Effectiveness of a brief stress reduction intervention for nursing students in reducing physiological stress indicators and improving well-being and mental health

Nursing students are faced with stress on a regular basis, which can impact physical and psychological functioning. Despite the identification of stress, anxiety, poor performance, and risk for depression, few studies identify measures to manage stress in a student nurse population. The purpose of this study was to examine the effectiveness of a brief mindfulness breathing intervention to decrease stress and ultimately the risk for depression while increasing self-efficacy with clinical skills performance in a 1st-year student nurse population. Participants were recruited from an associate degree nursing program at a northwestern university. Data gathered included demographic information, depression scores, physiological measures (i.e., blood pressure and pulse), self-efficacy scores, and skills performance scores. The design was a two-group (experimental and no-treatment control) true experimental randomized control trial with the following four repeated measures: (a) pretest, (b) posttest, (c) 2-month follow-up test, and (d) 4-month follow-up test. Data collection took place from November 2009 to March 2010. The sample (N = 85) was predominantly female (87.1%, n = 74) and Caucasian (89.4%, n = 86). Fifty-six of the participants were married and 46% of the participants identified themselves as parents of children still living at home. Analyses of variance demonstrated a greater mean decrease for the intervention group than for the treatment-as-usual group following the mindfulness breathing intervention for depression, F(1,82) = 6.864, p = .010; systolic, F(1,81) = 6.557, p = .012; and diastolic, F(1,81) = 6.078, p = .016-measures indicating the intervention may be of benefit. Pulse did not reach statistical significance. Analyses of variance for mindfulness, self-efficacy, and skills performance did not reach significance. Correlations conducted on measures indicated that as depression decreased, systolic and diastolic measures also decreased. As mindfulness increased, self-efficacy increased, and as self-efficacy increased, skills performance also increased. These results suggest that mindfulness may be of benefit as a method to decrease the risk for depression while contributing to increased self-efficacy and skills performance in a student nurse population. Although not all measures achieved statistical significance, the findings are encouraging for increasing feelings of confidence, leading to a more rewarding educational experience in nursing students

EFFECTIVENESS OF A BRIEF STRESS REDUCTION INTERVENTION FOR NURSING STUDENTS IN REDUCING PHYSIOLOGICAL STRESS INDICATORS AND IMPROVING WELL-BEING AND MENTAL HEALTH by Diane K. Leggett A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Health Promotion and Education The University of Utah December 2010 Copyright © Diane K. Leggett 2010 All Rights Reserved Th e Un i v e r s i t y o f Ut a h Gr a d u a t e S c h o o l STATEMENT OF DISSERTATION APPROVAL The dissertation of Diane K Leggett has been approved by the following supervisory committee members: Karol L. Kumpfer , Chair August 11, 2010 Date Approved Margaret F. Clayton , Co-Chair August 11, 2010 Date Approved John Richard Graham , Member August 11, 2010 Date Approved Keely Cofrin Allen , Member August 11, 2010 Date Approved Dale Maughan , Member August 11, 2010 Date Approved and by Glenn E. Richardson , Chair of the Department of Health Promotion and Education and by Charles A. Wight, Dean of The Graduate School. ABSTRACT Nursing students are faced with stress on a regular basis, which can impact physical and psychological functioning. Despite the identification of stress, anxiety, poor performance, and risk for depression, few studies identify measures to manage stress in a student nurse population. The purpose of this study was to examine the effectiveness of a brief mindfulness breathing intervention to decrease stress and ultimately the risk for depression while increasing self-efficacy with clinical skills performance in a 1st-year student nurse population. Participants were recruited from an associate degree nursing program at a northwestern university. Data gathered included demographic information, depression scores, physiological measures (i.e., blood pressure and pulse), self-efficacy scores, and skills performance scores. The design was a two-group (experimental and no-treatment control) true experimental randomized control trial with the following four repeated measures: (a) pretest, (b) posttest, (c) 2-month follow-up test, and (d) 4-month follow-up test. Data collection took place from November 2009 to March 2010. The sample (N = 85) was predominantly female (87.1%, n = 74) and Caucasian (89.4%, n = 86). Fifty-six of the participants were married and 46% of the participants identified themselves as parents of children still living at home. Analyses of variance demonstrated a greater mean decrease for the intervention group than for the treatment-as-usual group following the mindfulness breathing intervention for depression, F(1,82) = 6.864, p = .010; systolic, F(1,81) = 6.557, p = .012; and diastolic, F(1,81) = 6.078, p = .016-measures indicating the intervention may be of benefit. Pulse did not reach statistical significance. Analyses of variance for mindfulness, self-efficacy, and skills performance did not reach significance. Correlations conducted on measures indicated that as depression decreased, systolic and diastolic measures also decreased. As mindfulness increased, self-efficacy increased, and as self-efficacy increased, skills performance also increased. These results suggest that mindfulness may be of benefit as a method to decrease the risk for depression while contributing to increased self-efficacy and skills performance in a student nurse population. Although not all measures achieved statistical significance, the findings are encouraging for increasing feelings of confidence, leading to a more rewarding educational experience in nursing students. TABLE OF CONTENTS Page ABSTRACT ....................................................................................................................... iii LIST OF TABLES ........................................................................................................... viii CHAPTER 1. INTRODUCTION....................................................................................................1 Summary of Chapters ...............................................................................................2 Significance of the Study .........................................................................................3 Research Aims .........................................................................................................7 Participant Selection Criteria ...................................................................................8 Design ......................................................................................................................9 Research Questions and Hypotheses ......................................................................10 Limitations .............................................................................................................12 Delimitations ..........................................................................................................13 References ..............................................................................................................13 2. LITERATURE REVIEW .......................................................................................19 Stress and Response ...............................................................................................22 Stress and Learning ................................................................................................24 Stress and Self-Efficacy .........................................................................................25 Nursing Student Stressors ......................................................................................31 Stress, Self-Efficacy, and Interventions .................................................................32 Mindfulness............................................................................................................33 Mindfulness-Based Stress Reduction ....................................................................36 Mindfulness-Based Stress Reduction and Nursing Students .................................41 Summary ................................................................................................................43 References ..............................................................................................................44 3. EFFECTS OF MINDFULNESS BREATHING INTERVENTION ON STUDENT NURSES' STRESS AND RISK FOR DEPRESSION MAIN RESULTS..........................................................................53 Background ............................................................................................................53 vi Page Purpose ...................................................................................................................57 Research Questions and Hypotheses ......................................................................57 Methods..................................................................................................................58 Analyses and Results .............................................................................................67 Discussion ..............................................................................................................75 Limitations .............................................................................................................78 Recommendations ..................................................................................................79 Conclusion .............................................................................................................80 References ..............................................................................................................80 4. EFFECTS OF MINDFULNESS BREATHING ON MINDFULNESS, SELF-EFFICACY, AND SKILLS PERFORMANCE IN FIRST-YEAR STUDENT NURSES .....................................................................87 Purpose ...................................................................................................................89 Research Questions and Hypotheses ......................................................................89 Methods..................................................................................................................91 Data Analysis Procedures and Results ...................................................................95 Discussion ............................................................................................................105 Limitations ...........................................................................................................107 Recommendations ................................................................................................108 Conclusion ...........................................................................................................109 References ............................................................................................................109 5. SUMMARY AND CONCLUSIONS ..................................................................113 Research Questions ..............................................................................................113 Results ..................................................................................................................115 Study Limitations .................................................................................................118 Applications .........................................................................................................119 References ............................................................................................................121 APPENDICES A. CONSENT AND AUTHORIZATION ................................................................123 B. STUDENT CLINICAL COMPLETION APPRAISAL FORM ..........................127 C. DEMOGRAPHIC SURVEY ...............................................................................130 D. MINDFUL BREATHING SCRIPT .....................................................................133 vii Page E. DEBRIEFING SCRIPT .......................................................................................136 F. DAILY PRACTICE LOG AND PHYSIOLOGICAL MEASURES ...................138 LIST OF TABLES Table Page 3.1 Frequency and Percentage of Gender .....................................................................59 3.2 Frequency and Percentage of Race ........................................................................59 3.3 Frequency and Percentage of Marital Status ..........................................................59 3.4 Frequency and Percentage of Ages of Participant's Children Living at Home ..................................................................................................................60 3.5 Analyses of Variance on Depression Variable Across Four Repeated Measures by Group: Intervention Compared With Control ...................................69 3.6 Means and Standard Deviations on Center for Epidemiologic Studies Depression Scale Over Four Repeated Measures by Group: Intervention Compared With Control ....................................................................70 3.7 Analyses of Variance Results of Blood Pressure and Pulse Measures by Group: Intervention Compared With Control ........................................................71 3.8 Means and Standard Deviations on Research Variables by Group: Intervention Compared With Control ....................................................................73 3.9 T Tests on Physiological Measures by Depression ................................................75 4.1 Effects of Mindfulness Breathing on Mindfulness Attention Awareness Scale (Analyses of Variance by Group): Intervention Compared With Control by Four Repeated Measures ......................................................................97 4.2 Means and Standard Deviations on Research Variables by Group (Intervention Compared With Control): Mindfulness Attention Awareness Scale ....................................................................................................98 4.3 Analyses of Variance on Research Variables by Group: Intervention Compared With Control .........................................................................................99 ix Table Page 4.4 Means and Standard Deviations on Research Variables by Group (Intervention Compared With Control): Student Clinical Completion Appraisal Form ....................................................................................................101 4.5 Analyses of Variance on Research Variables by Group: Intervention Compared With Control .......................................................................................102 4.6 Means and Standard Deviations on Research Variables by Group: Intervention Compared With Control ..................................................................103 4.7 Pearson Correlations on Research Variables .......................................................104 CHAPTER 1 INTRODUCTION The purpose of this study was to investigate a brief stress reduction intervention as a method of decreasing stress and ultimately the risk for depression while increasing self-efficacy with clinical skill performance in a 1st-year student nurse population. Health care has been identified as an area of increased stress for workers (Geiger-Brown, Muntaner, & Trinkoff, 2004; Marine, Routsalainen, Serra, & Verbeek, 2009; Tveito & Eriksen, 2009) with higher expectations, increased demands, limited time, and decreased social support. These factors contribute to adverse psychological and physical symptoms, decreased work performance, absenteeism, and burnout. With the nursing profession contributing to the largest portion of providers, stress and its effects are an area of concern. Prior to practicing as a nurse, an individual must complete educational requirements and pass board examinations to obtain a license for practice. Stress can begin early in the profession during the educational process (Beddoe & Murphy, 2004; Evans & Kelly, 2004; Jones & Johnston, 1997; Watson et al., 2009; Young, Bruce, & Turner, 2001), with some students reporting decreased feelings of confidence and an ability to complete tasks (Evans & Kelly; Moscaritolo, 2009). This diminished confidence in ability can increase anxiety and stress, leading to a lack of confidence and, potentially, the risk for depression. Tasanapradit (2008) found that medical students were at a higher risk for depression, as measured by the Center for Epidemiologic Studies Depression Scale, from stress associated with demands of university training. Thus, learning stress management techniques as a student has the potential to contribute to improved student and professional outcomes. Although studies have been conducted relating to stressors, outcomes, and some interventions, this study addressed the lack of knowledge connecting stress management and self-efficacy in skills performance. Self-efficacy is defined as a personal belief in an ability to produce certain outcomes (Bandura, 1997; Janz, Champion, & Strecher, 2002), which is an important aspect for clinical skills. Bandura stated, "Students who have a low sense of efficacy to manage academic demands are especially vulnerable to achievement anxiety" (p. 235). The current study conducted a trial of a brief stress management intervention among 1st-year nursing students to decrease stress and the risk for depression while increasing mindfulness and self-efficacy. Summary of Chapters This dissertation followed a three-article format. The content for each of the chapters is outlined in the following paragraphs: Chapter 1 is an introduction and overview of the dissertation and research. A description and summary of each chapter are included. The significance, purpose, research procedures, and study limitations are introduced. Chapter 2 is the literature review, which is written as an article for publication. This review includes information on stress and its effects on the individual, stress reduction interventions, self-efficacy, and mindfulness. This information is discussed in relation to health professions and, more specifically, nurses and nursing students. Chapter 3 is a discussion of the main results of the brief mindfulness intervention 3 on improving a participant's risk for depression and physiological stress measures. This chapter is written as an article for publication. Chapter 4 includes secondary results of the study examining the effectiveness of the brief mindfulness intervention on improving mediators of actually improving the hypothesized mindfulness awareness, self-efficacy, and clinical skills performance. Correlations of mindfulness with other outcome measures are also examined. This chapter is written as an article for publication. Chapter 5 contains a discussion of the implications of the study results for including a brief mindfulness intervention when teaching clinical skills to 1st-year nursing students, including the limitations and recommendations for future research and practice. Significance of the Study Stress is defined as "a condition in which the person experiences changes in the normal, balanced state" (Berman, Snyder, Kozier, & Erb, 2008, p. 1061). Stress is an almost universal experience and can occur from both positive and negative experiences. The stress response leads to physiological changes in the body described as a fight or flight response (Berman et al.; Sapolsky, 2004; Smeltzer, Bare, Hinkle, & Cheever, 2007). These changes disrupt the normal functioning of systems in the body and result in an adaptation response to regain homeostasis or stability. Stress can be an actual physical threat or the thoughts of a possible threat. The anxiety produced from thoughts can become as damaging physically as an actual threat (Sapolsky). Small amounts of stress assist individuals to maintain an alert state of mind that increases attention and learning, but prolonged exposure to stress can lead to decreased functioning and a decline in health both mentally and physically (Berman et al.; Sapolsky; Smeltzer et al.). Research has 4 demonstrated that individuals with chronic stress have more depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale depression instrument (Mortimer et al., 2005; Tasanapradit, 2008). Diminished feelings of well-being can lead to an increase in the risk for depression with a decrease in learning and positive feelings of accomplishment. This downward trend can increase anxiety, contributing to further negative emotions (Anisman & Zacharko, 1982; Dolan, 2002; Kendler, Hettema, Butera, Gardner, & Prescott, 2003; Kendler, Karkowski, & Prescott, 1999; Paykel et al., 1969). Practicing Nurses The work environment is frequently a source of stress with workplace relations, physical demands, and mental demands. Nursing has been identified as an occupation with high stress levels from increasing patient acuity, extended work hours with varying time schedules, and daily exposure to illness, pain, and loss (Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2004; Fukuda, Ichinose, Kusama, Anndow, & Akiyoshi, 2008; Golbasi, Kelleci, & Dogan, 2008; McVicar, 2003; Watson et al., 2009). These factors increase the risk for chronic stress, emotional exhaustion, and burnout (Cohen- Katz et al.; Salovey, Rothman, Detweiler, & Steward, 2000; Sapolsky, 2004). Student Nurses Not only is the profession of nursing stressful but the journey to obtain a license to practice as a nurse has been identified as a high source of stress (Beck & Srivastava, 1991; Billingsley, Collins, & Miller, 2007; Jones & Johnston, 1997). Nursing students face many challenges during their educational process due to clinical placement, a theory-practice gap, and the nurse-student relationship (referred to as being the most stressful; 5 Beck & Srivastava; Billingsley et al.; Jones & Johnston; Levett-Jones, Lathlean, Higgins, & McMillan, 2009). Increased stress decreases learning and can lead to errors (Welker- Hood, 2006) with a resulting decline in a belief of capabilities to perform procedures. Bandura (1997) stated, "If people believe they have no power to produce results, they will not attempt to make things happen" (p. 3). This point is important, considering that much of the work of nursing students is based on performance and that the stressors previously listed relate to clinical performance. Maciejewski, Prigerson, and Mazure (2000) found that increased self-efficacy decreased the effects of stressful events in a probability sample of individuals over the age of 25. Manojlovich (2005) found that personal self-efficacy had a strong relationship with practice behaviors. Stress, feelings of inadequacy from lack of knowledge, and limited positive reinforcement from mentor nurses can contribute to diminished self-efficacy. All of these factors can lead to emotional burnout and increased risk of depression during the educational process (Cohen-Katz et al., 2004; Mackenzie, Poulin, & Seidman-Carlson, 2006). Stress and Interventions In order to enhance the learning environment and prevent adverse effects of stress, measures should be instituted early in the educational process. A variety of interventions have demonstrated the ability to manage educationally related stress and related symptoms (Brunero, Cowan, & Fairbrother, 2008; Jain et al., 2007; Jones & Johnston, 2000; Marine et al., 2009; Moscaritolo, 2009; Stephens, 1992). Few studies exist that examine the use of mindfulness in a student nurse population. The current study examined the use of mindfulness breathing to increase feelings of self-efficacy in the performance of skills in the clinical area and to increase feelings of well-being. Mindfulness is easily learned (Allen, Blashki, & Gullone, 2006), it decreases negative 6 responses such as fear or apprehension (Arch & Craske, 2006), and it positively affects well-being while decreasing tension, anxiety, and stress (Brown & Ryan, 2003). Meta-analytic reviews by Baer (2003) and Grossman, Nieman, Schmidt, and Walach (2004) found moderate effect sizes when averaged for studies investigating the usefulness of mindfulness as an intervention. Brown, Ryan, and Creswell (2007) examined findings in recent randomized clinical trials and found positive results for mental and physical health through the use of mindfulness. Studies have examined the use of mindfulness as an intervention to reduce stress in the health-care population, focusing mainly on practicing nurses, graduate nurses, or medical students (Cohen-Katz et al., 2005; Jain et al.; Mackenzie et al., 2006; O'Haver-Day & Horton-Deutsh, 2004; Shapiro, Astin, Bishop, & Cordova, 2005; Tsai & Crockett, 1993; Young et al., 2001). One study examined the use of mindfulness as a stress management technique. Beddoe and Murphy (2004) tested a convenience sample of baccalaureate nursing students for changes in stress and empathy following an 8-week course of mindfulness based on stress reduction training. The results demonstrated decreased stress, as measured by the Derogatis Stress Profile, and increased empathy, as measured by the Interpersonal Reactivity Index. The students also completed a posttest questionnaire that was used to correlate attitude and behavior changes. No studies were found that linked mindfulness breathing to self-efficacy and clinical skills. Hence, the current study was the first randomized control trial to examine the effect of a brief mindfulness breathing intervention to reduce clinical practice stress and depression and improvements in clinical skills in 1st-year nursing students. In addition, the hypothesized mediators of increased mindfulness and increased self-efficacy were also measured. 