care strategies and decrease perceived stress among baccalaureate nursing students.
2. Literature Review
For over 2 decades, mindfulness has been formally studied as a strategy to mitigate mental health strain. Burnout and job-related stress are heavily associated with healthcare professionals, as well as for students who are pursuing a degree in healthcare-related fields [5, 6]. Nursing students experience considerable stress and anxiety due to demanding responsibilities, the intensity of material, along with management of class schedules [7–11]. Elevated levels of stress are increasing among all health profession students [12]. The demands of the nursing major can lead to elevated levels of anxiety, while negatively impacting student grades, clinical performance, and overall mental health [13, 14]. A growing body of literature has identified a range of beneficial physiological and psychological outcomes from the regular practice of mindfulness meditation. In addition, among healthcare professionals, studies showed that mindfulness meditation claims to reduce stress, anxiety, and burnout and enhance resilience [15].
More mindfulness interventions are deemed a necessary part of some nursing schools’ curricula. We are in an era where mindfulness and mental health concerns loom large [8]. Mindfulness emerges as a potent tool for alleviating psychological distress and promoting emotional well-being [6, 7, 16, 17]. Literature supports incorporating mindfulness into the classroom to promote self-care [18, 19]. Future consideration for college credit may be an option to make mindfulness more appealing to college students [18–20]. The discussion warrants incorporating mindfulness meditation practice into the curriculum. Although the vast majority of available research shows psychologic and physiologic benefits to mindfulness practice, Stinson et al. [21] found that some students experienced anxiety rather than a reduction in anxiety after participating in such practices [15, 22].
Future consideration into collaboration with college campus wellness and disability centers may be helpful due to increasing rates of reported anxiety and stress among college students [23]. Increased collaboration between wellness centers and disability services on college campuses can potentially provide a comprehensive, coordinated approach to supporting the mental health and well-being of students. By integrating resources, promoting inclusivity, and ensuring early intervention such as mindfulness meditation, these collaborations can help address the rising rates of anxiety and stress among college students. Additionally, resources can foster a healthier, more supportive campus environment for all students, regardless of their background or challenges [8, 11, 23, 24].
By making wellness and disability services a priority in collaboration, campuses can work toward creating a culture of well-being that extends beyond crisis intervention. Students may be better equipped to handle future stressors, whether academic or personal, if they have support throughout their college years. Programs that focus on preventative care and interventions that relieve perceived anxiety and stress can help reduce the long-term impact of anxiety and stress; however, there is little research to support this. Another gap in the literature is that all areas have not been explored extensively, both nationally and internationally to conclude the cause and effect of mindfulness interventions on students’ emotional regulation [25]. The current body of evidence also fails to address if all aspects of mindfulness research can be replicated among all age groups, ethnicity, and socioeconomic status. Further research is warranted on meditation strategies and whether self-care management improvement is evident after implementation in a variety of populations before a conclusion can be made.
3. Methods
3.1. Aim
This prestudy/poststudy evaluates the impact of incorporating self-care practices throughout the curriculum within a baccalaureate nursing program on student stress management. The specific research questions are as follows:
Will incorporating self-care practices within the curriculum increase student use of self-care strategies?
Will students’ perceived stress scores decrease after receiving self-care practice education?
3.2. Design
A descriptive pretest/posttest design was used to evaluate the impact of incorporating 5-min guided mediation practices throughout the curriculum within a baccalaureate nursing program on student stress management.
3.3. Participants
Convenience sampling was used to obtain participants during the Fall 2023 semester. The nursing program is designed to be completed in five semesters, and students are categorized from levels four through eight based on progression. Level four is the first semester upon acceptance into the nursing program; students typically start in the second semester of the sophomore year. Levels five and six occur in the junior year, and levels seven and eight occur in the senior year.
The study population consisted of level four (n = 56), level five (n = 42), and level six (n = 18) baccalaureate nursing students enrolled in nursing courses at three different campuses. The nursing curriculum on all campuses (one in-person and two satellites) is consistent, and instruction is delivered via streaming service to the satellite campuses.
