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The effects of mindfulness meditation on stress levels among student registered nurse anesthetists: a pilot study

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The effects of mindfulness meditation on stress levels among student registered nurse anesthetists: a pilot study

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Content MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS

i

THE EFFECTS OF MINDFULNESS MEDITATION ON STRESS LEVELS AMONG
STUDENT REGISTERED NURSE ANESTHETISTS: A PILOT STUDY
by
Jorge Lopez

_________________________________________________________________________

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2021
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS ii

The following manuscript was contributed to in equal parts by Jorge Lopez, Jesus Recio, and
Melissa Wohlers.
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Acknowledgements
On behalf of Jorge Lopez, Jesus Recio, and Melissa Wohlers, we sincerely thank Dr.
Elizabeth Bamgbose, PhD, CRNA for serving as our Capstone Chair, as well as Dr. Charles
Griffis, PhD, CRNA, Dr. Theresa Norris, PhD, CRNA, and Rev. Jim Burklo for serving on our
doctoral capstone committee. Their guidance and support during the development and
implementation of this study was invaluable. We would also like to acknowledge and thank our
biostatistician, Dr. Amanda Goodrich, PhD for conducting the statistical analysis of our research,
and continuing to provide guidance throughout the data interpretation and presentation process.
In addition, we deeply appreciate the SRNAs at USC Keck School of Medicine Program of
Nurse Anesthesia who participated in, and supported the advancement of, our research.

MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS iv
Table of Contents

Acknowledgements ....................................................................................................................... iii
List of Tables .................................................................................................................................. vi
List of Figures ............................................................................................................................... vii
Abstract ........................................................................................................................................ viii
Chapter 1 ......................................................................................................................................... 1
Introduction ................................................................................................................................. 1
Research Question and Specific Aims ........................................................................................ 1
Background and Significance ...................................................................................................... 2
Physiological Effects of Stress ................................................................................................ 2
Physiologic Effects of Mindfulness ......................................................................................... 4
Stress Reduction Strategies in Healthcare ............................................................................... 4
Chapter 2 ......................................................................................................................................... 7
Literature Review ........................................................................................................................ 7
SRNAs and Stress .................................................................................................................... 7
Mindfulness-Based Stress Reduction Program Adaptations ................................................... 9
Mindfulness Meditation Duration ....................................................................................... 9
Mindfulness Meditation Delivery Method ........................................................................ 10
Mindfulness Meditation Feasibility, Longevity, and Adherence ...................................... 12
Chapter 3 ....................................................................................................................................... 14
Methodology .............................................................................................................................. 14
Procedures ............................................................................................................................. 15
Perceived Stress Scale ....................................................................................................... 17
REDCap ............................................................................................................................. 17
Statistical Methods ................................................................................................................ 18
Chapter 4 ....................................................................................................................................... 19
Results ....................................................................................................................................... 19
Chapter 5 ....................................................................................................................................... 22
Discussion.................................................................................................................................. 22
Limitations ............................................................................................................................. 25
Conclusion ................................................................................................................................. 26
Disclosures ................................................................................................................................ 27
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References ..................................................................................................................................... 28
Appendix A ................................................................................................................................... 34

MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS vi
List of Tables
Table 1: Perceived Stress Scale score by socio-demographic characteristic…….……....………19
Table 2: Median (IQR) PSS scores and stratification by gender………………………………...21

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List of Figures
Figure 1: Perceived Stress Scale score by gender……………………………………....………..20
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS viii
Abstract
Medical learners and healthcare professionals are susceptible to high levels of stress,
which is associated with medical errors, poorer patient care, and negative
psychological conditions. Twelve SRNAs in their second year of graduate school at USC
participated in a five-week online mindfulness program that covered areas such as body scan
meditation, sitting meditation, progressive muscle relaxation, loving-kindness meditation, and
compassion for oneself, and attention to emotions, thoughts, and bodily functions. The Perceived
Stress Scale (PSS) was used to quantify stress before, immediately after, and four weeks
following the program. The median pre-intervention PSS score among the participants was 20.5.
Male SRNAs demonstrated a trend toward increased PSS scores between the three-time
intervals, however this was not statistically significant (9, 9, and 12, p = 0.662). Female SRNAs
demonstrated a statistically significant overall reduction in PSS scores between the three-time
intervals (21, 17, and 14, p = 0.028) and between baseline scores and at the four-week follow-up
(21 vs. 14, p = 0.048). A five-week online mindfulness program significantly reduced stress
among female SRNAs. The change in perceived stress scores among male participants during
and after the intervention was too small to detect any significant association.
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Chapter 1

