Stress Reduction Through Mindfulness Meditation in Student Registered Nurse Anesthetists - AANA
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Stress Reduction Through Mindfulness Meditation in Student Registered Nurse Anesthetists Taylor Foley, DNP, CRNA Jennifer Lanzillotta-Rangeley, PhD, CRNA Student registered nurse anesthetists (SRNAs) experi- delivery system for mindfulness meditation train- ence high levels of stress related to the level of dif- ing, decreasing stress during a 10-day trial. SRNAs ficulty and time commitment associated with an inte- attended a mindfulness presentation and completed grated Doctor of Nursing Practice anesthesia program. an introductory guided mindfulness meditation mod- Although some degree of stress is necessary for moti- ule using the Headspace application on their personal vation, unmanaged stress can contribute to illness, smart phone. Preintervention and postintervention dissatisfaction, and substance use. A search of the surveys (N=33) using the Depression Anxiety Stress literature showed that mindfulness meditation training Scales 21-item questionnaire were analyzed using the reduces stress and improves academic performance Wilcoxon signed rank test. Results showed significant in graduate student populations. An evidence-based reductions (P
Sample population Author
Healthcare students: pharmacy and allied health Barbosa, et al,6 2013
Medical students Phang et al,7 2015
Undergraduate students Hindman et al,8 2015; Greeson et al,9 2014; Sampl et al,10 2017
Undergraduate women Anastasiades et al,11 2017
Nursing students Alsaraireh & Alousch,12 2017
Physicians Staffaroni et al,13 2017
New emergency department nurses Economides et al,14 2018
Novice pediatric nurses Morrison Wylde et al,15 2017
Mental health professionals Rudaz et al,16 2017
Table. Articles With Sample Populations Similar to Student Registered Nurse Anesthetists
gap in an integrated nurse anesthesia program, we used to maintain their current stress level, effectively curbing
the Lazarus Theory of Stress, Coping, and Adaptation to increases in stress compared with the control group
develop an EBP project to deliver mindfulness medita- whose stress levels increased over time.10 Mindfulness
tion training to SRNAs. The goals of the project were to meditation programs are beneficial to both graduate and
reduce overall stress in SRNAs, provide SRNAs with an undergraduate students and help manage stress, which
introduction to mindfulness meditation, and introduce was shown to lead to a decrease in anxiety.6-10,16
a form of mindfulness meditation training that has been • Mindfulness Meditation Effects on Stress-Related
shown to be effective in reducing stress. Complications. Mindfulness meditation may decrease
stress-related complications. Correlations have been
Review of Literature found between baseline mindfulness meditation levels,
A literature review was conducted to assess the ef- depression, and suicidal ideation.11 One study found that
ficacy of mindfulness meditation in the mitigation of there was a decreased level of suicidal ideation among
stress in SNRAs. The literature review was conducted undergraduate women scoring higher on a mindfulness
using the research databases Scopus, PubMed, and meditation questionnaire as opposed to those who had
Cumulative Index to Nursing & Allied Health Literature lower scores. The researchers concluded that teaching
(CINAHL). The following keywords were used in the mindfulness meditation techniques to college students
search: mindfulness, anxiety, meditation, and graduate who experience stress and depression may reduce the
student. Inclusion criteria included peer-reviewed articles risk of suicide.11 Mindfulness meditation was found
written in English, scoring level III or higher on the to outperform exercise, a common nonpharmacologic
Johns Hopkins Nurse Evidence-based Practice (JHNEBP) strategy for depression.12 Although both exercise and
Rating Scale,5 and a sample population comparable to mindfulness meditation were found to reduce symptoms
SRNAs. Exclusion criteria included articles that were of depression, mindfulness meditation was superior to
below level III on the JHNEBP rating scale and articles physical exercise among nursing students.12
in populations other than those identified as comparable • Long-term Effects of Mindfulness Meditation
populations to SRNAs. Ten articles met the inclusion cri- Training. The long-term effects of mindfulness medita-
teria (Table).6-15 Additionally, 1 systematic review of the tion training on healthcare providers has not been well
literature pertaining to health science graduate students studied. The longest follow-up in the reviewed random-
was identified, and that review identified 8 articles on ized controlled studies was 3 weeks after the intervention
this subject.16 No articles were found on the effects of and did show retention of reduced anxiety levels.5 Only
mindfulness meditation specific to the SRNA population, one identified study examined the long-term effects but
although articles were found in populations comparable did not measure mindfulness meditation or anxiety of
to SRNAs. The literature on this topic was not well de- the participants.13 This study examined the long-term
veloped; there is a need for randomized controlled trials use of mind-body medicine skills in residents, fellows,
and prospective designs. Additionally, most studies on and clinicians 0 to10 years after graduation from medical
this subject relied on participant self-reports. school. These physicians were enrolled in a mind-body
• Mindfulness Meditation as a Stress Reduction Tool. medicine course during their time in medical school and
Mindfulness meditation was found to be an effective mindfulness meditation training was a covered topic.