7 Research Aims The purpose of this study was to develop and test a brief intervention to reduce stress, feelings of inadequacy, and risk for depression by increasing self-efficacy associated with critical nursing skills and, thereby, improve skills performance in 1st-year nursing students. In order to achieve this goal, the following three aims were proposed: 1. Aim 1, to determine the immediate and 4-month longitudinal effectiveness of a brief intervention for stress management to increase mindfulness, increase self-efficacy, decrease feelings of inadequacy leading to a risk for depression, and improve clinical skill performance with 1st-year nursing students 2. Aim 2, to determine the association of mindfulness to physiological measures of stress (i.e., blood pressure and pulse), increase self-efficacy, emotional well-being or risk of depression, and clinical performance in a sample of 1st-year nursing students 3. Aim 3, to determine if students at higher risk for depression, as measured by the Center for Epidemiologic Studies Depression Scale (Radloff, 1977) scores of 16 or greater, have considerable improvements in mindfulness, self-efficacy, and physiological measures of stress (i.e., blood pressure and pulse) than lower-risk students at baseline. An additional, longer-term goal of this study was to include stress reduction modules in the regular curriculum at the university should this study demonstrate their effectiveness. Publications and presentations at conferences will help to disseminate the results to other university nursing programs. 8 Participant Selection Criteria Participants in this study were recruited from 120, 1st-year nursing students enrolled in 1 of 12 fall classes known as Foundations of Nursing Practice Clinical. Participants were 2-year associate degree nursing students. The students were in their 1st year of the nursing program. The participants were both men (15%) and women (85%), with ages ranging from 19 to 50 years. None of the students was below the age of 19 years. The ethnicity of the participants was approximately 90% Caucasian. Age 19 was selected as the cutoff for inclusion because the youngest age of students enrolled in the Foundations of Nursing Practice Clinical classes was listed as 19, which allowed all students the opportunity to participate. Inclusion criteria included all students enrolled in 1 of the 12 Foundations of Nursing Practice Clinical classes who had voluntarily signed consent forms to participate in the research (see Appendix A). Exclusion criteria included any enrolled students who did not sign the consent forms to participate in the research or who did not complete the Foundations of Nursing Practice Clinical class and dropped out of the study. Design The design was a two-group (experimental and no-treatment control) true experimental randomized control trial design with the following four repeated measures: (a) pretest, (b) posttest, (c) 2-month follow-up test, and (d) 4-month follow-up test. The no-treatment control group was a treatment-as-usual group that received the psychological measurements (i.e., blood pressure and pulse) and the regular Foundations of Nursing Practice Clinical class but received no brief mindfulness stress management treatment modules. The 12 Foundations of Nursing Practice Clinical classes were randomly assigned in order to receive the brief stress intervention or the no-treatment 9 intervention in the regular Foundations of Nursing Practice Clinical classes. Because all students in the 12 Foundations of Nursing Practice Clinical classes received the treatment group or the control group, the effective sample size was 12 classes. Because of the nesting effects, statistical methods to control for this interdependency were conducted in the data analysis using hierarchical linear modeling. Research Questions and Hypotheses Research questions and hypotheses guided the study. Research Question 1 Compared with the no-treatment group, is there a decrease in depression scores after participating in the brief stress reduction intervention as measured by the Center for Epidemiologic Studies Depression Scale (Radloff, 1977)? Hypothesis 1 It was hypothesized that the mean decrease and effect sizes for the depression scores in the treatment group would be larger than the treatment-as-usual group. Research Question 2 Compared with the no-treatment control group, are the participants' physiological measures of stress (i.e., blood pressure and pulse) lower at later measurements than at baseline following participation in the mindfulness breathing? 10 Hypothesis 2 It was hypothesized that the mean decrease in effect sizes for the physiological measures of stress (i.e., blood pressure and pulse) scores in the treatment group would be larger than the treatment-as-usual group. Research Question 3 Is there greater improvement in higher-risk students for relative risk of depression, as determined by the Center for Epidemiologic Studies Depression Scale (Radloff, 1977) scores of 16 or greater, in measures of stress, as determined by physiological measures of blood pressure and pulse, than lower-risk students at baseline? Hypothesis 3 It was hypothesized that the higher-risk students for depression at baseline would have larger improvements in outcomes. Research Question 4 Compared with the no-treatment control group, is there an increase in mindfulness scores for the brief stress reduction intervention participants after completing the mindfulness breathing as measured by the Mindfulness Attention Awareness Scale (Brown & Ryan, 2003)? Hypothesis 4 It was hypothesized that the mean increase and effect sizes for the mindfulness scores in the treatment group would be higher than the treatment-as-usual group. 11 Research Question 5 Compared with the no-treatment control group, is there an increase in self-efficacy after completing the mindfulness breathing stress reduction intervention as measured by the Student Clinical Completion Appraisal form (see Appendix B)? Hypothesis 5 It was hypothesized that the mean increase in effect sizes for the self-efficacy scores in the treatment group would be higher than the treatment-as-usual group. Research Question 6 Compared with the no-treatment control group, is there an increase in clinical performance skills following participation in the mindfulness breathing as demonstrated by individual performance grading sheets? Hypothesis 6 It was hypothesized that the mean increase and effect sizes for the clinical performance skills scores in the treatment group would be higher than the treatment-as-usual group. The null hypothesis to be tested for all of these hypotheses is that there will be no difference between the treatment and control groups in the outcome measure of interest in the research question and hypothesis. Limitations Limitations of this study reflect possible threats to internal validity. For example, 12 stress management was discussed in the classroom setting with all of the students several times during the semester, which may have led to a change in behavior not related to the intervention in both the control and treatment-as-usual groups. The questionnaires were administered five times over a 4-month span, which could have led to familiarity with the measures that may have had an effect on the results. For those students nested in classes within a school, the selection of participants presented the greatest challenge. Students were randomized by groups or classes according to clinical instructors. Statistical control was managed by using hierarchical linear modeling for analysis, which allows for a multilevel analysis (Bickel, 2007; Osborne, 2000). Another limitation was that the study could not be conducted until after approval by the Institutional Review Board of the University of Utah, which delayed the intervention until the end of the clinical skills class. Delimitations Because a true experimental design was used, threats to internal validity should be controlled; however, there could have been threats to external validity of the results such as generalization or fidelity to the curriculum. The sample for this study consisted of a group of nursing students located in a university in northern Utah. 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Part 1: Description and empirical support for mindfulness-based interventions. Archives of Psychiatric Nursing, 18(5), 164-169. Osborne, J. W. (2000). Advantages of hierarchical linear modeling. Practical Assessment, Research, & Evaluation, 7(1). Retrieved August 16, 2009, from http://PAREonline.net/getvn.asp?v=7&n=1 Paykel, E. S., Myers, J. K., Dienelt, M. N., Klerman, G. L., Lindenthal, J. J., & Pepper, M. P. (1969). Life events and depression: A controlled study. Archives of General Psychiatry, 21, 753-760. Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385-401. Salovey, P., Rothman, A. J., Detweiler, J. B., & Steward, W. T. (2000). Emotional states and physical health. American Psychologist, 55(1), 110-121. Sapolsky, R. M. (2004). Why zebras don't get ulcers (3rd ed.). New York: Henry Holt and Company. Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress reduction for health-care professionals: Results from a randomized trial. International Journal of Stress Management, 12, 164-176. Smeltzer, S., Bare, B., Hinkle, J. L., & Cheever, K. H. (2007). Brunner and Suddarth's textbook of medical-surgical nursing (11th ed.). Baltimore, MD: Lippincott, Williams & Wilkins. Stephens, R. (1992). Imagery: A treatment for nursing student anxiety. Journal of Nursing Education, 31(7), 314-320. Tasanapradit, Q. D. D. P. (2008). Depression and stress among the first-year medical students in University of Medicine and Pharmacy, Hochiminh City, Vietnam. Journal of Health Research, 22(Suppl.), 1-4. Tsai, S., & Crockett, M. S. (1993). Effects of relaxation training: Combining imagery and meditation on the stress level of Chinese nurses working in modern hospitals in Taiwan. Issues in Mental Health Nursing, 14, 51-66. 17 Tveito, T. H., & Eriksen, H. R. (2009). Integrated health program: A workplace randomized controlled trial. Journal of Advanced Nursing, 65(1), 110-119. Watson, R., Gardiner, E., Hogston, R., Stimpson, A., Wrate, R., & Deary, I. (2009). A longitudinal study of stress and psychological distress in nurses and nursing students. Journal of Clinical Nursing, 18(2), 270-278. Welker-Hood, K. (2006). Does workplace stress lead to accident or error? American Journal of Nursing, 106(9), 104. Young, L. E., Bruce, A., & Turner, L. (2001). Evaluation of a mindfulness-based stress reduction intervention. Canadian Nurse, 97(6), 23-26. CHAPTER 2 LITERATURE REVIEW Stress, a common occurrence in daily living for the majority of people, has been defined as "a condition in which the person experiences changes in the normal, balanced state" (Berman, Snyder, Kozier, & Erb, 2008, p. 1061), identified as homeostasis. Psychological or emotional homeostasis is referred to as mental well-being. Psychological homeostasis is maintained through feelings of love, security, self-esteem, and positive interactions with others (Berman et al.). An alteration in the physiological or psychological environment perceived as a threat is termed stress. The change in homeostasis from stress leads to what has been identified as a stress response (Berman et al.; Sapolsky, 2004; Smeltzer, Bare, Hinkle, & Cheever, 2007) and initiates physiological changes in the body described as the fight or flight response. Interestingly, psychological disruptions have the capacity to elicit the same response in the body as a physical stressor (Sapolsky). An example of a psychological change affecting homeostasis would be the individual receiving news of a job loss. Thoughts of fear or anger may arise that in turn begin the physiological responses of the fight or flight reaction. The response to regain homeostasis can be more difficult to control unless the individual is able to manage thought processes. "The stress response can become more damaging than the stressor itself, especially when the stress is purely psychological" (Sapolsky, p. 13). Stress can lead to negative emotional states that "are thought to be associated with unhealthy patterns of psychological functioning" (Salovey, Rothman, Detweiler, & 21 Steward, 2000, p. 110) and has been suggested as a contributing factor in physical ailments, emotional and mental disturbances, and altered social interactions (Berman et al., 2008; Pelletier, 2000; Smeltzer et al., 2007). These changes can lead to declines in overall feelings of well-being. Health-care professions are vulnerable to stress and the related conditions from high demands in caring for others with limited time, personnel, and increased acuity. Anxiety, exhaustion, depression, and decreases in immune function are some of the documented results of stress in this population (Beck & Srivastava, 