Introduction
Student Registered Nurse Anesthetists (SRNAs) experience high levels of stress
throughout their academic journey that may continue when they enter the workforce as
healthcare professionals (Chipas & Mckenna, 2011; Chipas, 2012; Phillips, 2010). Stress among
medical learners and healthcare professionals is an issue with consequences that extend beyond
the individual who experiences it and has been associated with higher risks of committing
medical errors, poorer patient care, and negative psychological outcomes (i.e depression, anxiety,
and burnout) (Fahrenkopf et al., 2008; Shanafelt et al., 2010; Chipas & Mckenna, 2011).
Furthermore, SRNAs are medical learners who are concurrently in didactic and clinical training.
Stress may pose challenges to an SRNA’s learning, both in the classroom and during clinical,
because stress is the number one impeding factor to academic performance among college
students (American College Health Association, 2010). Therefore, it is imperative to effectively
and safely manage stress among SRNAs. The effects of mindfulness meditation on reducing
stress among healthcare professionals and medical learners (i.e. nursing students, medical
students, and residents) are well-documented (Burton et al., 2017; Chen et al., 2019; Daya &
Hearn 2018). However, there is a gap in the literature regarding the effects of mindfulness
meditation on SRNAs.
Research Question and Specific Aims
The authors of this paper posed this research question: Does participation in a
mindfulness meditation program reduce stress levels in second year SRNAs at the three-year
USC Program of Nurse Anesthesia? The specific aims of this project included the following:
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 2
1) Conduct a thorough literature review, examining and synthesizing best evidence
regarding mindfulness meditation on stress levels among medical learners.
2) Determine if participation in a mindfulness meditation program reduces stress, as
indicated by Perceived Stress Scale (PSS) scores.
3) Determine if participation in a mindfulness meditation program sustains a four-week
reduction in stress levels among second year SRNAs as indicated by responses to the PSS
post-intervention survey.
Background and Significance
Stress is the body’s reaction to an event or thought that precipitates an emotional,
psychological, and/or physical response. While short-term stress can provide motivation and
strengthen interpersonal relationships, prolonged or excessive stress in healthcare workers can
interfere with focus and memory, increase anxiety, diminish clinical performance, and ultimately
affect patient safety. Dhabhar (2018) defines short-term stress responses lasting minutes to hours
as a protective mechanism that may serve to enhance cognitive and physical performance. In
contrast, chronic or long-term stress lasting for several hours per day, for weeks or months, often
has deleterious health consequences. A stressor is any internal or external event, force, or
condition that an individual considers to be demanding, challenging, or threatening individual
safety, which may require adjustment or coping strategies. Coping strategies can be defined as an
action, a series of actions, or a thought process used in meeting a stressful or unpleasant situation
or in modifying one’s reaction to such a situation (VandenBos, 2006).
Physiological Effects of Stress
The physiological systems of the human host are programmed to preserve and achieve a
steady state and homeostasis. However, this ideal equilibrium is consistently challenged by
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS

