Mindfulness practice has been found to reduce recurrent depressive episodes (Khoury et al, 2013), improve memory (Coffey et al, 2010) and reduce stress (Pascoe et al 2017). It can also help students cope with university life (Barnes et al, 2017). It has been described as being able to give uninterrupted attention to any task, including conversation, without judgement or criticism (Kabat-Zinn, 2003; Brown et al, 2007). It is concerned with developing non-judgemental awareness. A common approach is to focus on the sensations of breathing, noting every inhale and exhale, and patiently returning attention to breathing each time it wanders. This allows an internalised focus from both external and internal distractions. Deliberate focus on breathing has also been shown to increase activity in physiologically calming centres such as the parasympathetic nervous system (Tang et al, 2009).
Although some studies have highlighted potential negative effects of mindfulness, including insomnia and hypersensitivity to light (Jonsson et al, 2014; Lindahl et al, 2017), it is recognised internationally that mindfulness training can positively impact holistic wellbeing (Jennings et al, 2013; Goyal et al, 2014). Paying attention to what is happening in the present moment, including the individual's thoughts and feelings, and what is happening around them, improves mood and how individuals feel about themselves and others (Kuyken et al, 2013).
The use of mindfulness techniques has been shown to lead to improvements in attention, while correlational research has also demonstrated improvement in wellbeing (Slade, 2010) and resilience (Bower et al, 2015). Wellbeing includes the tendency towards happiness, but also satisfaction with life and a sense of purpose, both personally and socially (Michaelson et al, 2012). Resilience is a trait that can help people cope with adversity, trauma and difficult events. It is an ineffable quality, which allows individuals to cope effectively with failure; often supported by a positive and optimistic attitude (Masten, 2001).
Health service students may experience high levels of psychological morbidity because of the nature of healthcare education (Jimenez et al, 2010; Chernomas and Shapiro, 2013), which includes secondment to clinical placements; these have been identified as causing particular stresses (Chernomas and Shapiro, 2013). One recent study in The Lancet Public Health demonstrated that mindfulness training could be effective in improving student mental health and wellbeing as part of a wider mental health strategy (Galante et al, 2018).
Aims
Engaging in mindfulness techniques may positively impact the psychological wellbeing of students undertaking clinical training. This is of vital importance to ensure optimum learning, and prepare them for future healthcare practice with its associated challenges (Ratanasiripong and Wang, 2011). The authors offered mindfulness meditation as part of a 6-week teaching programme supporting medical and PhD nursing students, and carried out an evaluation of this activity and the associated impact on their ability to become more mindful and resilient.
Method
This cross-faculty, interprofessional teaching involved the School of Medicine and Biomedical Sciences and the School of Nursing and Midwifery across the undergraduate–postgraduate spectrum. All medical students participating in consolidative learning in preparation for summative assessment and all PhD nursing students in any year of their study and preparing for annual reviews or vivas were invited to participate. Students were sent details of the workshop via email and were invited to a series of six sessions, which included an introductory session and a final evaluation.
Four fifth-year undergraduate medical students and six first- and second-year nursing PhD students took part. The study comprised a mindfulness-based workshop, followed by five weekly 30-minute sessions of mindfulness training, which included a 15-minute meditation exercise. The first session, the workshop, was held in January 2018 and included an overview and introduction to mindfulness, the related evidence base and the potential impact of mindfulness. A mindfulness-based meditation exercise was also carried out and participants were taught the principles of meditation. Sessions 2 to 6 included a follow-up meditation practice session and a reflection on how mindfulness had been useful (or not) in the previous week. Participants were asked about barriers to meditation and offered suggestions to improve practice.
Resilience and outcome measures were completed at baseline and on completion of session 6. Participants completed the Brief Resilience Scale (BRS) (Smith et al, 2008) and the Mindfulness Attention Awareness Scale (MAAS) (Feldman et al, 2007) at baseline and post-intervention.
The BRS is a self-rating questionnaire. It aims to measure the ability of an individual to recover from stress or adversity. The scale includes three positive valence items (items 1, 3, and 5) and three negative valence items (items 2, 4, and 6). The items are rated on a 5-point Likert-type scale ranging from 1 (‘strongly disagree’) to 5 (‘strongly agree’). High total scores indicate higher levels of resilience. BRS internal consistency reliability coefficients (Cronbach's alpha) have been reported and range from 0.80 to 0.91. Test–retest reliability has been reported to range from 0.61 to 0.69 (Smith et al, 2008).