1991; Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2004; Fukuda, Ichinose, Kusama, Anndow, & Akiyoshi, 2008; Geiger-Brown, Muntaner, & Trinkoff, 2004; McVicar, 2003; Peterson et al., 2008; Salovey et al.; Tveito & Eriksen, 2009; Watson et al., 2009). The educational process itself can be a source of stress as individuals proceed through multiple levels of learning. Life events as well as academic pressures contribute to stress, affecting the emotional well-being of students. A report by the American College Health Association (2008) identified 50% of students reporting higher than usual to tremendous stress affecting academic performance. Jones and Johnston (1997) found higher stress levels in nursing students than in other college students across the 4-year program of study. Higher stress levels have implications for students in nursing programs that will last 2 to 4 years since stress longer than 6 months is termed chronic stress, putting the nursing student population at higher risk for anxiety and depressive symptoms (Finlay-Jones & Brown, 1981; Kessler, 1997; Paykel et al., 1969). Skills are an important part of the health-care learning environment, with competency at an acceptable level expected prior to performing in the clinical setting. Learning and performance are enhanced with increased feelings of self-efficacy (Bandura, 1977, 2001). Unfortunately, self-efficacy is eroded with stress and anxiety that can impede learning and performance. Studies examining the effects of stress on learning 22 have documented decreased retention of material and limited recall that have implications for professions depending on skill proficiency in the workplace (Anderson et al., 2004; Beddoe & Murphy, 2004; Hains et al., 2009; Locken & Norberg, 2005; McVicar, 2003; Moscaritolo, 2009; Palumbo et al., 2007; Tanaka, Takehara, & Yamaguichi, 2006). Limited studies document the effects of stress on self-efficacy in this population and the connection among stress, learning, and self-efficacy. Addressing stress to limit negative effects is an important aspect to improve learning, skills performance, and feelings of well-being. An examination of methods utilized for stress reduction in health-care professionals, nurses, and student nurses includes cognitive therapy, mindfulness training, cognitive-behavioral therapy with relaxation, and mindfulness-based stress reduction. Mindfulness and mindfulness-based stress reduction have become more prevalent in recent years with the introduction of a mindfulness-based stress reduction program in a university setting (University of Massachusetts Worcester Campus Center for Mindfulness, n.d.). Studies linking mindfulness and wellness have documented benefits with regular practice (Allen, Blashki, & Gullone, 2006; Astin, 1997; Baer, 2003; Brown & Ryan, 2003; Brown, Ryan, & Creswell, 2007; Grossman, Nieman, Schmidt, & Walach, 2004; Kabat-Zinn, 2003; Poulin, Mackenzie, Soloway, & Karayolas, 2008; Shapiro, Oman, Thoresen, Plante, & Flinders, 2008). With origins in Eastern philosophy and meditation practices, mindfulness assists individuals to focus attention on them and their immediate surroundings. Mindfulness is also believed to contribute to memory recall, self-actualization, and healthy living (Hirst, 2003). In addition, mindfulness is easily adopted, increases attentiveness, and decreases stress (Allen et al., 2006; Brown & Ryan, 2003). The incorporation of mindfulness into a program identified as reducing stress holds promise for those impacted by increasing 23 stress levels. Stress and Response Stress and the accompanying response involve the whole body, which has the potential to create more damage than the actual stressor. Sapolsky (2004) discussed the negative effects of stress on hormone production, cardiovascular health, metabolic and gastrointestinal changes, immunity, pain, sleep, memory, and aging. The stress response elicits release of energy in the form of glucose, simple proteins, and fats. Heart rate, respirations, and blood pressure increase to deliver energy sources throughout the body, but minor systems such as digestion, growth, tissue repair, and reproduction slow down. A negative effect of continued exposure to the stress response is suppression of the immune system and increased risk of disease (Beck & Srivastava, 1991; Nelson, Lust, Stiry, & Ehlinger, 2008; Smeltzer et al., 2007). A review of literature by Salovey et al. (2000) demonstrated a decrease in immunity, mood, and feelings of health with an increase in respiratory illness from stress across a variety of populations. Research has demonstrated a link among stress, disease, mental health, and decreased feelings of wellness (Geiger-Brown et al., 2004; Näslindh-Ylipanagar, Sihvonen, Sarna, & Kekki, 2008; Nelson et al., 2008; Smeltzer et al., 2007). Näslindh- Ylipanagar et al. found increased health complaints among men with higher levels of stress and anxiety. These men also suffered from insomnia and feelings of depression. Nelson et al. demonstrated an association between stress and adverse health changes among college students. Stressors faced during the educational experience contribute to higher levels of physical and psychological health complaints as measured by self-report measures and immune system measures (American College Health Association, 2008; Tasanapradit, 2008; Whitehouse et al., 1996). An increased risk of physical or 24 psychological illness, as measured by the General Health Questionnaire, was found among nursing students with the highest stress levels (Beck & Srivastava, 1991). Watson et al. (2009) concluded that life events and stress "contributed significantly to psychological distress" (p. 270) in nursing students and new nurses, which may lead to higher levels of work-related illnesses and attrition. Psychological distress that is not addressed can lead to depression and decreased involvement in life experiences (Anisman & Zacharko, 1982; Kessler, 1997; Paykel, 1978; Paykel et al., 1969). Stress and Learning Learning and academic performance are also negatively affected by increased stress (Beddoe & Murphy, 2004; Evans & Kelly, 2004; Locken & Norberg, 2005; Meisenhelder, 1987; Moscaritolo, 2009), which has implications in the health-care learning environment. Hormones released during the stress response contribute to memory impairment, disruption in learning, and depression (Sapolsky, 2004). Studies have shown physical and chemical changes in the area of the brain associated with learning and memory in both mice and humans exposed to stress that decrease memory recall and learning (Anderson et al., 2004; Burriss, Ayers, Ginsberg, & Powell, 2008; Hains et al., 2009; Palumbo et al., 2007). Another study identified higher levels of depression, anxiety, and memory impairment in health-care workers with greater work-related stress that contributed to disengagement, exhaustion, and burnout (Peterson et al., 2008). Health-care employees, specifically nurses, face multiple stressors that include limited personnel to manage patient care, long hours with fluctuating shifts, acute needs of patients, and managing the unexpected. Tvieto and Eriksen (2009) found that most of the sick leave in Norway was for health-care workers. Stress can build in individuals, 25 leading to exhaustion, psychological distress, burnout, and exodus from the stressor that, in the case of nurses, is the job (Watson et al., 2009). An examination of nurses and nursing students by Watson et al. found high levels of stress, as measured by a brief life events inventory and a work-stress inventory. The General Health Questionnaire provided information for psychological health related to anxiety, insomnia, social dysfunction, and depression. Results indicated that increased stress levels contributed to higher scores on somatic symptoms, including depression. McVicar (2003) identified increased levels of stress in the nursing profession leading to emotional exhaustion. The health-care environment is also facing a shortage of nurses from multiple factors that include stress (American Association of Colleges of Nursing, 2008; Buerhaus et al., 2007). Stress begins early in the nursing career as a nursing student. Jones and Johnston (2000) found higher levels of stress in 1st-year nursing students when compared with medical students or the general female population, which "may carry a risk to the affective well-being of the student" (p. 481). Moscaritolo (2009) stated, "When students cannot manage stress, the normal line of defense is broken and anxiety results" (p. 19). The physical and mental health of nursing students is at risk with continued exposure to stress-producing situations. Beck and Srivastava (1991) found stress levels to be consistently high for all levels of nursing education, with the presence of psychiatric symptoms higher than the general population. Feelings of frustration, discouragement, and inadequacy were voiced by students, with greater than 50% of them reporting increased stress levels with their choice of nursing as a career. Stress and Self-Efficacy Negative emotions and the cycle of frustration, stress, and decreased learning contribute to the erosion of confidence to produce positive outcomes. This loss of 26 confidence affects the self-efficacy of students, decreasing the desire to continue trying and further increasing vulnerability to anxiety (Bandura, 1997). Bandura (1989) stated, "It requires a strong sense of efficacy to remain task oriented in the face of . . . failures" (p. 1176). Self-efficacy is a personal belief or confidence in the ability to produce an outcome. Bandura (1997) believed self-efficacy to be central to choice of actions by individuals, stating, "If people believe they have no power to produce results, they will not attempt to make things happen" (p. 3). Students want to succeed and feel satisfaction with their educational goals, which decreases when self-efficacy is diminished. The concept of self-efficacy as an aspect of behavioral change was first addressed by Bandura (1977) and has continued to evolve. Bandura (1997) believed that many factors contribute to an individual's ability to function within society but also believed that self-efficacy is foundational. He stated, "Beliefs of personal efficacy constitute the key factor of human agency" (p. 3). As a foundation, self-efficacy guides actions for desired outcomes even in the face of adverse conditions or situations. Self-efficacy beliefs are derived from the following four sources: (a) mastery experience, (b) vicarious experience, (c) verbal persuasion, and (d) physiological status (Bandura, 1997). Mastery experience is believed to be the most influential component of self-efficacy by providing genuine evidence of perseverance to succeed. Throughout life, individuals face multiple experiences that require a certain level of performance. Simple things such as an infant learning to sit unassisted, hold items, or walk provide opportunities for achievement. Positive experiences give impetus to continue trying whereas negative outcomes reduce the belief in self and the possibility for achievement. "After people become convinced that they have what it takes to succeed, they persevere in the face of adversity and quickly rebound from setbacks" (Bandura, 1997, p. 80). Factors such as previous successes or failures, level of difficulty, or amount of 27 effort an individual is willing to put forth contribute to the building of self-efficacy through experiences. Learning new skills, performance requirements, limited practice time, and the need to transfer theory knowledge to the clinical situation create stress in the nursing student. Success in achieving goals will increase feelings of efficacy in the student, but students often believe there is a gap in knowledge needed that leads to decreased feelings of success (Beck & Srivastava, 1991; Evans & Kelly, 2004; Jones & Johnston, 1997). Vicarious experiences, another source of acquiring self-efficacy, are provided through observation. Referred to as modeling (Bandura, 1997), individuals observe the actions of others that succeed or fail in a variety of activities. These observations provide a guide from which to determine personal capabilities. Bandura observed that "the greater the assumed similarity, the more persuasive are the models' successes and failures" (p. 87). Because an individual's environment is not static, multiple opportunities for the observation of modeling occur on a regular basis, which can increase self-efficacy. Modeling others is not the only method available; self-modeling is also effective for increasing efficacy. "Seeing oneself perform successfully can enhance proficiency in at least two ways: it provides clear information on how to best perform skills, and it strengthens beliefs in one's capabilities" (Bandura, p. 94). For the nursing student, multiple opportunities to self-model exist, but this follows the observance of instructors and the nurse's performance. The student then attempts to achieve the skill level of the seasoned professional and finds the performance to fall below the observed