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intrinsic and/or extrinsic factors described as stressors (Tsigos et al, 2020). As a result, stress can
be termed as a state of disequilibrium, in which the body attempts to counteract through
physiologic and behavioral responses in order to reestablish homeostasis. This stress response is
composed of several complex neuroendocrine, cellular, and molecular signals located throughout
the central nervous system (CNS) and periphery, which can be influenced by an individual’s
genetic, environmental, and developmental composition. The body’s inability to mitigate stress
(either through inadequate response, excessive signaling, or ineffective or inappropriate
prolongation of reactions), may potentially lead to adverse effects. Such effects include changes
in metabolism, growth, reproduction, physiologic function, immune response, and behavioral
and personality development (Tsigos et al, 2020).
There are several stress centers throughout the body that receive and interpret
neurosensory, blood-borne, and limbic signals through specific pathways (Yuede et al., 2018).
The activation of these acute stress systems allows for brief behavioral and physical changes that
inherently improve the chances of survival. These changes include increasing hypothalamic-
pituitary-adrenal axis (HPA) activity, cortisol levels, cytokine release, sympathetic functions
(heart rate, blood pressure, norepinephrine release), synaptogenesis, memory function,
hyperactivation of serotonin (5HT) neurons, as well as decreased dendritic branch length (as a
result of excessive glutamate release). However, an inability to appropriately respond to acute
stress and return to homeostasis results in a chronic stress response. Chronic stress effects reflect
the impact of a prolonged increase in circulating cortisol and norepinephrine, including: cell
death, decreased volume of brain regions important for memory (hippocampus and prefrontal
cortex), vascular damage, suppression of growth factors, increased insulin resistance, oxidative
stress, and impaired memory function (Yuede et al., 2018).
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 4
Physiologic Effects of Mindfulness
The introduction of mindfulness-based interventions (MBI) has been shown to have
several positive physiologic and behavioral changes ultimately remediating stress-induced
effects (Garland et al., 2017). Research has shown an association between MBI and beneficial
neuroplastic changes in the prefrontal cortex (PFC) and anterior cingulate cortex (ACC),
increasing activation and thickness in these areas which are important for cognitive control.
Mindfulness-based interventions have also been associated with structural and functional
changes in the amygdala, an area that has a central role in fear processing, negative emotions,
anxiety, avoidance, attentional bias, behavioral improvements, and punishment sensitivity. A
randomized controlled trial (RCT) study by Taren et al. (2015) found participants introduced to
MBI not only demonstrated a reduction in right amygdala-subgenual ACC activity, but this
change also correlated with a decrease in chronic HPA-axis activation. This decreased HPA
activation indirectly decreased hypersecretion of corticotropin-releasing factor (CRF) and
adrenocorticotropic hormone (ACTH), reflecting a decrease in adrenal cortex stimulation-driven
cortisol production.
Stress Reduction Strategies in Healthcare
Encountering frequent stressors for prolonged periods of time can lead to negative
psychological outcomes that can have an adverse effect on medical learners’ academic and
clinical performance and continue to impact health professionals after they enter the workforce.
(McConville et al., 2017). For example, stress-related ailments (i.e. depression, anxiety and
burnout) were inversely correlated with academic performance (Mihăilescu et al., 2016); and
although acute stress has been shown to improve psychomotor performance, excessive and
chronic stress in clinical settings have significant detrimental impacts on cognitive function and
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS

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memory, which may lead to decreased clinical performance (i.e. communication and decision
making) and medical errors (Tawfick et al., 2018). The cost implications of excessive stress in
the clinical setting are significant; approximately 20 billion dollars each year in United States
healthcare system spending is attributed to medical errors. Additionally, stress-related
absenteeism contributes to loss of productivity (James et al., 2013).
In 2004, the American Association of Nurse Anesthetists (AANA) responded to the high
prevalence of stress and stress-related ailments among certified registered nurse anesthetists
(CRNAs) and SRNAs by establishing the AANA Health and Wellness Program to design,
implement, and monitor strategies of health promotion that focus on wellness and self-care. The
AANA endorses mindfulness meditation as an approach to improving mental health and well-
being. While the University of Southern California Program of Nurse Anesthesia (USC PNA)
has employed many of the AANA Health and Wellness interventions, there are currently no
routine mindfulness meditation programs built into the curriculum.
Student Registered Nurse Anesthetists experience personal stressors (e.g. strains on new
roles, interpersonal relationships, finances, sleep deprivation, and body image) and curriculum
stressors (e.g. work overload, fear of failing to meet expectations, conflict with peers, faculty, or
preceptors, fear of making clinical errors, and passing certification boards) (Chipas, 2011;
Chipas, 2012; Phillips, 2010). When SRNAs begin clinical residency, stress levels increase as
they transition from the role of didactic student to medical learner and begin interacting with
patients and making critical clinical decisions (Chipas & McKenna, 2011). Pressure to perform
elevates during the final year of school as SRNAs study for certification boards and transition
into their professional role as an advanced practitioner.
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 6
This team of researchers uses the following operational definition of mindfulness: it is a
mental state achieved by focusing one’s awareness on the present moment, while calmly
acknowledging and accepting one’s feelings, thoughts, and bodily sensations (Oxford Online
Dictionary, 2021). Mindfulness meditation stems from Buddhist meditation, as the practice of
being aware of one’s internal and external environment through a non-judgmental perspective
(Kabat-Zinn, 1982). Kabat-Zinn created the first Mindfulness Based Stress Reduction (MBSR)
program for the management of chronic pain in the United States during the 1970s. Kabat-Zinn’s
eight-week MBSR program consisted of weekly two-hour classes and asked participants to
complete daily 45-minute meditation exercises at home. The practice and incorporation of
mindfulness meditation has expanded in recent years, leading researchers to study the effects of
MBSR programs on stress levels among varying populations, including healthcare personnel and
medical learners.