3.4. Intervention
The study was conducted between August 2023 and December 2023 and scaffolded across three out of five semesters in the nursing program. At the beginning of each class, faculty administered a 5-min meditation from a selection of YouTube videos (audio, visual, or tactile). The YouTube videos were selected and screened by a clinical psychologist and limited to 5 min. Each video incorporated audio and visual methods focused on various aspects of mindfulness including general meditation, grounding, or visualization practice to appeal to a variety of preferences among participants. Students who chose not to participate in the study or the meditation were asked to sit quietly to limit distractions for participating students. Scheduled class activities resumed following the meditation period.
3.5. Data Collection and Analysis
Two instruments assessed the perceived stress and self-care strategy integration among participants. The Mindfulness Self-Care Scale (MSCS-Brief) is a 24-item tool measuring the frequency of self-care behaviors from one (never) to five (regularly) (α = 0.93). Permission was obtained from the creator of the MSCS-Brief to utilize the instrument [26]. The Perceived Stress Scale (PSQ) is a validated, reliable tool developed by Levenstein et al. [27]. The PSQ is a 30-item, 4-point Likert scale used to assess perceived levels of stress related to life events within the past year. Google Forms was used for survey administration, and data was secured on a password-protected device. The Statistical Package for the Social Sciences (SPSS) software was used to analyze descriptive statistics on student demographic data. Paired t-tests were used to compare participants’ mindfulness and self-care scores and perceived stress scores before and after the intervention period. The pretest was administered at the beginning of the semester during the first week of class. The posttest was administered at the end of the semester, approximately 16 weeks later.
3.6. Ethical Considerations
This study was approved by the University Institutional Review Board (IRB). Students were informed at the beginning of the semester that participation was voluntary, and no grade would be associated with involvement. Informed consent was obtained by participants before the completion of the pre- and postsurveys.
4. Results
To evaluate the impact of the intervention on nursing students’ mindfulness behaviors, two-sample t-tests assuming equal variances were conducted to compare the means pre to post. Comparing individual subscales of the MSCS returned no significant differences between pre- and postscore averages. Observing means on individual items that were at least 0.5 points higher or lower between timepoints, specific items on the scale were evaluated using t-tests. Of the items evaluated, significant differences were found between two items. A significant difference was found on the item, I did something creative to relax, from pre (M = 1.74, SD = 0.87) to post (M = 2.92, SD = 1.51) timepoints (t = −2.77, p = 0.01). A significant difference was also found on the item, I did sedentary activities instead of exercising, from pre (M = 3.58, SD = 0.84) to post (M = 2.83, SD = 1.03) (timepoints t = 2.21, p = 0.04). Students who reported stress scores posttest indicated somewhat lower scores than reported in other literature regarding nursing students (M = 25, SD = 7.03) with scores ranging from 11 to 40 [28].
Approximately 12% of the sample indicated complete unfamiliarity with meditation, grounding, or visualization. These results were prior to any intervention measures. For further demographic information, see Table 1. Demographic testing indicated that there were no significant differences in pretest perceived stress related to age, sex, race/ethnicity, or program level. Familiarity with types of meditation was only related to program level. To test the hypothesis that mindfulness practiced in class would reduce negative mental health outcomes, paired sample t-tests were conducted. Comparison of the subscales indicated that in contrast to hypothesized patterns, perceived stress at the end of the semester (M = 17.36, SD = 6.09) was significantly higher than perceived stress at the beginning of the semester (M = 19.22, SD = 7.18), t (49) = −2.01, p = 0.05. There were no significant differences in depression or anxiety.
