The education process for nurses is difficult and stressful, with multiple stressors that affect students in different ways and at different levels of intensity (Galbraith & Brown, 2011). Although after-degree programs are delivered over a shorter time than traditional 4-year programs (students have completed a degree in another field prior to entering into the after-degree program), they also have the potential to amplify the experience of stress for after-degree students (Beck, Hackett, Srivastava, McKim, & Rockwell,1997; Sawatzky, 1998) because of the condensed and accelerated nature of the program (Cangelosi, 2007; D'Antonio et al., 2010; Kohn & Truglio-Londrigan, 2007; Reeve, Shumaker, Yearwood, Crowell, & Riley, 2013; Shiber, 2003; Utley-Smith, Phillips, & Turner, 2007).
Although the need to provide assistance with stress management for after-degree nursing students is recognized, there has been little research done in this area (Galbraith & Brown, 2011). Early studies have mainly investigated the occurrence of stress, its effects, and how these effects are influenced by specific intervention techniques in the traditional nursing student population (Galbraith & Brown, 2011).
Mindfulness has been increasingly valued in the psychotherapeutic and medical fields, and decades of research have resulted in the development of accessible mindfulness meditation programs for stress reduction (Irving, Dobkin, & Park, 2009). Previous studies investigating mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990) with nursing students found that MBSR reduced stress, anxiety, anger, and depression and increased their ability to cope with stressful events (Beddoe & Murphy, 2004; Chen, Yang, Wang, & Zhang, 2013; Kang, Choi, & Ryu, 2009; Linden, Turner, Young, & Bruce, 2001; Moscaritolo, 2009; Shields, 2011; Shirey, 2007; Song & Lindquist, 2015; McConville, McAleer, & Hahne, 2017).
Relatively few studies focus on the effectiveness of adaptations to the traditional program (Kabat-Zinn, 2003). That said, a modified MBSR program of 6 hours was judged by participants to be as effective as participants who used Kabat-Zinn's original 8-week program (Klatt, Buckworth, & Malarkey, 2009). This suggests that positive participant outcomes may not be affected by shortening the number of training hours in an MBSR program. The purpose of this current study was to explore after-degree nursing students' first-person experiences of the effects of an 8-hour MBSR-B intervention.
A qualitative evaluation design was used to understand participant perspectives and experiences of an 8-hour MBSR-B program (Patton, 1980, 2002). Four female and one male participant (between 25 and 34 years of age), who were recruited through in-class presentations by the primary author, were asked during individual digitally recorded semistructured interviews to describe their experience of stress while learning and practicing MBSR-B based on two 4-hour training sessions followed by 4 weeks of daily practice. Participants were enrolled in a Bachelor of Nursing after-degree program, were undertaking their final acute care clinical practice rotation, and had no previous experience with MBSR. All participant names are pseudonyms. Ethics approval was obtained from the human subject research committee at the researcher's (R.M.) university.
Data Collection and Analysis
Data were generated through individual digitally recorded semistructured interviews conducted by the primary author (R.M.) following the completion of the MBSR-B intervention, consisting of the 8-hour MBSR-B program and 4 weeks of daily practice. Participants tracked their practice to ensure they met the intervention expectation of 20 to 30 minutes per day. Interviews lasted between 45 and 90 minutes. Interviews were transcribed verbatim and entered into NVivo 10 software for thematic analysis (Braun & Clarke, 2006). After reading each transcript for correctness and understanding, the transcripts were analyzed line by line. Important statements and words became codes. Codes were then grouped according to similarity and recoded as potential categories. Categories were then collapsed based on similarity. Finally, the metatheme of self-awareness was identified as linking the categories that captured the participants' experiences of the MBSR-B intervention. Trustworthiness was established by maintaining an audit trail, reaching consensus among the researchers regarding coding and the development of themes, and maintaining reflexive memos throughout the research process (Morse, 2018).
Qualitative data analysis generated four categories: (a) hitting a reset button, (b) self-compassion, (c) avoiding a downward spiral, and (d) using an internal coping mechanism. These categories are linked by a metatheme of self-awareness.
Hitting a Reset Button
Participants found they were able to use a personal reset button that helped them recognize elevated stress levels and change their perception of a stressful experience into a positive one. Some participants noted that hitting an internal reset button made them “feel a lot calmer” (Katie).
It is like we are going to press reset. We are going to start off fresh and brand new and are going to tackle all those issues again; but we are going to try it a little differently. The stressors are still there. They exist. We are just going to take a break, reset, and try it again. It is like I have a new plan. We are going to get this done and it is not going to be a big deal.
Katie's comment clearly showed how she was able to recognize her stress and consciously change her perception of that stress.
Some participants felt an increased sense of self-compassion and acceptance in their clinical practice and were better able to accept their capabilities and limitations. This was effectively explained by Dawn as she described her self-talk:
I was constantly telling myself that I was inadequate and needed to do other things. Now I feel like I have less judgement and more acceptance. I say to myself, “You are doing the best you can right now with your current knowledge base, with your current experience. You need to be easier on yourself. You need to chill out. You need to do the best you can for your patients and for you.” I felt like I had a more nurturing relationship with myself.
Dawn's comments indicated she has a more accepting attitude toward herself and her clinical practice after realizing the presence of negative thoughts and deciding to view the situation from a different perspective.