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Chapter 2
Literature Review
SRNAs and Stress
Chipas and McKenna (2011) used a self-assessment survey tool in a cross-sectional
observational study to analyze and compare the variation in stress levels between SRNAs and
CRNAs. This study evaluated the coping mechanisms utilized to combat the effects of stress.
There were 7,537 CRNA and SRNA respondents; approximately a 26.9% response rate of
eligible anesthesia providers. The authors reported on an average day, SRNAs rated their stress
level at 7.2 and CRNAs rated their stress level at 4.7, on a 10-point Likert scale. Students
reported associating 90% of their stress with school-related work, but additional contributing
factors included financial debt, strains on interpersonal relationships, and their new role as
students. Only 27% of SRNA respondents sought professional help for mental health.
In a subsequent survey study, Chipas et al. (2012) evaluated a more descriptive
comparison of student stress levels between front-loaded and integrated nurse anesthesia
programs. Front-loaded programs are set up to deliver the didactic portion of the program before
the clinical experiences, whereas integrated programs offer the same learning experiences via
simultaneous classroom and clinical education. The results indicated that students enrolled in
integrated programs had higher stress levels than those in front-loaded programs, 7.9 and 7.1
(p<0.05), respectively. The data was statistically analyzed using an independent t-test and
Pearson correlation coefficient, with a sample size of 1,374 SRNAs. Student stress levels among
various ethnicities were also analyzed; results indicated minority students, Hispanics, and
African Americans specifically, had higher perceived stress level scores than White students.
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 8
Depression also played a large role in the well-being of SRNAs, with 47.3% of students
indicating that they were depressed while in nurse anesthesia school, and 17.1% on prescription
medication for stress-related symptoms. As much as 21.2% of students reported experiencing
suicidal ideation, with 6.3% knowing someone who had committed suicide while in nurse
anesthesia school.
Phillips (2010) surveyed twelve nurse anesthesia graduates (less than two years out of
school), representing five different nurse anesthesia programs. This qualitative study was
analyzed using grounded theory methodology. The results identified three theoretical stages of
stress: transitioning into the program (first 9 months of their respective programs), finding their
way (months 10-18 of the program), and transitioning out (months 19-28 of the program). The
twelve graduate students who participated in this study shared 739 qualitative passages relating
specifically to personal stressors and 724 passages referencing the curriculum stressors. The
most cited personal stressors within these passages referenced relationships with spouse or
significant other (122), financial problems (113), relationships with classmates (102), and role
strain (102). The most frequently identified curriculum stressors within these passages included
ineffective time management (84), adjusting to different teaching styles (83), clinical
assignments (75), and competence as future clinical providers (70). There were a total of eight
subgroups within the category of personal stressors, including role strain, lack of personal time,
relationships with children or family, body image, relationships with spouse or significant other,
relationships with classmates, sleep deprivation, and financial problems. There were fifteen
subgroups within the category of curriculum stressors, including expectations, class structure,
ongoing personal conflict with peers, fear of reprimand, conflict with faculty or clinical
instructors, ineffective time management, clinical assignments, adjusting to different teaching
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styles, clinical evaluations, fatigue and workload, competence as a future clinical provider, fear
of clinical error, fear of clinical instructors’ perception of competence, taking certification board
examinations, and fear of dismissal from the program. Based on those responses, the author
offered recommendations for action. The first recommendation was for nurse anesthesia faculty
to consider incorporating professionally guided group counseling sessions and including stress
management training programs in an effort to increase the motivation of SRNAs. Phillips also
recommended his study to be replicated but aimed specifically at students currently enrolled in
different semesters of a nurse anesthesia program, in order to gain a fuller understanding of the
student’s experience within a rigorous nurse anesthesia graduate program.
