Enhancing Safety Education of Nursing Students: The Use of Focused-Awareness Meditation to Promote Attentional Efficiency

Although an undisputed and over-arching goal of pre-licensure registered nurse (RN) education is the development of nurse graduates prepared to deliver safe patient care, this clear objective has not been fully realized. In many cases, graduate nurses are under-equipped for what has become an increasingly complex and distracting healthcare workplace and many novice nurses report conditions of cognitive overload impacting their ability to provide safe care (Gabel Speroni, Fisher, Dennis & Daniel, 2013; Holden, et al., 2011; McGillis Hall et al., 2010; Unver, Tastan, & Akbayrak, 2012). More than ever, today’s nurse requires a superiorly efficient attentional acuity to function safely in clinical workplaces which are filled with interrupting and distracting stimuli that must be efficiently distinguished from salient cues and warning signals. An educational effort toward improving cognitive self-regulatory skills of nurse graduates is therefore especially important to the quality and safety of their novice nursing practice yet current strategies in nursing education do not adequately prepare graduates for this level of attentional complexity.  This gap is problematic to the development of safe healthcare practitioners.  

     Several nurse scholars have noted a need for increased research on nurse cognition (Benner, Sutphen, Leonard, & Day, 2010; Fryer, 2012; Ironside, n.d. QSEN Institute; Mowinski Jennings, Sandelowski, & Mark, 2011) and others in nursing, education and psychology have drawn a theoretical link between the positive outcomes of formal cognitive training, such as focused-awareness meditation, and the requisite thinking-in-action skills needed for clinical healthcare practice.( Helber, Zook, & Immergut, 2012; Shapiro, Brown, & Astin, 2011; Sherwood & Horton-Deutsch, 2012).  Focused-awareness meditation is an exercise of purposeful self-regulation of attention that with consistent daily practice is suggested to heighten one’s trait-ability to pay attention in a discerning and concentrated way despite external and/or internal distractors (Kabat-Zinn, 1995; Nhat-Hanh, 2011).This position is supported by a rapidly accumulating body of neuroscientific evidence demonstrating positive interventional effect of the regular practice of focused-awareness meditation on the ability to sustain attention, filter informational cues, and regulate distracting stimuli in healthy adult populations. (Jensen, Vangkilde, Frokjaer & Hasselbalch, 2012; Kozasa et al., 2012; Larson, Steffen, & Primosch, 2013; MacLean, et al., 2010; Zeidan, Moore, Gruber, Derose, & Malinowski, 2012).   It is further suggested in the seminal work of Lazar (2005) and Davidson and colleagues (2002) that this type of mental training improves attentional efficiency in a permanent way through a process of neuroplasticitydemonstrable on fMRI of the brain as increased cortical thickness’ in specific neural areas associated with attention. There have not been, however, any studies specific to nursing students investigating meditation and attention regulation skills, leading to the question of whether such cognitive training in pre-licensure education might be an effective and transformative strategy for developing attentional self-regulatory skills necessary for safe nursing practice. 

     The purpose of this presentation is to disseminate findings from a randomized control trial exploring the effectiveness of meditation training and practice on pre-licensure nursing students’ attentional efficiency.  A convenience sample of 52 nursing students were randomly assigned to experimental (n = 28) and control (24) groups and outcomes on attentional efficiency (alerting, orienting, and executive networks) were measured by a functional computerized program – the Attention Network Test (Fan, McCandliss, Sommer, Raz, & Posner, 2002) – in a pre-posttest design. Experimental group participants received online training in mindfulness meditation (a type of focused-awareness meditation) and meditated for ten minutes daily for four weeks in addition to their standard nursing curriculum. A waitlist control group received the same standard nursing education curriculum but did not meditate. Individual characteristics of perceived stress and mindfulness were explored for confounding effect as well as additional dependent variables. 

     Although no group differences on alerting and orienting networks were found, executive network efficiency scores did reveal group differences F (1, 49) = 4.26, p < .05 with meditation demonstrating moderate strength η_p² = .080 for enhancing efficiency of executive attention functions.  Additional significant outcomes specific to the meditation group were reduced perceived stress and increased mindfulness F (2, 47) = 7.16, p < .01, η_p²= .234.  

     Overall, this study provides beginning suggestive evidence of the benefits of cognitive training in the form of focused-awareness meditation for enhancing the efficiency of executive functions of attention, decreasing perceived stress, and increasing the mindfulness characteristics of pre-licensure nursing students.  The findings have possible implications for the safety education of nurses in that executive attention is considered a foundational component of situational awareness and accurate decision-making in technically complex work environments (Fore & Sculli, 2013; Sitterding, Broome, Everett & Ebright, 2012).  Furthermore the negative effect of stress on human performance is also well-studied as in the seminal work: To err is human (Institute of Medicine, 2000).  Of further note are recent nursing studies demonstrating upward trends in patient safety outcomes following training of healthcare workers in mindfulness practices (Brady et al., 2012; Hallman et al., 2014).

     Although additional research is warranted, this first study of meditation and attention in a nursing student population may have implications for the development of safe healthcare practitioners and serve to enhance nursing education methodology worldwide.  Incorporating cognitive training practices, such as focused-awareness meditation, into existing quality and safety education curriculum may assist students in building intrinsic attentional and other self-regulatory skills necessary for the complexity of today’s nursing practice.