Nursing students experience anxiety related to academic concerns, clinical performance, and personal matters throughout their nursing education (Chernomas & Shapiro, 2013). Although mild-to-moderate levels of anxiety can increase motivation to learn, high levels can create a barrier to the learning process and may impair memory and contribute to an inability to concentrate (Wallace, Bourke, Tormoehlen, & Poe-Greskamp, 2015).
Spielberger (1966) defines anxiety as "subjective feelings of tension, apprehension, nervousness, and worry" (p. 8) and describes two types. State anxiety refers to a temporary emotional state that consists of subjective feelings of tension and apprehension, with increased autonomic nervous system activity that often fluctuates in intensity. Trait anxiety refers to the tendency to respond with anxiety to perceived threats from the environment; a person with a high trait anxiety feels more threatened by a situation than persons with low trait anxiety. Anxiety has been reported by college students as an obstacle for achieving passing grades and being able to graduate. A national survey (N = 765) found that more than 62 percent of students who withdrew from college did so for mental health problems; 11 percent reported anxiety as the primary reason. Anxiety has surpassed depression as the most common problem among students in surveys of college counselors (Grasgreen, 2012).
Nash and Newberg (2013) defined "mindfulness" as cultivating a habit of experiencing and living in the present. Hoge et al. (2013) reported mindfulness meditation as a cost-effective, low-stigma, and easily accessible intervention for reducing anxiety. Mindfulness meditation training teaches methods that increase awareness of the present moment and raise awareness of thoughts, emotions, and bodily sensations (Hoge et al., 2013). A variety of meditation modalities have been used among university students (Manocchi, 2017; Sedlmeier et al., 2013; Van Der Riet, Levett-Jones, & Aquino-Russell, 2018). However, research connecting mindfulness meditation and its effect on anxiety and retention of nursing students is limited. The purpose of this study was to test the effectiveness of mindful meditation in reducing anxiety and increasing retention in baccalaureate nursing students. Two research questions were explored: 1) Does mindfulness meditation decrease BSN students' level of state and trait anxiety? 2) Does mindfulness meditation increase student retention during the first and second semesters of junior year nursing courses?
METHOD
This quasi-experimental study used a convenience sample of 166 first- and second-semester junior BSN students. Initially, 85 students agreed to participate in the intervention, but 36 attended no meditation sessions and were excluded from data analysis. The result was an intervention group of 49, with a comparison group of 117. The mean age of the sample was 24 (range: 19 to 47). The intervention group was 88 percent female; the comparison group was 78 percent female. All participants completed a demographic form and the State-Trait Anxiety Inventory for Adults (STAI; Spielberger, 1983) at the beginning and end of their junior semester. The intervention group completed the author-developed Mindfulness Meditation Intervention (MINS) for Nursing Students Evaluation Form at the conclusion of the semester. Institutional review board was obtained from a state university. Participation was voluntary, and students were assigned code numbers to ensure confidentiality.
The 40-item STAI was used to evaluate how students felt in the present moment (State anxiety) and how they usually felt (Trait anxiety). The STAI is a reliable and valid instrument with Cronbach's alpha scores ranging from .86 to .95 (Spielberger, 1983). The MINS evaluation form provided data about students' perceived stress and anxiety before and after mindfulness meditation sessions. Students were also asked how participating in meditation sessions impacted their education experience. The intervention and comparison groups were assessed for baseline academic differences using results from a standardized admission assessment exam; a t test for independent samples revealed no significant differences at baseline.
The intervention group was provided eight weekly 60-minute mindfulness meditation sessions during spring and fall 2015. These sessions were led by an RN who is also a licensed clinical social worker experienced in mindfulness meditation therapy. The intervention group (n = 49) attended at least one meditation session; 65 percent attended two to five sessions. A room provided in the nursing building for meditation was dimly lit with minimal noise and distraction and no personal technology devices; ambient sounds provided a calming atmosphere. Students were invited to sit comfortably aligned for optimal breathing and relaxation and were given instructions on proper diaphragmatic breathing and awareness of breath. Students were taught mindfulness concepts (e.g., self-compassion, mindful eating, walking meditation) and encouraged to practice mindfulness in their daily life.
RESULTS
Pre- and postintervention STAI scores were analyzed using paired t-tests. Data were analyzed using SPSS V24. The intervention group had a statistically significant decrease in STAI Trait scores postintervention (pre M = 44.74, post M = 39.53), t(46) = 3.76, p = .000. Mean STAI State scores decreased but the mean difference was not significant (pre M = 45.06, post M = 41.91, p = .068). The comparison group had significant increases in State, t(111) = -3.90, p = .000, and Trait, t(111) = -2.73, p = .007, anxiety scores between the beginning and end of the study (pre State M = 41.29, post State M = 46.27; pre Trait M = 41.63, post Trait M = 44.28).
Normative scores on the STAI were established previously with college students (N = 855) with mean State scores ranging from 36.47 to 38.76 and mean Trait scores ranging from 38.30 to 40.40 (Spielberger, 1983). Nursing students in the current study scored higher than the normative sample on both the pre- and postintervention STAIs, suggesting that nursing students may have a higher propensity toward anxiety than other students. The postintervention STAI was administered during the week of final examinations, a time of high anxiety. That STAI scores decreased from the beginning to the end of the semester for the intervention group suggests that mindfulness meditation may be effective in reducing nursing students' anxiety, supporting the first research question.
Retention of students in the intervention group was essentially equivalent to the comparison group (intervention, n = 42, 86 percent; comparison, n = 99, 85 percent). A chi-square statistical test found no significant difference in progression between the groups (x2 = 0.387, p = .824). The BSN program provides remediation resources in which all nursing students can participate, obviating the impact of the intervention on retention. Data were collected through students' comments on the MINS evaluation form. More than 80 percent of the intervention students reported that the meditation sessions had a positive impact on their education experience. Students identified that mindfulness meditation decreased their manifestations of anxiety, including apprehension, lack of focus, and worry.
DISCUSSION AND CONCLUSION
Strengths of this study included the use of a standardized measurement tool with strong reliability and validity, having comparison and intervention groups, and students' ease of access to the meditation sessions. Limitations included a lack of random assignment, a small sample size, and the use of one site.
The stresses of nursing school warrant exploration of means to help students cope. This study provides a holistic coping strategy for academia and practice. Faculty should instill the value of holistic interventions early in the program to allow students to practice mindfulness meditation and reap its benefits. Rizer, Fagan, Kilmon, and Rath (2016) found that perceived benefits of mindfulness meditation, not perceived susceptibility to stress, influenced the intention to practice meditation. As research indicates that nurses in clinical practice experience burnout, compassion fatigue, and moral distress (Lyndon, 2016), meditation sessions may encourage students to engage in holistic practices that will help them in their careers as RNs. Recommendations for future studies include scheduling sessions at convenient times for students, ensuring the environment is conducive to mindfulness meditation, obtaining a larger sample, and partnering with other nursing education programs.
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