| N | % | |
|---|---|---|
| Age range | ||
| 18–20 | 51 | 39.2 |
| 21–22 | 39 | 30.0 |
| 23–30 | 31 | 23.8 |
| 31–40 | 5 | 3.8 |
| 41+ | 4 | 3.1 |
| Sex | ||
| Male | 13 | 10.0 |
| Female | 116 | 89.2 |
| Race/ethnicity | ||
| White | 83 | 64.3 |
| Black or African American | 32 | 24.8 |
| Asian | 5 | 3.9 |
| Prefer not to say | 9 | 7.0 |
| Program level | ||
| IV | 64 | 49.2 |
| V | 47 | 36.2 |
| VI | 19 | 14.6 |
There was a significant difference between the number of participants at the beginning of the study (n = 56) and post (n = 14). To further evaluate the impact of mindfulness in class on nursing students’ mindfulness behaviors overall, paired sample t-tests were conducted. Only two of the mindfulness subscales demonstrated significant differences from pre to post. In line with the hypotheses, mindfulness awareness increased from pre (M = 9.24, SD = 3.10) to post (M = 10.19, SD = 3.45), t (49) = −2.20, p = 0.03. Counter to hypothesized direction, physical care declined from pre (M = 12.43, SD = 3.21) to post (M = 11.32, SD = 3.48), t (49) = 2.26, p = 0.03. Post hoc analyses of factors that may have impacted results indicated that the reported participation level was not significantly related to outcomes. Correlations of pretest and posttest variables indicated that pretest perceived stress was significantly positively correlated to posttest stress r (50) = 0.52, p = 0.001 and depression r (50) = 0.36, p = 0.001 and was negatively correlated with posttest self-compassion r (50) = −0.32, p = 0.03 and posttest mindful awareness r (50) = −0.30, p = 0.03. The 14 students who participated at the end may have been more likely to score higher in self-care compared to the 42 students who elected not to participate since they participated voluntarily. Additionally, the risk for the confounding variable of stress levels being different at the start versus the end of the semester could also contribute to study limitations.
5. Discussion
The study examined the impact of integrating a mindfulness intervention into the baccalaureate curriculum. Familiarity and awareness of mindfulness strategies were key study findings. Results indicated that 12% of participants were unfamiliar with meditative practices, and an increase in mindfulness awareness was noted following the intervention period. These results show the need to incorporate self-care strategies into the nursing curriculum to assist students with stress management development to ensure sustainability of future nursing practice. One particularly interesting finding was the contrast in hypothesized patterns of perceived stress. Higher stress is usually indicated during the final exam period and could explain the incongruences between the hypothesized and expected outcomes. Although stress increased, it is important to note that participant means were still lower than in other published studies [3].
The study had several limitations. Students maintained autonomy and self-selected their participation in the meditative practice, potentially impacting intervention participation rates and introducing self-selection bias. Bias could also be attributed to a specific geographical population as the study was conducted at a single university. Current mental health states of each participant could contribute to limitations as mindfulness can be very subjective. Participants who engaged in meditation reported an increased ability to recall the mindfulness practices, which influenced survey responses. Technological issues, such as streaming pauses and sound distortion between campuses, disrupted mindfulness sessions. Testing accommodations posed challenges to intervention adherence due to location changes, though instructors addressed this by providing links to mindfulness practices and coordinating with proctors. Additionally, course content demands affected the consistency of intervention delivery, potentially limiting the generalizability of the findings.
Students who decided not to continue to participate voiced that they felt the interventions took up valuable class time. On exam days, students voiced they would rather get straight to the exam rather than prolong their start time. It was also hard to distinguish whether students were actively participating in the meditation versus sitting quietly with heads down and eyes closed.
As far as recommendations for educators who may want to incorporate this practice into their curriculum, suggestions would include first obtaining student feedback on whether they would like to have the meditations on exam days or only class days. Mindfulness practices during this study were always incorporated at the beginning of a class. Benefits may also be found using the interventions at the end of class.
6. Conclusion
Results from this study highlight the need to integrate interventions to address stress management strategies among baccalaureate nursing students. Although the single site and small sample size reduce the generalizability, the design is replicable to other undergraduate nursing programs which could strengthen the reliability of research results. Future research can offer more insight into the relationship between mindfulness participation and final course grades, instructor benefits of mindfulness practice, and the correlation between mindfulness interventions before exam administration and exam scores.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request. All data have been anonymized where necessary to protect participant confidentiality.