stress reduction tool in all 5 studies that directly tested More than half of the physicians continued to use these
this metric.6-9,16 These studies included medical students, techniques after graduation.13 This suggests that mind-
pharmacy and allied health students, and a randomized fulness meditation may continue to be used as a posi-
controlled trial with undergraduate, graduate, and profes- tive coping mechanism for career stress in the medical
sional students. Mindfulness meditation enabled students profession. This is promising for the use of mindfulness
www.aana.com/aanajournalonline AANA Journal August 2021 Vol. 89, No. 4 285meditation training in SRNAs since, “during their edu- Study data were collected and managed using Research
cational experience, SRNAs begin to establish patterns Electronic Data Capture (REDCap) tools. REDCap is a
of responding to stressors that they may take with them secure, web-based software platform designed to support
into their professional lives.”1 If mindfulness meditation data capture for research studies.20,21
training is established during SRNAs’ education and they Participants were invited via email to a presentation
find it to be a useful stress management technique for called Introduction into Mindfulness Meditation for
themselves, they may be more likely to use it in their Stress Management. Email invitations included a link to
career, potentially reducing their risk of maladaptive a preintervention survey through REDCap. This survey
stress management techniques.1 included demographic information, previous mindful-
• Mindfulness Meditation Training Modalities. The re- ness meditation experience, and a standardized stress
viewed studies implemented several different modalities scale. Each survey participant was also asked to create a
of mindfulness meditation training. All studies showed unique user code so that individual preintervention and
that mindfulness meditation training, regardless of mo- postintervention surveys could be compared. Lunch was
dality, was effective in reducing anxiety and increasing provided by the College of Nursing to increase atten-
mindfulness. The students participating in the smart dance. Seventy-one of 74 SRNAs who were enrolled in
phone group using Headspace (Headspace) found that the program attended the presentation. The presentation
it was equally effective as in-person mindfulness train- consisted of an overview of mindfulness meditation and
ing.14 This is important, as this intervention is scalable an introduction to the application Headspace. Attendees
and could potentially reach more people by elimination were invited to participate in the project and asked to
of limiting factors such as class size, teacher availability, complete the 10-day free trial offered by Headspace, over
and scheduling conflicts among participants. It is notable the course of the next 10 days, after which a postint-
that smart phone application was less effective than in- ervention survey was sent to all participants. The first
person training for participants exhibiting signs of post- session was done together as a class to familiarize the
traumatic stress disorder.15 participants with the software. Over the course of the
• Lazarus Theory of Stress, Coping, and Adaptation. trial period, reminder emails were sent to participants to
Mindfulness meditation as an intervention for stress re- encourage the completion of the daily guided meditation.
duction can be understood more clearly when one consid- Headspace is a guided mindfulness meditation train-
ers the Lazarus Theory of Stress, Coping, and Adaptation. ing platform available on smart devices and online. It
This theory describes stress as a process involving 3 offers a free introductory 10-day basics course in mind-
unconscious appraisals of stressors: the primary appraisal fulness meditation as well as a subscription service with
where the initial judgment about an event is made, the categories of guided meditation courses. Courses, includ-
secondary appraisal where the individual assesses his or ing the 10-day basics course, include an audio recording
her response to the event, and the third appraisal or reap- that instructs the user through a 10-minute meditation
praisal in which the event is continuously and dynami- session. The 10-day basics course is targeted at individu-
cally reassessed as it develops.17 Stress is experienced als with limited or no experience with meditation and
during the appraisal process if an individual feels that he is supplemented by instructional videos that provide
or she cannot deal with the event or has not responded context and background for each meditation session.
appropriately.17 Mindfulness meditation training serves The Depression Anxiety Stress Scales 21-item (DASS-
as a lens to better view and understand both actions and 21) questionnaire was chosen as the standardized stress
emotions. It helps to increase awareness of the present scale because of its tested validity and reliability, its
and increases focus, which helps to reduce false assump- relatively short format, its availability in the public
tions due to lack of situational awareness. This may be domain for free use and reproduction, and its efficacy in
why higher levels of mindfulness meditation result in less measuring the negative emotional states of depression,
stress. Additionally, it helps to quiet the noise of errant anxiety, and stress.22 The DASS-21 is a combination of 3
thoughts and decrease the focus on future stressors such self-report scales: 1 measuring depression, 1 anxiety, and
as an upcoming test or perceived challenging clinical 1 stress. This instrument allows separate measurements
experience. Mindfulness-based therapy was originally de- of each scale. The scales of the DASS-21 were chosen
veloped as an adjunct for treating major depressive disor- because they have been shown to have a “high internal
ders and has been shown effective in reducing depressive consistency and to yield meaningful discriminations in
symptoms and preventing relapse of depression.18,19 a variety of settings; the scales should meet the needs
of both researchers and clinicians who wish to measure
Methods current state or change in state over time (eg, in the
This project was implemented at a university DNP course of treatment) on the three dimensions of depres-
anesthesia program. The institutional review board de- sion, anxiety and stress.”23 This scale was used to assess
termined this project to be exempt from its oversight. the effectiveness of the use of Headspace as an emotional
286 AANA Journal August 2021 Vol. 89, No. 4 www.aana.com/aanajournalonlinewellness tool for SRNAs and to determine if there was a
significant decrease in the metrics of depression, anxiety,
and/or stress after the intervention. This scale was dis-
tributed to participants via pre- and postintervention
surveys to complete before the intervention and after the
10-day intervention period. The DASS-21 manual pro-
vides a scoring scale that delineates results in each of the
3 categories of depression, anxiety, and stress as normal,
mild, moderate, severe, or extremely severe.
