Guided Reflection and Deep Breathing to Reduce Stress and Anxiety During Clinical: A Pilot Study

Background: Stress among college students is a growing concern. Studies report a higher psychological distress rate among students in the Health Sciences than general population college students. Additionally, there is a growing body of evidence demonstrating college students enrolled in majors which include a clinical component, as is the case with Nursing, are at risk for increased stress and anxiety (Xuhua He, Turnbull, Kirshbaum, Phillips, & Klainin-Yobas, 2018). General population students report stressors including financial, support systems, adjusting to new environments, developing relationships away from home, making decisions without parental input, academics, and interpersonal circumstance, to name a few. Adult learners also name work, life and academic juggling of responsibilities as major stressors (Cheng-Hoo & Hsiang-Chu, 2015; Xuhua He et al., 2018). Health Sciences students have added stressors related to clinical performance, clinical placement, harming patients and clinical faculty (Xuhua He et al., 2018). Specifically, studies have shown nursing student stress is directly related to a perceived lack of professional skills and knowledge (Hsiang-Chu, 2015). Stress has been shown to negatively affect student’s performance as well as their health and wellbeing. If left unchecked, stress will cause students to drop out of nursing programs or out of the nursing profession within the first few years of practice (Cheng-Hoo & Hsiang-Chu, 2015).

It is not realistic to think we can remove these stressors from student’s academic or private lives, as is not realistic to think we can remove stressors from the nursing profession. The aim should be to teach students how to deal with stress. Teaching students the strategies needed to flourish in nursing school will hopefully result in healthier, more competent nurses, decreased turnover and better retention, especially during the first few years of practice.

In order for stress reducing techniques to be effective, they need to be embedded into the nursing curriculum. Students need to be taught about these techniques and be allowed to practice them (Cheng-Hoo & Hsiang-Chu, 2015; Hsiang-Chu, 2015; Huber & Pence, 2018). Deep breathing was chosen as one of the techniques for this pilot due to its known positive effects on stress. Deep breathing can reduce sympathetic fight-or-flight responses. This reduces stress and anxiety, therefore improving motor abilities and allowing for improved academic performance (Perciavalle et al., 2017). The use of deep breathing techniques has also been shown to improve stress in daily life. Students will ideally continue to use this technique in their daily lives once they become proficient at using it in their professional lives.

Much of nursing education is based on experiences. Experiences are described as being composed of 2 different but interwoven phenomena, apprehension and comprehension. Apprehension occurs when the student is participating in the actual experience, while comprehension happens outside the experience, at a later time; both are needed in order for learning to take place (Hsiang-Chu, 2016). Guided reflection provides the means for comprehension of the clinical events. This clinical pilot chose guided reflection as the second technique in hopes of helping students process clinical events. This will allow for learning to take place, therefore reducing the perceived lack of professional skills and knowledge and consequently reducing stress. Mindfulness, as well as guided reflection, have shown to greatly reduce stress in nurses, leading us to believe this will also be a technique students will opt to adopt long-term (Hsiang-Chu, 2015; Van der Riet, Levett-Jones, & Aquino-Russell, 2018)

Purpose: This pilot study had two purposes, first we sought to examine if nursing students felt a reduction in stress and anxiety when deep-breathing and guided reflection techniques were taught and implemented during clinical. Furthermore, the pilot sought to examine if students felt these techniques were worth adopting into their nursing practice long term.

Setting and Participants: A convenience sample of nursing students was used for this pilot. The sample consisted of two different clinical groups; one group had seven students the other had eight students. All students were level 2 Master of Science for Entry to the Profession of Nursing (MEPN) at a large university. This was their first Medical-Surgical clinical experience. Students were placed in general Medical-Surgical units.They cared for one patient at the beginning of the rotation. By the end of the rotation most students were caring for three patients. The rotation consisted of 18 days divided into two, 12-hour days per week. A different faculty member taught each clinical group, both faculty members are full time in the MEPN program at this University. The groups attended clinical at different local hospitals. One hospital is a private, nonprofit 487-bed acute care hospital, and the city’s only Level-I trauma center. The other is a locally governed, 641-bed nonprofit, regional hospital, and the city’s only comprehensive stroke center.

Methods: Students were given the first week of clinical to adjust to their surroundings and complete their orientation activities. During post-conference on the first day of the second week of clinical, students were presented with a PowerPoint explaining the purpose of the pilot. The PowerPoint also addressed the need for stress reduction and the importance of learning and practicing stress reduction techniques not just while in nursing school but also once entering the profession. How stress affects nursing students, nursing and nursing retention was discussed. The PowerPoint described the two different techniques used for the pilot and how implementation will occur. The techniques used for this pilot were: guided reflection, and deep breathing.

Guided reflection was implemented 12 of 18 clinical days during post conference in the form of a five-minute reflection; students were asked to reflect using two questions given to them by the faculty. The same questions were used each day. Relaxation music was played during the reflection time, and students were encouraged to get comfortable. Students chose whether to reflect in writing or not.

Deep breathing was implemented throughout the clinical day in the form of a finger tap on the instructor’s name badge. The faculty member used the tap to remind the student to take a deep breath; the student used the tap to signal the faculty they needed a moment to take a deep breath in order to collect themselves.

Once the PowerPoint presentation was complete, students were allowed plenty of time to ask questions and voice concerns. During this time, students were assured their participation was voluntary and in no way tied to their clinical performance. In order to guarantee consistency in the methods, all information given to students during the power point presentation was scripted. Implementation of the two techniques started the next clinical day. Following the first reflection, every morning students were given a reminder to draw from the prior day’s reflection and apply it to their practice that day. This reminder was also scripted to guarantee consistency. Both groups used the two techniques for at least 12 of their 18 clinical days.

Data Collection: At the end of the clinical rotation the faculty member will send an email containing an anonymous Qualtrics survey. Students will be reminded of the fact the survey is anonymous and their choice to complete it. The survey will contain demographic questions as well as questions regarding the use of the two techniques. Questions will be based on a likert scale except for 2 open-ended questions. The survey will take approximately 10 minutes to complete. Four days after the first email, a reminder email will be sent. The survey will be open for seven days. Data will be entered into SPSS and analyzed using descriptive statistics. The answers to the two open-ended questions will be analyzed, coded and grouped into themes.