skill. This belief of diminished performance can contribute to decreased feelings of self-efficacy. A third method of increasing individual self-efficacy is through verbal persuasion. Individuals encouraged by other individuals of importance to them can increase feelings of efficacy if the encouragement is realistic. During the performance of skills or tasks, 28 positive feedback on the ability of an individual to succeed can enhance the feelings of efficacy while increasing efforts and competence. "Perceived self-efficacy contributes to performance accomplishments over and above the effects of skill development" (Bandura, 1997, p. 102). It is important to note that false praise or encouragement can actually have a negative effect on self-efficacy. Whereas verbal persuasion is useful in building self-efficacy, Bandura noted that "it is more difficult to instill enduringly high beliefs of personal efficacy" (p. 104) through verbal persuasion than it is to decrease feelings of efficacy. Instructors and nurses acting as mentors will give encouragement and praise to the nursing student, but students do not always believe that the encouragement is realistic. There are occasions when those over the student are stern and give little or no praise, which decreases feelings of adequacy and self-efficacy. The last method of increasing self-efficacy examines an individual's physical and mental state. In a balanced state, physiological indicators such as pulse and respiration are within individual average parameters, but when faced with a situation requiring new or stressful skills performance, these indicators increase in rate. An individual with lower feelings of self-efficacy and the stressful physiological response may "generate further stress through anticipatory self-arousal" (Bandura, 1997, p. 106). This response can lead to even greater distress and further declines in beliefs of ability. Change in physical status can be attributed to other conditions and individual differences in response, but it is important to note as it may affect feelings of efficacy. As noted earlier, the mental state or thoughts of an individual can affect the physiological state, and it can also contribute to increasing or decreasing self-efficacy. An individual with positive memories and emotions from prior experiences is more likely to attempt a new skill than one with negative memories and emotions. The same can be said of an individual's psychological 29 state, with positive moods increasing and negative moods decreasing efficacy (Bandura). College students and nursing students list decreased time and increased stress as a contributor to a decline in health status, which may affect feelings of efficacy (Beck & Srivastava, 1991; Billingsley, Collins, & Miller, 2007; Evans & Kelly, 2004; Nelson et al., 2008). Each of these methods contributes to an individual's feelings of self-efficacy at various stages of life, with occurrences or events, social situations, and a variety of environments. Bandura (1989) believed that people's beliefs about abilities were central to the choice of action to achieve a desired outcome, stating: "People devise ways of adapting flexibly to remarkably diverse geographic, climatic, and social environments . . . to realize desired outcomes" (Bandura, 2001, p. 22). College is a time in life in which choices made can affect outcomes on an individual's life for an extended period of time. During this time, a career choice is made with the decision to apply oneself to learning. Students with increased self-efficacy have been shown to achieve better outcomes (Bandura, 1997). This point is significant to consider when examining the loss of confidence with feelings of inadequacy experienced by nursing students early in the educational process (Beck & Srivastava, 1991; Billingsley et al., 2007; Evans & Kelly, 2004; Jones & Johnston, 2000). Self-efficacy has been compared with self-esteem, but it is important to note that self-efficacy and self-esteem are not the same. Self-efficacy is a belief in personal capabilities, and self-esteem is a judgment of self-worth (Bandura, 1997; Lawrance & McLeroy, 1986). The daily tasks of nurses and student nurses involve the performance of skills and confident decision making in the care of others. A strong sense of self-efficacy is needed for confidence and should be developed during training (Dory & Beaulieu, 2009). Education, training, and practice will improve confidence of an individual moving 30 through the role of a student to that of an employee. Golbasi, Kelleci, and Dogan (2008) found a strong correlation to job satisfaction and self-confidence, which has implications for the nursing workforce and students entering the profession. Nursing Student Stressors Students across all levels of nursing education frequently list as a stressor the gap between theory and practice when entering the clinical area (Beddoe & Murphy, 2004; Billingsley et al., 2007; Evans & Kelly, 2004; Moscaritolo, 2009), which contributes to doubts with regard to the choice to pursue nursing education. The nursing student enters the clinical facility armed with classroom knowledge and skills practiced on mannequins but quickly learns that more knowledge and practice are needed. This knowledge contributes to the stress of establishing a satisfactory learning relationship with the assigned staff nurse, which is another area of concern listed by students (Levett-Jones, Lathlean, Higgins, & McMillan, 2009). Other areas listed as stressors for students include fear of failure or mistakes, questioning one's ability to perform or complete tasks, rapidly changing circumstances, finances, lack of personal time, and lack of timely feedback from instructors (Billingsley et al.; Jones & Johnston, 1997, 2000; Levett-Jones et al.; Locken & Norberg, 2005; Moscaritolo; Stephens, 1992; Watson et al., 2009). Another concern is the negative effect of stress and anxiety on learning and performance of nursing students. Hughes (2005) stated, "Stress contributes to anxiety, which can in turn interfere with students' academic performance" (p. 22). Skills and task performance at an acceptable level for patient care are required prior to and during clinical situations. It has been demonstrated that nursing students experiencing stress have impaired learning as well as impaired performance (Beddoe & Murphy; Locken & Norberg; Stephens). Being 31 impaired creates a cycle of frustration, increasing stress, and further declines in learning capabilities. Evans and Kelly found that 45% of the nursing student population studied had a decrease in self-image and 54% expressed a loss of confidence. A concern for the student nurse population is the risk for depression from decreased self-image and loss of confidence (Kendler, Hettema, Butera, Gardner, & Prescott, 2003). Stress, Self-Efficacy, and Interventions Acknowledging and addressing stress early in the nursing profession while providing methods for management will contribute to increased job satisfaction. The relationship among stress, learning, academic performance, and self-efficacy should be addressed in the beginning of nursing education to give students tools to use throughout the following years and into the working environment. Interventions that have demonstrated positive effects on decreasing stress, anxiety, and health-related complaints and increasing coping include cognitive therapy (Brunero, Cowan, & Fairbrother, 2008), mindfulness training (Cohen-Katz et al., 2005; Mackenzie, Poulin, & Seidman-Carlson, 2006; Moscaritolo, 2009), and cognitive-behavioral training with relaxation (Jones & Johnston, 2000; Norvell, Belles, Brody, & Freund, 1987; Yung, Fung, Chan, & Lau, 2004). An examination of the effectiveness of each method demonstrated a combination of cognitive-behavioral training and relaxation to be the most effective in reducing stress (Marine, Routsalainen, Serra, & Verbeek, 2009). Yung et al. were able to account for 53% of the changes in the participants' scores to be attributable to the relaxation intervention. A 1-day stress management program using cognitive-behavioral training decreased stress and improved nurses' mental attitude at work (Brunero et al.). The program consisted of one 8-hour workshop and self-directed learning to reinforce the intervention. 32 Mindfulness A method that has demonstrated positive outcomes on physical and mental health is mindfulness or mindfulness meditation. Mindfulness is identified as paying attention on purpose to the current situation or present moment (Allen et al., 2006; Bhikkhu, 1997; Brown & Ryan, 2003; Brown et al., 2007; Gunaratana, 1990; Kabat-Zinn, 1994; Moore, 2008) and is cultivated by following the breath as it moves in and out. Attention and awareness are considered a part of everyday existence, but mindfulness can assist individuals to decrease the amount of automatic thoughts, reactions, and behaviors that occur throughout each day. "Because mindfulness permits an immediacy of direct contact with events as they occur, . . . consciousness takes on a clarity and freshness that permits more flexible . . . responses" (Brown et al., p. 212). Gunaratana explained, "Mindfulness is mirror-thought. It reflects only what is presently happening and in exactly the way it is happening. There are no biases" (p. 83). Mindfulness has been shown to increase positive feelings and "enduring shifts in the processing of negative emotion under stress" (Kabat-Zinn, 2003, p. 147). In a study of young adults in a community setting, McKee, Zvolensky, Solomon, Bernstein, and Leen- Feldner (2007) found higher anxiety scores with lower mindfulness scores; they also found those with lower anxiety scores had higher mindfulness scores, indicating positive outcomes with mindfulness. These findings indicate that mindfulness can help an individual gain control of his or her thoughts, which can lead to increasing stress. An examination of mindfulness by Brown and Ryan (2003) found those practicing mindfulness reported more feelings of well-being and positive emotional states, with a decrease in tension, anxiety, depression, fatigue, and stress. An inverse relationship was also found with depression (as measured with the Center for Epidemiologic Studies Depression Scale and Beck Depression Inventory), anxiety (as measured with the State- 33 Trait Anxiety Inventory and Profile of Moods States), and physical health (as measured with a subjective and objective self-report). Grossman et al. (2004) found that "improvements were consistently seen across a spectrum of standardized mental health measures including psychological dimensions of quality of life scales, depression, anxiety, coping style, and other affective dimensions of disability" (p. 40). Throughout the course of a day, there are constant events around each individual. The changes in scenery, weather, conversations, and even thoughts occur on a regular basis without much notice until a nonroutine occurrence brings attention to the individual. This inattention is termed mindlessness, which "is linked to all those habitual behaviors performed without attention" (Hirst, 2003, p. 362). Mindfulness training assists individuals in paying attention to circumstances as they occur, to develop a clear awareness of each moment. Mindfulness is "often associated with the formal practice of mindfulness meditation. Mindfulness, however, is more than meditation" (Shapiro, Carlson, Astin, & Freedman, 2006, p. 374); it is awareness. Becoming aware of thoughts, reactions, and emotions allows individuals to consciously pay attention to each moment of each experience with greater comprehension, which often results in a shift of perspective. Focusing attention during a task can decrease preoccupation with other thoughts, assisting in the successful completion of the task, and can guide to more effective goal attainment (Brown et al., 2007). When a stressful situation arises, mindfulness provides a method to see circumstances as they really are without overriding emotional attachments, leading to a more calm approach for the situation (Gunaratana, 1990). This adaptation was demonstrated in a study by Arch and Craske (2006) using a brief, focused breathing exercise adapted from a mindfulness course with college students prior to viewing negative or aversive picture slides. Students utilizing focused breathing reported lower negative emotional responses than the control group. 