The MAAS is a 15-item instrument and a valid measure of trait mindfulness and involves what the authors conceptualise as the two components of consciousness: awareness and attention. Awareness is described as that which operates in the background of the mind and what allows us to notice things around us without focusing exclusively on them. Attention refers to the ability to focus awareness on a specific experience. The scale measures an individual's tendency to enter a state of mindfulness and is a valid and reliable method for quantifying mindfulness. The scale uses a 6-point Likert-type scale (‘almost always’ to ‘almost never’) and respondents rate how often they act on automatic pilot, are preoccupied, and do not pay attention in the present moment. An internal consistency (coefficient alpha) of 0.82 has been reported and expected convergent and discriminant validity correlations. For example, the MAAS was significantly positively correlated with wellbeing and negatively correlated with rumination. In addition, in a study of mindfulness practitioners versus a matched community of controls, MAAS scores were significantly higher in the mindfulness practitioners.
At the end of session 6, students were invited to take part in a discussion to reflect upon and evaluate their experiences. Six PhD nursing students agreed to take part in the discussion. The medical students were unable to participate due to workload.
Data analysis
Quantitative analysis
MAAS and BRS scores were collated and exported in standard (Excel) spreadsheet format for analysis. Following descriptive statistical analysis (mean, median, standard deviation and standard error), comparative analysis was undertaken using Mann-Whitney U non-parametric testing, with statistical significance being assumed at P values of <0.05
The discussion was audio-recorded and transcribed and a simple thematic analysis (Braun and Clarke, 2006) undertaken by HN and IKW to elucidate key themes.
Results
MAAS scores improved from a median of 2.5 to 3.73 (P=0.04), with a corresponding increase in median BRS scores from 18.5 to 22.0 (P=0.02). For both mindfulness and resilience, there was thus a statistically significant improvement in score metrics, signifying improvements in being able to cope with stress, accompanied by an enhanced awareness and attention to what is taking place in the present. These results are depicted in Figure 1 and Figure 2.
The discussion to evaluate the mindfulness training took place with the six students in a classroom in the School of Nursing and Midwifery. A series of questions were asked to elicit their experiences and any challenges they faced. The students reported a positive experience and a commitment to mindfulness practice. They felt calmer, less stressed and more able to deal with negative thoughts positively. Three themes were identified:
The impact of mindfulness and maintaining practice
Mindfulness practice was viewed positively by the students, who quickly felt more content and able to remain more present in daily events. They thought less about the past and future and more about the moment they were experiencing:
‘Mindfulness helped me … like somehow when you don't think about your future or your past, OK, let's do it now. Let's keep the present. So you are stopping your thoughts for a while, which somehow refreshes your mind to go and think what you are doing right now.’
For some, the value of mindfulness was in helping them gain personal insight and acknowledge a clearer picture of their personal goals, which they felt was likely to lead to increased happiness and peace. One student said:
‘I think meditation might help me to find myself in some way … like sometimes when you are thinking things about your study, your timeline, your class, submitting work. Your family at home. Managing your budget … Sometimes you have a lot of thinking and you forget yourself. But when you sit down and try meditations and try to forget all of these dramas around you, you find yourself then. Well, I am doing the PhD for myself for my happiness with my life.’
Another student commented:
‘So key thing … it helped me, I will say, to bring somehow peace in me.’
Although the benefits of mindfulness were clearly apparent and students recognised that recurrent practice improved their ability to be mindful, they also reported challenges to maintaining mindfulness practice, including finding time to practice regularly and prioritising the activity. One student described their main challenge:
‘I think keeping it going. Whenever we were doing it quite regularly, I was quite good at doing it at home every morning. And then I sort of got a bit lax about it. And then stopped. So I think just being able to keep it up. Because I think I noticed more of a benefit whenever I did it every day. You feel better during the day and you focus more during the day if you start your day off on that. But then you're like … oh I could get another 10 minutes' sleep instead of getting up and doing it. So I think there is like a discipline that you need to just take the time out and not be doing something else, like sleeping. Or watching TV.’
Improvements in wellbeing
All students reported positive improvements in wellbeing from improved sleep patterns, improved coping, less stress, a feeling of being ‘happy’ and reduced feelings of anger. Students said:
‘For my sleep, first of all, especially at first … I have difficulty getting to sleep, but now with mindfulness somehow it has helped.’