Mindfulness-Based Stress Reduction Program Adaptations
With appropriate adaptations focused on the role of stress, study results reveal that
mindfulness-based stress reduction programs demonstrate feasibility and effectiveness, and may
be implemented successfully (Kabat-Zinn, 1982). Kabat-Zinn’s original MBSR program
consisted of weekly 2-hour meditation classes and daily 45-minute homework over eight weeks,
however modern meditation programs have been adapted to accommodate a more feasible time
commitment for medical learners.
Mindfulness Meditation Duration
Shorter versions of MBSR programs were created to accommodate the complex schedule
of medical learners and have been shown effective in reducing stress. Erogul et al. (2014)
conducted a randomized control trial (RCT) that demonstrated weekly 75-minute mindfulness
sessions and 20-minute daily mindfulness exercises over eight weeks significantly decreased
PSS scores by 24% among 58 first-year medical students compared to a control group (p = 0.03).
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 10
Additionally, a RCT of 65 medical students in their last two years of study showed that 30
minutes of mindfulness meditation a day over eight weeks significantly reduced PSS scores
when compared to a control group (-3.44, CI -6.20 to -0.68) (Warnecke et al., 2011). A
prospective RCT of 88 medical students demonstrated 10-20 minutes of mindfulness meditation
over 30 days significantly reduced PSS scores in both per-protocol and intention-to-treat
analyses (Yang, Schamber, Meyer, & Gold, 2018).
Mindfulness Meditation Delivery Method
Various methods of mindfulness delivery have been studied, including formal mindful
programs led by a trained instructor, as well as informal or self-regulated mindfulness practices
(Lebares et al., 2018). Research suggests the incorporation of formal and informal mindfulness
practice provides significant benefit to medical learners.
In-person. Erogul et al. (2014) implemented a similar approach to a mindfulness
intervention with 58 first year medical students, incorporating formal group instruction and daily
independent meditation at home. At baseline, PSS scores for the intervention group were 17.6, as
compared to control group scores of 18.3. At the conclusion of the initial intervention, PSS
scores were significantly different between the treatment and control group (13.3 vs. 17.3,
p=0.03, 95% CI (0.37-6.89)). The reduction in PSS scores trended toward improvement at six-
months follow-up but were not statistically significantly. This could be due to significantly low
adherence to the requested weekly minimum of 140-minutes of mindfulness exercises at home––
the average among participants was 40 minutes. Also, the authors state that the study was
underpowered due to a low effect-size.
Virtual. Smartphone applications that instruct mindfulness exercises offer a feasible and
flexible mode of delivery for medical learners and have been shown to effectively reduce stress.
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Yang et al. (2018) evaluated the effects of using Headspace, an audio-guided meditation
program, on stress among medical students. The meditation training program consists of audio-
guided mindfulness exercises that range from “taking notice of the body at rest, breathing with
intention, and breathing normally to noticing sounds, sensing emotions, and acknowledging
thoughts without assigning judgment [that] are delivered in a calm manner with intermittent
breaks in audio” (Yang, Schamber, Meyer, & Gold, 2018). Perceived Stress Scale scores
significantly decreased after 30 days of using Headspace for 10-20 minutes daily. The average
days of use was 11.97, and 74% of students continued using Headspace during the subsequent 30
days after the initial 30-day study period. However, selection bias may have contributed to high
compliance and adherence, since participation in this study was voluntary and those that
volunteered may have been experiencing higher stress levels and were more willing to
participate in a program that could potentially reduce their self-acknowledged stress.
Cavanagh et al. (2013) conducted a randomized controlled trial (RCT) measuring the
effectiveness of a 2-week online self-guided mindfulness-based intervention (MBI) on reducing
PSS and anxiety/depression among 104 college students from a university in South England. The
study focused on common elements of well-established MBI such as MBSR, mindfulness-based
cognitive therapy (MBCT), as well as 10-minute daily guided meditation audio tracks to
implement in their online training. The students were randomly selected to start a two-week, self-
guided MBI study and were randomly assigned to one of two groups: MBI or a wait-list control.
The study measured each student’s stress and anxiety/depression prior to and after the