34 The positive effects of mindfulness indicate that it is an intervention with potential for individuals faced with chronic stress such as nurses and nursing students. The use of mindfulness interventions demonstrated a decrease in habitual thought, increased attention and awareness, and decreased overall stress in a psychiatric nursing practice (O'Haver-Day & Horton-Deutsh, 2004), which has implications for increasing attention and learning in nursing students. Ott (2004) found mindfulness meditation to decrease stress and contribute to a feeling of inner calmness with both formal and informal practice. A 1-month study comparing relaxation and mindfulness meditation in a group of medical and nursing students found the following: "Comparison of effect sizes indicates that mindfulness and relaxation are similar with respect to reducing distress; however, mindfulness appears to be more effective in enhancing positive states of mind" (Jain et al., 2007, p. 20). In a review of mindfulness-based studies, Brown et al. (2007) found that "empirical research to date supports the role of mindfulness in well-being" (p. 220), with a reduction in stress symptoms, better task performance, more effective goal attainment, and greater optimism. A study conducted with nurses and human services professionals demonstrated "that mindfulness-based interventions offer a unique opportunity for participants to reduce the effects of stress in their lives and improve their well-being" (Poulin et al., 2008, p. 78). This point is important to consider, with increasing stress levels resulting in decreased performance, more use of sick leave, and employees choosing to leave the job. Interventions that can contribute to decreasing attrition while improving personal health should be examined. A randomized controlled study by Shapiro et al. (2008) with undergraduate college students demonstrated a decrease in stress with mindfulness practice and increased well-being. An interesting note from the study is the low dropout rate of only 3 from the 47 participants at the 2-month follow-up. This finding suggests 35 that the intervention was beneficial enough for participants to continue the practice. When utilized by nursing students, mindfulness has been able to decrease stress and anxiety while increasing empathy and learning (Beddoe & Murphy, 2004; Billingsley et al., 2007; Moscaritolo, 2009). Mindfulness-Based Stress Reduction Another method that has demonstrated positive outcomes is mindfulness-based stress reduction. A comparative study examining the use of cognitive-behavioral stress reduction and mindfulness-based stress reduction found that participants in the mindfulness-based stress reduction group had better outcomes on all measures (Smith et al., 2008). Mindfulness-based stress reduction is a program incorporating mindfulness meditation, yoga, discussions, instruction, and daily practice. The program was introduced in 1979 at the University of Massachusetts to assist individuals in dealing with stress, pain, and illness (University of Massachusetts Worcester Campus Center for Mindfulness, n.d.). The basic program consists of once weekly meetings for 8 weeks in 2- to 2.5-hour sessions, with 1 week including an all-day session. Participants are expected to practice at least 6 days during the week for 45 minutes outside of the classroom (Astin, 1997; Beddoe & Murphy, 2004; Brown & Ryan, 2003). The program has been revised and adapted for a variety of situations, but the mindfulness component remains the same. Early studies following introduction of the program demonstrated positive effects on individuals in reducing symptoms from a variety of medical conditions such as cancer and heart disease and in decreasing pain and stress (Kabat-Zinn, 1992). A review of literature by Baer (2003) found mindfulness-based stress reduction to be effective in relieving pain, alleviating anxiety and depression, reducing symptoms in individuals with fibromyalgia or psoriasis, and achieving significant reductions in depression with cancer 36 patients. A calculation of effect sizes "suggests that mindfulness-based interventions have yielded at least medium-sized effects, with some effect sizes falling within the large range" (p. 135). Baer stated, "Although the current empirical literature includes many methodological flaws, findings suggest that mindfulness-based interventions may be helpful in the treatment of several disorders" (p. 125). Later studies have verified the association among mindfulness, a decrease in psychological distress, and reported medical symptoms with increased feelings of wellness (Koerbel & Zucker, 2007; Matchim, Armer, & Stewart, 2008; Nyklícek & Kuijpers, 2008; Shapiro et al., 2008). Although positive results with chronic conditions indicate the usefulness of mindfulness-based stress reduction as part of the treatment regimen, a review of five research articles by Koerbel and Zucker (2007) found weaknesses with small sample sizes and high attrition. "Attrition rates of the studies may reflect the fact that MBSR [mindfulness-based stress reduction] is not a program that appeals to everyone" (Koerbel & Zucker, p. 273). The program requires a commitment of time, willingness to be attentive, and dedication to continue the practice. Education with regard to the involvement and examination of methods utilizing shorter time frames while maintaining consistency prior to initiation into a program may assist in decreasing attrition rates. Despite weaknesses in the studies, "MBSR [mindfulness-based stress reduction] . . . continues to provide researchers with a body of knowledge that makes it a legitimate health behavior intervention" (Koerbel & Zucker, p. 274). The use of mindfulness-based stress reduction has been found to be useful in decreasing stress and anxiety, inducing relaxation, and improving quality of life for participants (Astin, 1997; Baer, 2003; Beddoe & Murphy, 2004; Carmody & Baer, 2008; Carmody, Reed, Kristeller, & Merriam, 2008; Poulin et al., 2008; Young, Bruce, & Turner, 2001). Participants in a qualitative study examining the usefulness of 37 mindfulness-based stress reduction for the treatment of depression described the use of breathing techniques as beneficial during stressful situations. Practice logs demonstrated a link between the amount of practice documented during the week and the amount of positive change present (Mason & Hargreaves, 2001). A randomized study of cancer patients using an abbreviated form of mindfulness-based stress reduction provided "evidence that a relatively brief mindfulness meditation-based stress reduction program can effectively reduce mood disturbance, fatigue, and a broad spectrum of stress-related symptoms in cancer patients" (Speca, Carlson, Goodey, & Angen, 2000, p. 619). Obtaining positive results with shorter sessions is encouraging for those investigating the use of a mindfulness-based stress reduction program but are deterred by time requirements. The utilization of shorter sessions also has implications for retention when conducting interventions with a variety of individuals. Regardless of the time involved in learning the practice itself, it is believed that anyone undertaking mindfulness-based stress reduction should be committed to the development of mindfulness on a regular basis. Kabat-Zinn (2003) stated, "It takes a personal commitment and perseverance in formal practice gradually to establish a degree of stability in one's capacity to attend, especially to stressful or aversive objects, including emotional turbulence" (p. 150). Brown and Ryan (2003), in a study of mindfulness-based stress reduction with 58 cancer patients (90-minute sessions once a week and a one-time longer session for 2 to 3 hours), were also able to produce positive results with shorter sessions. The results indicated that participants were able to achieve mindfulness in the shorter time frame, and those with higher mindfulness scores had lower levels of distress, tension, and mood disturbances. Results of early studies with mindfulness-based stress reduction found a more rapid clearing of psoriasis in those practicing mindfulness than in those not practicing an improved immune function and a decrease in a prostate cancer indicator (Kabat-Zinn). 38 It is believed that the process of mindfulness induces relaxation, which may contribute to positive effects in a variety of settings (Baer, 2003). The effects of relaxation have been termed the relaxation response that "results in generalized decreased sympathetic nervous system activity" (Beary & Benson, 1974, p. 118; Wallace, Benson, & Wilson, 1971). This response results in a decreased respiratory rate, oxygen consumption, and muscle tone. This response could also be of benefit for individuals suffering with stress and related symptoms. Shapiro, Schwartz, and Bonner (1998) were able to decrease stress in medical and premedical students with the introduction of mindfulness-based stress reduction, and a group of health-care professionals were able to decrease stress and demonstrate greater self-compassion with the use of mindfulness-based stress reduction (Shapiro, Astin, Bishop, & Cordova, 2005). Stress has also been indicated as a causative factor in heart disease. Robert-McComb, Tacon, Randolph, and Caldera (2004) demonstrated a decrease in breathing patterns and cortisol levels with individuals practicing mindfulness-based stress reduction when compared with the control group. A meta-analysis of 10 studies demonstrated that "although derived from a relatively small number of studies, these results suggest that MBSR [mindfulness-based stress reduction] may help a broad range of individuals to cope with their clinical and nonclinical problems" (Grossman et al., 2004, p. 35). Mindfulness-Based Stress Reduction and Nursing Students Young et al. (2001) examined the use of the traditional 8-week session of mindfulness-based stress reduction with 30, 3rd-year nursing students by employing a quasi-experimental pretest and posttest design. Both the control group and the intervention group completed the Health Status Profile scale, with only 15 students in the 39 intervention group attending the mindfulness-based stress reduction sessions. The scale was completed by both groups at the conclusion of an 8-week training session. Despite the small sample size, "The MBSR [mindfulness-based stress reduction] intervention produced small to moderate effect sizes for health-related effects, sense of coherence, and physical symptoms. Psychological symptoms had by far the greatest decrease" (pp. 25- 26). During focus group discussions, at which time the focus group leaders were able to gain information with regard to the student's perception of the program and satisfaction with the intervention, qualitative findings were obtained from students in the intervention group. Students found the intervention to be of benefit in achieving balance in their lives and recommended the course be incorporated into the nursing curriculum. As discussed previously, nursing students face many stressors throughout their training. Stress not only affects learning, self-efficacy, and achievement but it can also affect the responses of students to individuals assigned to their care while in training. Moscaritolo (2009) conducted a literature review examining a variety of methods to improve the learning environment for nursing students, concluding, "The literature indicates that mindfulness training is an effective interventional strategy to decrease anxiety among undergraduate nursing students" (p. 22). A group of baccalaureate nursing students (N = 16) introduced to an 8-week session of mindfulness-based stress reduction in a nonexperimental design with a no-comparison group were able to decrease anxiety and stress levels, as measured by the Derogatis Stress Profile. They showed no statistically significant changes in empathy scores, as measured by the Interpersonal Reactivity Index (Beddoe & Murphy, 2004). Beddoe and Murphy believed the limited change in empathy scores was due to the profession attracting those with greater empathy; thus, pretest empathy scores were already elevated. Even with higher pretest empathy scores, a decrease in anxiety and 40 stress will have long-term benefits for empathy by allowing student nurses or nurses to focus on the individual in their care rather than on personal distress. Of interest is that none of these studies with nursing students measured actual changes in mindfulness awareness and increased self-efficacy, which are hypothesized mediators of the reductions in stress and anxiety or the nursing students' improvements in clinical skills if they have a brief mindfulness intervention. The ability to decrease anxiety and stress in the nursing profession should also contribute to retention in the workplace. The continued exposure to stress, anxiety, and feelings of inadequacy and the resulting physiological and psychological responses lead to exhaustion and eventual burnout. The use of mindfulness-based stress reduction can decrease these symptoms and improve personal and professional outcomes (Cohen-Katz et al., 2005; Mackenzie et al., 2006). Summary Stress is an inevitable part of life and is encountered on a regular basis throughout a normal day. Something as simple as finding shoes or deciding what to have for a meal can create stress. Stress can occur from both positive and negative influences. Some stress enhances an individual's alertness, assisting in learning and the completion of tasks (Berman et al., 2008; Smeltzer et al., 2007). Concern arises with continued exposure to stress and the accompanying responses that disrupt the balance of an individual physically, psychologically, and emotionally. A brief description of these effects has been demonstrated in this literature review. This literature review explored the connection among stress, learning, self-efficacy, and mindfulness-based stress reduction. Positive outcomes included increased attentiveness and positive attitudes and decreased psychological and physical symptoms 41 of stress. This intervention can address the needs of those in the health-care learning environment, specifically student nurses. Providing tools for this population will contribute to job satisfaction and retention for the profession. With projected shortages of nurses to work in health care, methods to maintain nurses are important. To date, studies have focused on the traditional 8-week course, but few have examined the effects of decreased training time. No recorded studies exist that examine the effects on self-efficacy with a reduction in stress on student nurses and learning. The current study addressed the links among stress, learning, self-efficacy mitigation, and risk for depression with an abbreviated version of the mindfulness-based stress reduction intervention program among undergraduate nursing students. References Allen, N. B., Blashki, G., & Gullone, E. (2006). Mindfulness-based psychotherapies: A review of conceptual foundations, empirical evidence, and practical considerations. Australian and New Zealand Journal of Psychiatry, 40, 285-294. American Association of Colleges of Nursing. (2008, September 29). Nursing shortage fact sheet. 