Preintervention and postintervention survey responses
were matched via unique user code and were compared.
A single-tailed t test was used to assess for a significant
decrease in depression, anxiety, and stress. DASS-21 Figure. Student Registered Nurse Anesthetists’
scores were compared for each individual and then aver- Depression, Anxiety, and Stress Scores Before and
aged to assess for overall reduction in each metric. After Mindfulness Meditation Intervention
Postintervention surveys also included application
usage questions to assess for participant engagement the category of anxiety, a 32% reduction was also seen.
with the intervention. Questions included average ses- The average anxiety score on the preintervention survey
sions completed and average minutes meditated. The was 18.3, which is categorized as severe. In the postint-
postintervention surveys also included questions to ervention survey the average score was 12.4, which is
gauge participants’ plan to continue using mindfulness categorized as moderate. In the category of stress there
meditation after the end of the project. These questions was an average reduction of 47%. The average preinter-
included: “Do you intend to continue using some form of vention score for stress was 11.3, which is categorized as
mindfulness meditation? (yes/no)”, “If yes, in what way normal. The average postintervention stress score was 6,
do plan to continue using mindfulness meditation in the also categorized as normal.
future? (using the Headspace application, self-practice, On postintervention survey items pertaining to
using other guided meditation applications, using free planned continuation of mindfulness meditation train-
sources such as other guided mindfulness meditation ing, 41 (95%) of 43 participants indicated that they in-
applications or YouTube videos, or none of the above)?” tended to continue practicing some sort of mindfulness
meditation after the conclusion of the project. Nineteen
Results of 43 survey respondents (44%) reported they planned to
The introductory lecture was attended by 71 of 74 SRNAs continue using the application Headspace. With multiple
enrolled in the DNP Nurse Anesthesia Program. Of the responses allowed, 27 of 43 (63%) planned to continue
74 preintervention surveys distributed, 53 (71.6%) were mindfulness meditation with self-practice, 9 of 43 (21%)
completed. Postintervention surveys were sent to all 74 planned to continue with other guided meditation apps,
SRNAs after the completion of the intervention; of those, 14 of 43 (33%) planned to continue mindfulness medita-
43 were completed. Thirty-three matched preinterven- tion with the use of YouTube videos, and 2 of 43 (5%)
tion and postintervention surveys were completed by planned to continue with another method.
participants. Survey results showed that 22 (66.6%)
of these 33 participants had minimal to zero previous Discussion
meditation experience. Usage questions in the posttest Mindfulness meditation has been found to increase aca-
revealed the average number of sessions completed was demic performance and reduce test anxiety.10 Although
6.5 of 10, and when all sessions were combined, the total no evidence was found during the literature review to
average time meditated was 51.2 minutes. A Wilcoxon support the translation of these benefits directly into the
signed rank test showed significant reductions in depres- clinical setting, it has been noted that unmanaged stress
sion (Z=−3.36, Ppotential to reduce the prevalence of impaired providers and burnout in anaesthesia: relevant topics for anaesthesiologists
and healthcare managers? Eur J Anaesthesiol. 2012;29(7):311-319.
constitutes an improvement to patient safety. doi:10.1097/EJA.0b013e328352816d
As shown by the results of this project, there was 4. Volkow ND, Koob GF, McLellan AT. Neurobiologic advances from
a significant decrease in all measured negative emo- the brain disease model of addiction. N Engl J Med. 2016;374(4):363-
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jbi.2008.08.010 Name: Taylor Foley, DNP, CRNA
22. Depression Anxiety Stress Scales (DASS). Psychology Foundation of Contribution: This author made significant contributions to the concep-
Australia. Updated July 26, 2018. Accessed March 31, 2020. http://
tion, synthesis, writing, and final editing and approval of the manuscript
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to justify inclusion as an author.
23. Lovibond SH, Lovibond PF. Depression Anxiety Stress Scales. 2nd ed.
Psychology Foundation; 1995. Disclosures: None.
Name: Jennifer Lanzillotta-Rangeley, PhD, CRNA
AUTHORS Contribution: This author made significant contributions to the concep-
Taylor Foley, DNP, CRNA, is faculty at the University of Cincinnati Col- tion, synthesis, writing, and final editing and approval of the manuscript
lege of Nursing, Cincinnati, Ohio, and a Certified Registered Nurse Anes-
to justify inclusion as an author.
thetist at the University of Cincinnati Medical Center, Cincinnati, Ohio.
Email: foleytr@ucmail.uc.edu Disclosures: None.
Jennifer Lanzillotta-Rangeley, PhD, CRNA, is an assistant professor at The authors did not discuss off-label use within the article. Disclosure
the University of Cincinnati College of Nursing. statements are available for viewing upon request.
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