‘I find it somehow helped me to cope … and you know how you feel when you are under stress and I feel that taking a breath and this panic, you will ignore it with a smile on your face. Which is really good.’
‘OK, you are believing you are happy. So you know what makes you stressful, [what] things may be bothering you. You do what you can do and the rest will hopefully be fine. So don't think about past. Just think about here.’
‘I noticed I was a lot less stressed. A lot less stressed. Things wouldn't fluster me as much. You just sort of accept something has happened and just go with it.’
If panic or anger arose, students reported using breathing techniques, and observation skills, taught during the mindfulness sessions, to manage these difficult emotions. Two students commented:
‘And I think [about] anger management—so when something really bad happens in front of me, it just plays in my mind slowly. So I can observe it first. And then think about it. And then act.’
‘Yeah. It is like I am a third party. I am not like in the same situation. It is really good.’
Improved academic endeavour
All students felt that the mindfulness techniques supported them in their academic work. They noticed increased focus, particularly after a meditation session. This was particularly helpful for students who sometimes felt overloaded with the number of activities they had to complete:
‘My studies—meditation helps me in my focus, taking bit by bit. Like [whatever] overwhelming task I have, it is like, it's OK. We are going to break it down till I reach the finish point.’
‘But I realised I can forget everything during these sessions … after these sessions I can work more easily and [be] more productive’
Students felt that the breathing exercises, which were incorporated into the meditation activity, were particularly helpful. They allowed students to slow down and reorganise their thoughts, which resulted in equanimity and composure. They also reported being able to observe their actions and make changes as necessary. Two students commented:
‘I think the really nice thing about this is the breathing. When you feel whatever about a situation, if you want to hold [a breath] and release it, that second you are taking a breath, it gives you time really to somehow reorganise. I don't know how to describe it.’
‘I find that it helps me concentrate better. So if I was reading a book, I can sometimes get three pages down and realise I haven't taken in any of the information, because I was thinking of something completely different. But I notice now, when my mind does that, I can bring myself back. So my focus and concentration has got a lot better from doing it.’
Limitations of the study
This evaluation was limited by the small number of participants located in one university and findings are not generalisable. The sample of PhD nursing students is unlikely to be representative of nursing undergraduates within the UK as PhD nursing students are often experienced clinicians or academics and not representative of the majority of nurses in the country. This aside, PhD and undergraduate nursing students are likely to face similar problems related to academic pressures and university life. Only PhD nursing students took part in the focus group so the views of the medical students are not represented.
Discussion and conclusion
This evaluation has demonstrated that it is possible to offer and manage a mindfulness-based activity over a number of weeks to medical and PhD nursing students. Mindfulness can induce varied positive psychological effects (Coffey et al, 2010; Keng et al, 2011; Kim et al, 2013; Carlson et al, 2013), and this study found significant improvements in being able to cope with stress, with enhanced awareness and attention to what is taking place in the present, including increased attention and resilience. This is likely to impact positively on psychological symptoms including those related to workload stress and pressures. Similar to other studies (Galante et al, 2018; van der Riet et al, 2018) the authors would argue that mindfulness is a useful addition to medical and nursing curricula (Noble et al, 2018).
Galante et al carried out a randomised controlled trial at the University of Cambridge, providing mindfulness training to students. Their findings suggest that mindfulness helps to maintain mental health and wellbeing, as well as engendering resilience to academic stress (Galante et al, 2018). Nursing and medicine programmes are known to induce stress responses and have heavy workloads when compared with other, non-medical courses (de Vibe et al, 2013). Including mindfulness-based activities in the curriculum allows an opportunity to teach students resilience skills at the very start of their careers and stand them in good stead for the challenges ahead. Mindfulness also has the potential to help facilitate the prevention of mental illness among these students (Macaskill, 2013). This is particularly pertinent considering university counselling services are reporting increasing numbers of students with mental health issues (NUS–USI, 2017). Early interventions in the mental health of young people can play a significantly crucial role in the overall outcome (Patel et al, 2007; Macaskill, 2013).
Our future work will include the development of an online intervention for students with key stakeholders including the Geriatric Mood Disorders Mind-Body Intervention Research (‘Geri-PARTy’) lab at the McGill University-affiliated Jewish General Hospital, Canada, which focuses on mindfulness research (https://geriparty.com), and Farset Labs, Belfast (https://www.farsetlabs.org.uk) to evaluate, design and plan for future implementation.