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CHAPTER 3 EFFECTS OF MINDFULNESS BREATHING INTERVENTION ON STUDENT NURSES' STRESS AND RISK FOR DEPRESSION MAIN RESULTS Background Stress is a part of daily life with deadlines, relationships, or even disruptions in routine. Stress has been defined as "a condition in which the person experiences changes in the normal, balanced state" (Berman, Snyder, Kozier, & Erb, 2008, p. 1061), referred to as homeostasis. This alteration can occur from an overload or stressor in either the physical or psychological environment that is perceived as a threat. The change in homeostasis from stress leads to what has been identified as a stress response (Berman et al.; Sapolsky, 2004; Smeltzer, Bare, Hinkle, & Cheever, 2007), and it initiates physiological changes in the body described as the fight or flight response. Interestingly, psychological disruptions have the capacity to elicit the same response in the body as a physical stressor (Sapolsky). The response to regain homeostasis can be more difficult to control unless the individual is able to manage thought processes, or "the stress-response can become more damaging than the stressor itself, especially when the stress is purely psychological" (Sapolsky, p. 13). Prolonged exposure to stress can lead to declining emotional states that "are thought to be associated with unhealthy patterns of psychological functioning" (Salovey, Rothman, Detweiler, & Steward, 2000, p. 110), and it has been suggested as a contributing factor in both physical and mental health (Berman et al., 2008; Pelletier, 2000; Smeltzer et al., 2007). The impact from the unhealthy pattern of functioning can result in decreased feelings of well-being and risk for depression. Health-care professions are vulnerable to stress and the related conditions from high demands in caring for others with limited time, personnel, and increased acuity. Anxiety, exhaustion, depression, and decreases in immune function are some of the documented results of stress in this population (Beck & Srivastava, 1991; Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2004; Fukuda, Ichinose, Kusama, Anndow, & Akiyoshi, 2008; Geiger-Brown, Muntaner, & Trinkoff, 2004; McVicar, 2003; Peterson et al., 2008; Salovey et al.; Tveito & Eriksen, 2009; Watson, Gardiner, Hogston, Stimpson, Wrate, & Deary, 2009). The educational process for employment in health care can be a source of stress as individuals proceed through multiple levels of learning. Life events as well as academic pressures contribute to stress, affecting the emotional well-being of students. A report by the American College Health Association (2008) identified 50% of students reporting higher than usual to maximum stress affecting academic performance. Jones and Johnston (1997) found higher stress levels in nursing students than other college students across the 4-year program of study. These findings have implications for students in nursing programs that will last 2 to 4 years since stress longer than 6 months is termed chronic stress. This type of stress puts the nursing student population at higher risk for anxiety and depressive symptoms (Finlay-Jones & Brown, 1981; Kessler, 1997; Paykel et al., 1969). An examination of nurses and nursing students by Watson et al. (2009) found high levels of stress, as measured by a brief life-events inventory and a work-stress inventory. The General Health Questionnaire provided information for psychological health related 55 to anxiety, insomnia, social dysfunction, and depression. Results indicated that increased stress levels contributed to higher scores on somatic symptoms, including depression. Another study identified higher levels of depression, anxiety, and memory impairment in health-care workers with greater work-related stress that contributed to disengagement, exhaustion, and burnout (Peterson et al., 2008). Psychological distress that is not addressed can lead to depression and decreased involvement in life experiences (Anisman & Zacharko, 1982; Kessler, 1997; Paykel, 1978; Paykel et al., 1969). Learning and self-efficacy are other areas affected by increased stress and anxiety in the student nurse population. Moscaritolo (2009) stated, "When students cannot manage stress, the normal line of defense is broken and anxiety results" (p. 19). The physical and mental health of the nursing student is at risk with continued exposure to stress-producing situations. Negative emotions and the cycle of frustration, stress, and decreased learning contribute to the erosion of confidence to produce positive outcomes. This loss of confidence affects the self-efficacy of the student, decreasing the desire to continue trying and further increasing vulnerability to anxiety (Bandura, 1997). Bandura (1989) stated, "It requires a strong sense of efficacy to remain task oriented in the face of . . . failures" (p. 1176). Students want to succeed and feel satisfaction with their educational goals, which decreases when self-efficacy is diminished (Bandura, 1997, 2001). Studies examining the effects of stress on learning have documented decreased retention of material and limited recall, which has implications for the student nurse population (Anderson et al., 2004; Beddoe & Murphy, 2004; Hains et al., 2009; Locken & Norberg, 2005; McVicar, 2003; Moscaritolo, 2009; Palumbo et al., 2007; Tanaka, Takehara, & Yamaguichi, 2006). Students across all levels of nursing education frequently list as a stressor the gap between theory and practice when entering the clinical 56 area (Beddoe & Murphy; Billingsley, Collins, & Miller, 2007; Evans & Kelly, 2004; Moscaritolo), which contributes to doubts with regard to the choice to pursue nursing education. Other areas listed as stressors for students include fear of failure or mistakes, questioning of ability to perform or complete tasks, rapidly changing circumstances, finances, lack of personal time, and lack of timely feedback from instructors (Billingsley et al.; Jones & Johnston, 1997, 2000; Levett-Jones, Lathlean, Higgins, & McMillan, 2009; Locken & Norberg; Moscaritolo; Stephens, 1992; Watson et al., 2009). Limited studies exist that document the effects of the connection among stress, learning, and depressive symptoms. Interventions that have demonstrated positive effects on decreasing stress, anxiety, and health-related complaints and on increasing coping include cognitive therapy (Brunero, Cowan, & Fairbrother, 2008), mindfulness training (Cohen-Katz et al., 2005; Mackenzie, Poulin, & Seidman-Carlson, 2006; Moscaritolo, 2009), cognitive-behavioral training with relaxation (Jones & Johnston, 2000; Norvell, Belles, Brody, & Freund, 1987; Yung, Fung, Chan, & Lau, 2004), and mindfulness- based stress reduction (Smith et al., 2008). The current study examined the benefits of a brief mindfulness-based stress reduction in a group of 1st-year nursing students. Purpose The purpose of this study was to determine the effectiveness of a brief mindfulness breathing intervention in reducing stress and the risk for depression in 1st-year nursing students by measuring depression scores and physiological measures (i.e., blood pressure and pulse). 57 Research Questions and Hypotheses Research questions and hypotheses guided the study. Research Question 1 Compared with the no-treatment group, is there a decrease in depression scores after participating in the brief stress reduction intervention as measured by the Center for Epidemiologic Studies Depression Scale (Radloff, 1977)? Hypothesis 1 It was hypothesized that the mean decrease and effect sizes for the depression scores in the treatment group would be larger than the treatment-as-usual group. Research Question 2 Compared with the no-treatment control group, are the participants' physiological measures of stress (i.e., blood pressure and pulse) lower at later measurements than at baseline following participation in the mindfulness breathing? Hypothesis 2 It was hypothesized that the mean decrease in effect sizes for the physiological measures of stress (i.e., blood pressure and pulse) scores in the treatment group would be larger than the treatment-as-usual group. Research Question 3 Is there greater improvement in higher-risk students for relative risk of depression, 58 as determined by the Center for Epidemiologic Studies Depression Scale (Radloff, 1977) scores of 16 or greater, in measures of stress, as determined by physiological measures of blood pressure and pulse, than lower-risk students at baseline? Hypothesis 3 It was hypothesized that the higher-risk students for depression at baseline would have larger improvements in outcomes. Methods Sample The research sample consisted of 11 males and 74 females, ranging in age from 19 to 45 years, and they were 89.4% Caucasian. Demographics are illustrated in Tables 3.1, 3.2, 3.3, and 3.4. Participants in this study were recruited from 120 nursing students enrolled in 1 of 12 fall clinical classes in a course at a northwest university referred to as Table 3.1 Frequency and Percentage of Gender Gender Frequency % Male 11 12.9 Female 74 87.1 Total 85 100.0 59 Table 3.2 Frequency and Percentage of Race Race Frequency % African American 1 1.2 Asian or Pacific Islander 3 3.5 Caucasian 76 89.4 Hispanic/Latino 3 3.5 Other 2 2.4 Total 85 100.0 Table 3.3 Frequency and Percentage of Marital Status Marital status Frequency % Married 48 56.5 Single 32 37.6 Divorced 4 4.7 Widowed 1 1.2 Total 85 100.0 60 Table 3.4 Frequency and Percentage of Ages of Participants' Children Living at Home Ages of children Frequency % None 55 54.5 0 to 5 years old 23 22.8 6 to 12 years old 10 9.9 13 to 18 years old 9 8.9 19 to 25 years old 4 4.0 Total 101 100.0 Foundations of Nursing Practice Clinical. The study commenced during the 11th week of a 15-week semester. Following approval from the Institutional Review Board of the University of Utah, I visited each clinical class,introduced the research, answered questions, and gave each student a consent to participate form (see Appendix A), which was to be returned the following week. From this sampling, 90 students returned the signed consent form. Five students were unable to complete the exercises and requested to withdraw from the study within the 1st week. The participants were 2-year associate degree nursing students in the 1st year of the nursing program. The inclusion criteria included all students enrolled in the 12 courses who voluntarily gave written consent to participate in the research (see Appendix A). The exclusion criteria included any enrolled student who did not sign the consent forms or those who did not complete the course and dropped out of the study. Design The current study included both descriptive and experimental components. 