Avoiding a Downward Spiral
Most participants felt they were able to detect and cope with stress as it was happening, rather than letting it build and get out of control and becoming “whirl-windy and frantic” (Dawn). They were also more proactive in handling stress “as it is happening, as opposed to a reflective process” (Alexandra). Katie noted how it felt for her: “It is like I am catching myself before I completely go into a downward spiral. It is like I tell myself, ‘Oh, wait. Stop. Think this through.’ This allows me to keep going.” Similar to Katie's ability to realize that she needs to pause and reflect on a specific situation, Smith provided detail into how he avoids a build-up of stress: “I find a way of talking to myself so that I do not get worked up, because I tend to do that.” Smith's comment seems to indicate that he often experiences increased stress as a direct result of his thoughts perpetuating the stressor and his reaction to it. The importance of moving past the stress before it becomes more problematic was discussed by Alexandra:
It definitely reduces my stress. Before, I would not really think about it and would allow it to build and build until it just blew up, and then I would move on from it. Whereas now I do not let it build and build. I just think about it and realize there is nothing I can do but to move on.
Using an Internal Coping Mechanism
Some participants noted how their prior use of external coping mechanisms for stress management was less frequent after learning how to use the internal techniques of MBSR-B. As an external way of managing stress, Katie used to go to the gym and work out by lifting weights. She noticed that the internal method of MBSR-B provided a similar effect in reducing her stress without having to go anywhere or needing any specific equipment: “I do not need a tool or an aid to do it.”
Similarly, Dawn traditionally only ever relied on external stress management practices, but realized MBSR-B offered her an effective and internal way to cope with stress:
I think it [MBSR-B] has been really helpful because before when I was stressed I would look forward to putting my feet up and having a glass of wine and chill. This was the only way I knew how to [manage stress]. Now, instead of having that glass of wine I have a glass of water and sit mindfully in silence. I give myself the space I need to deep-breathe and it has the exact same effect. This is awesome.
The categories of (a) hitting a reset button, (b) self-compassion, (c) avoiding a downward spiral, and (d) using an internal coping mechanism that emerged in this study reflect an overarching theme of self-awareness. Kabat-Zinn (2003) suggested that mindfulness practice aims to enhance a sense of awareness that is present at all times. This awareness would allow one to be more perceptive of thoughts and emotions in different situations, which may lead to the early detection of stress. The early detection of stress through increased self-awareness has been shown to be beneficial in managing stress in nursing students using mindfulness (van der Riet, Rossiter, Kirby, Dluzewska, & Harmon, 2015). In the current study, the development of a deeper sense of self-awareness was brought about by the practice of the MBSR-B techniques, which resulted in participants having the capacity to detect and manage their stress more efficiently and effectively.
Following the early detection of stress, the participants were able to “hit a reset button,” indicating they changed their perception of the situation, thus coping with the stress involved. Although this effect was greater for some than for others, the sentiment that the learned techniques worked to improve their recognition and coping with stress was common among the participants. The conscious detection and management of stress demonstrated the self-awareness often associated with MBSR practice (Pipe et al., 2009).
Further, early recognition through increased self-awareness reduced the amount of time some participants were affected by stress. Not dwelling on negative thoughts helped participants prevent the stress from becoming more than it initially was, therefore decreasing the amount of stress experienced. In doing so, stress did not accumulate, and participants were able to “avoid a downward spiral” by handling it early. This finding is crucial, as prolonged stress in nursing students during their training may lead to future impairment during their practice (Beck & Srivastava, 1991).
MBSR-B also offered a way for negative self-view to be recognized through self-awareness and replaced with a more self-compassionate attitude. This helped the participants to be more accepting of their challenges, which had a positive effect on their clinical practice. The development of increased self-compassion is a phenomenon linked with MBSR practice (Birnie, Speca, & Carlson, 2010). Also, having an increased sense of self-awareness allowed participants to use MBSR-B in ways that best suited them and their situation. This is a key finding given the stressful nature of after-degree nursing student academic course load and unpredictability of clinical practice settings (Beck & Srivastava, 1991). Using MBSR-B techniques situationally to reduce stress in the workplace has also been observed in nurses and may have a positive impact on patient interactions and outcomes (Foureur, Besley, Burton, Yu, & Crisp, 2013; Hunter, 2016) postgraduation.
Overall, the results of this study were consistent with the theory that MBSR teaches people to be more accepting of themselves and less self-critical, which for nurses relates to self-care (Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2004). The data suggested that the MBSR-B intervention helped participants manage stress. The findings may also assist and provide support for nursing educators in offering MBSR-B interventions as a means to manage stress in after-degree nursing students, which is consistent with support for stress management interventions from the literature (Yildirim, Karaca, Cangur, Acikgoz, & Akkus, 2017).
The sample for this study was small and all participants were undertaking a clinical course at one university. Although the sample was small, the personal experiences and detailed descriptions allow for small sample sizes in qualitative research (Creswell, 2013). Moreover, the small purposeful sample allowed in-depth investigation and understanding of the effects of MBSR-B on participant stress (Patton, 2002).
Other limitations of this study include time commitment and the potential for causing stress for the participants. As a result, consideration is required when developing the intervention, expectations for practice during the study, and the timing of the interviews, as well as support for participants who experience stress from the study.
The qualitative evaluation of this brief MBSR-B intervention suggested that it supports stress management in after-degree nursing students as MBSR has in studies with 4-year nursing students (Beddoe & Murphy, 2004; Chen et al., 2013; Kang et al., 2009; Linden et al., 2001; McConville, McAleer & Hahne, 2017; Moscaritolo, 2009; Shields, 2011; Shirey, 2007; Song & Lindquist, 2015). The findings supported the incorporation of stress management support into the nursing curriculum, and participants found the techniques learned from the intervention helped them effectively manage their stress. The positive impact for all participants in this study suggested that offering support for stress management for after-degree nursing students through use of an MBSR-B program should be considered. This type of support offered early in the education of RNs may have immediate and long-term effects on the health of those receiving the support, the organizations they will work for, and the people for whom these future nurses will care.
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