61 Descriptive measures included a Demographic Survey (see Appendix C) completed with the first set of questionnaires and a program evaluation completed with the final set of questionnaires. The independent variable in this study was a brief mindfulness breathing intervention taught by the primary investigator (6 classes) during clinical education laboratory times or treatment as usual of no intervention (6 classes). Dependent variables included physiological measures (i.e., blood pressure and pulse) and depression (Center for Epidemiologic Studies Depression Scale; Radloff, 1977). A two-group (i.e., experimental and no-treatment control) randomized control trial design with four repeated measures (i.e., pretest, posttest, 2-month follow-up test, and 4- month follow-up test) was utilized to determine the effects of the independent variable on the dependent variables (i.e., blood pressure, pulse, and Center for Epidemiologic Studies Depression Scale). All students in the study participated in the Foundations of Nursing Practice Clinical course (i.e., 12 classes), but only the intervention classes received the intervention of mindfulness breathing. The no-treatment control classes did not receive the brief mindfulness breathing treatment modules. All classes completed the pretest, posttest, 2-month follow-up test, and 4-month follow-up test. The 12 classes were randomly assigned to the treatment intervention or treatment-as- usual group using a number chart of generated random numbers. Students in the 6 treatment classes (n = 42) received the mindfulness breathing intervention and the remaining 6 classes (n = 43) were the no-treatment of no mindfulness breathing intervention in the regular Foundations of Nursing Practice Clinical course. Procedures Following Institutional Review Board approval from the University of Utah and the participating university, the 12 classes were randomized into groups by assigning each 62 class a number and then using a number chart of computer-generated random numbers. During a clinical laboratory education session, I approached students enrolled in the clinical classes. The students were informed about the research study and given opportunities to ask questions. Those students in the intervention classes also received information with regard to the mindfulness breathing sessions. Students agreeing to participate in the research were given a consent form (see Appendix A), with 1 week to complete and return the signed document. The following week the completed consent forms were collected. The control classes completed the Demographic Survey (see Appendix C), Center for Epidemiologic Studies Depression Scale (Radloff, 1977), Mindfulness Attention Awareness Scale (Brown & Ryan, 2003), and Student Clinical Completion Appraisal form (see Appendix B), and they had physiological measures taken following collection of the consent forms. For the intervention participants, prior to the first session of the intervention, each participant completed the Demographic Survey, Center for Epidemiologic Studies Depression Scale, Mindfulness Attention Awareness Scale, Student Clinical Completion Appraisal form, and each participant had physiological measures taken. The physiological measures and measurement tools were completed again posttest, 2 months follow-up, and 4 months follow-up for all participants. Instruments The instruments selected for this study were the following: (a) Center for Epidemiologic Studies Depression Scale (Radloff, 1977) and (b) physiological measures. All measures were administered pretest, posttest, 2-month follow-up test, and 4-month follow-up test for both the intervention and control groups. 63 Center for Epidemiologic Studies Depression Scale. The Center for Epidemiologic Studies Depression Scale is a self-report measure developed by Radloff (1977) to assess the intensity of "depressive symptomatology" (p. 385) in the general population. The scale was developed as a method of measuring an individual's current level of depression symptoms with an emphasis on emotions and mood. The Center for Epidemiologic Studies Depression Scale consists of 20 items that make up the following four subscales: (a) depressed affect, (b) positive affect, (c) somatic symptoms, and (d) interpersonal. The total scale has a high internal consistency, producing a coefficient alpha of .80 or above in previous studies (Golden et al., 2008; U.S. Department of Health & Human Services, 1985). The Center for Epidemiologic Studies Depression Scale has been proven useful in surveys of general populations to measure depression symptoms (Beekman et al., 1997; Mortimer et al., 2005; Radloff). Concurrent validity for measures of depressive symptoms ranges from .30 to .80 when compared with similar instruments (Caracciolo & Giaquinto, 2002; Radloff; U.S. Department of Health & Human Services). Scoring ranges from 0 to 60, with each of the 20 items having a low value of 0 to a high value of 3. Scores of greater than 16 have been recommended as a cutoff point for determining mild depression (Comstock & Hesling, 1976; Golden et al., 2008; Pandya, Metz, & Patten, 2005; Schein & Koenig, 1997; Weissman & Locke, 1983). Other studies have found variances in the general populations and gender differences, recommending scores of 17 up to 23 as a cutoff for determining mild depression (Ferketich, Schwartzbaum, Frid, & Moeschberger, 2000; Husani, Neff, Harrington, Hughes, & Stone, 1990; Roberts & Vernon, 1983). As a self-report measure, it is important to note that the Center for Epidemiologic Studies Depression Scale measures an individual's response to situations that have occurred over the previous week and may be affected by events such as illness. The Center for Epidemiologic Studies Depression Scale assesses self-reported 64 depressive symptoms, but it is not diagnostic of depression (Golden et al.; Pandya et al.); only a diagnostic evaluation can determine depression. Physiological measures (i.e., blood pressure and pulse). Physiological measures were taken using standardized equipment and procedures. Blood pressure and pulse measurements are a quick method of determining individual status and have been used by health-care providers as a first step in an assessment (Berman et al., 2008; Curran, n.d.; Smeltzer et al., 2007). Factors affecting a blood pressure reading include state of mind (i.e., stress and anxiety increase blood pressure), time of day (i.e., usually lower in the morning), gender (i.e., females from puberty to menopause are generally lower than males), and proper cuff size. A blood pressure cuff that is too small or too large will produce false high or low readings. Another factor that may influence the reading when repeated measures are taken is the choice of arms, as readings can differ from arm to arm (Berman et al.; Smeltzer et al.). To ensure an accurate reading in the participants, the cuff was measured for each participant for a width that was 40% of the arm circumference and was placed with the bladder of the cuff over the artery of the selected arm 1 to 2 inches above the antecubital space. The Microlife Blood Pressure Monitor was used for this assessment. The individual was seated with feet flat on the floor, arm resting on lap with elbow slightly flexed, palm facing up, and forearm at heart level. The deflated cuff was wrapped around the forearm (right or left depending on individual preference) and secured with the Velcro attachment. The individual was instructed to sit still until the measurement was completed as the start button was pushed. If a repeated measure was needed, a wait of 1 to 2 minutes between readings was instituted to ensure accuracy of the measurement (Berman et al., 2008). The monitor displayed both the blood pressure and the pulse. Recording of the blood pressure and pulse included the arm used to ensure consistency in 65 follow-up measurements. No elevated readings of greater than or equal to 160/100 (U.S. Preventive Services Task Force, 2004) were noted in this sample. Elevated readings would have been noted with instructions to contact the personal health-care provider for follow-up. The Microlife Blood Pressure Monitor was calibrated and tested at the factory with results on file and available upon request. The monitor was rated as high accuracy by the American Heart Association (Microlife Corporation, n.d.). An evaluation of blood pressure monitoring devices comparing mercury sphygmomanometers and automatic devices indicated that their use eliminated observer bias and were useful for blood pressure measurements (Buchanan, 2009). Intervention. Materials for the brief mindfulness breathing intervention were developed into a standardized curriculum, with the content adapted from evidence-based mindfulness breathing courses designed and tested by Bhikkhu (1997), Gunaratana (1990), and Kabat-Zinn (1992, 1994, 2006). The script for the mindfulness breathing intervention (see Appendix D) was reviewed by a trained mindfulness breathing facilitator prior to use. In order to maintain consistency, I conducted all sessions for the intervention groups. Participants in the intervention classes were instructed on a brief mindfulness breathing intervention for 3 consecutive weeks following enrollment. Week 1 participants were introduced to mindfulness breathing, mindfulness history, and uses for mindfulness breathing. Students were allowed to ask questions for clarifications at this time. Students were requested to make themselves comfortable, after which the mindfulness breathing script was followed to guide the participants through the breathing experience (see Appendix D). At the conclusion of the breathing script, students were guided through a debriefing exercise following a script to maintain consistency in each group. Debriefing 66 following the breathing exercise provided an opportunity for the participants to examine feelings and possible applications for the mindfulness breathing in clinical practice, school work, and daily life. The session lasted approximately 1 hour, 30 minutes. At the conclusion of the session, students were given a compact disc containing the mindfulness breathing script (see Appendix D) and instructed to continue daily practice at home. Students were also told to include any music with the compact disc that would help them to focus on breathing, if they desired. The intervention session was repeated at Week 2 and Week 3, using the mindfulness breathing script (see Appendix D) and the debriefing script (see Appendix E). Students were given color-coded weekly practice logs (see Appendix F) at the first session in order to record days of practice during the week, which they were instructed to return by Week 5. The daily practice logs (see Appendix F) were gathered at Week 5 with the data collection. Students in the intervention groups were asked to refrain from discussing mindfulness breathing with students other than those in their clinical group during the next 4 months so as to prevent a possible change in behavior in the control participants. Analyses and Results Because of nesting effects, statistical analysis was conducted using hierarchical linear modeling. Despite the random assignment of the groups for this study, students within a group tend to be more alike due to similar experiences as well as having the same clinical instructor. This tendency towards homogeneity in the group leads to a higher incidence of a Type I error (Bickel, 2007; Osborne, 2000). Hierarchical linear modeling provides a method to more accurately model the effects of the variable on the outcomes and addresses independence issues in the sample population. Missing data were determined to be missing completely at random, with pairwise deletion used for analysis. 67 Depression Outcomes Research Question 1 examined whether differences exist on depression by group (intervention compared with control), as measured by the Center for Epidemiologic Studies Depression Scale (Radloff, 1977), while participants are nested in teachers. The hierarchical linear mixed model analyses of variance demonstrated an increasing difference between groups, reaching a significance level by posttest (see Tables 3.5 and 3.6). Means and standard deviations for the depression measure demonstrated a downward trend for the intervention group; in contrast, the control group had an increase at 2-month follow-up and 4-month follow-up. Physiological Stress Measures: Blood Pressure and Pulse Research Question 3 examined whether differences exist on the participants' physiological measures of stress (i.e., blood pressure and pulse) by group (intervention compared with control) while participants are nested in teachers. The hierarchical linear mixed model analyses of variance reached statistical significance for systolic and diastolic measures by posttest but not for pulse (see Table 3.7). Interestingly, pulse did not demonstrate the same trend as did the blood pressure measures. The means and standard deviations demonstrated a greater decrease of physiological measures in the intervention group (see Table 3.8). 68 Table 3.5 Analyses of Variance on Depression Variable Across Four Repeated Measures by Group: Intervention Compared With Control CES-D (research variables) df F Sig. Cohen's d Pretest Between group 1 .623 .432 0.17 Within group 83 Total 84 Posttest Between group 1 3.056 .084 0.39 Within group 82 Total 83 2-month follow-up test Between group 1 3.643 .060 0.42 Within group 83 Total 84 4-month follow-up test Between group 1 6.864 .010** 0.58 Within group 82 Total 83 Note. CES-D = Center for Epidemiologic Studies Depression Scale. **Statistically significant between-group outcomes at the p < .01 alpha level. 69 Table 3.6 Means and Standard Deviations on Center for Epidemiologic Studies Depression Scale Over Four Repeated Measures by Group: Intervention Compared With Control Intervention (n = 42