intervention through measures such as, five facet mindfulness questionnaire (FFMQ), perceived
stress scale (PSS), Patient health questionnaire for depression and anxiety (PHQ-4), and
engagement and experience questionnaire. The results showed the intervention group had a
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 12
significant increase in mindfulness (p = 0.001), decrease in stress scores (p < 0.001), and
decrease in anxiety/depression (p = 0.004). The results from this study indicate even brief online
mindfulness practice is effective and beneficial in reducing stress and increasing mindfulness
levels among university students.
Auditory. Mindfulness training programs delivered via audio compact discs (CDs) have
been shown to reduce stress among medical learners but may not offer the same adherence to the
practice when compared to other forms of delivery. Warnecke et al. (2011) found a significant
reduction in PSS scores among medical students in their last two years of study when guided by
an audio CD for 30 minutes a day over eight weeks. Although only 32% of participants
continued the practice after the conclusion of the initial intervention, the reduction in PSS was
maintained in the eight-week follow-up. The limitations of this study include small sample size
in the treatment arm (n=31) and short period of follow-up. However, the authors note that the
follow-up assessment was collected within weeks of the school’s end-of-year assessments, which
they speculate is a period where students experience more stress. This shows that although the
study had modest adherence to mindfulness meditation practices, the effects of the initial
intervention were still sustained through a particularly stressful period.
Mindfulness Meditation Feasibility, Longevity, and Adherence
Several studies have examined the feasibility and utility of incorporating mindfulness
meditation in an attempt at stress reduction. Results predicting the retention of mindfulness
practice long-term are variable. Nonetheless, research does indicate an association between
adherence to mindfulness meditation practice and increased intervention effect. Lebares et al.
(2018) used the Credibility and Expectancy Questionnaire (CEQ) to focus primarily on the
feasibility and effectiveness of modified MBSR training on surgical interns and found no
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significant attrition rate from the control group (15%) to the intervention group (13%). These
authors found mindfulness practice times ranged from 5-20 minutes and were variably
maintained an average of 3 days per week throughout the follow-up year. Another study by Vibe
et al. (2013) examined the effects of a seven-week MBSR program on 288 medical and
psychology students. This study demonstrated the following changes: the sum of the duration of
home mindfulness practice was significantly associated with increased intervention effect (p <
.05). The degree of attendance to MBSR classes was also associated with significantly greater
treatment effect (p < .01). It can be inferred from this evidence, that the incorporation of
mindfulness practice appears to exert no negative effects, and possibly has beneficial effects over
time.
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 14
Chapter 3
Methodology
There were two sources for the data in this capstone project: an integrative review to
address specific aim #1, and a wellness-intervention study, described below, to address specific
aim #2 and #3.
This project used evidence-based research to create a novel integration of mindfulness
practice into the doctoral nurse anesthesia program at USC. In order to do so, the project focused
on second year graduate students at USC PNA. These second-year students were in their fifth
semester with four months of clinical experience providing anesthesia care to patients. It was
hypothesized that this particular time-period would be adequate in allowing for the appropriate
measurement of stress among the participants and an ideal time to introduce mindfulness
intervention. A comprehensive integrative review was used to expand and collect research
pertaining to the study. The review utilized valid and reliable databases, including CINAHL,
Pubmed, and PsycTESTS, explored the physical attributes of stress, and supported the
implementation of a mindfulness practice to reduce stress levels among medical learners, and
non-medical learners, alike. The different search terms included: mindfulness-based stress
reduction AND nurse, student led mindfulness, Kristin Neff AND mindfulness, Ruth Baer,
mindfulness AND stress reduction AND medicine, mindfulness AND stress AND healthcare
personnel, and nurse anesthetists AND stress, psychological. Based on these searches, several
Medical Subject Headings (MESh) terms were created to optimize relevant article findings.
Studies were screened using inclusion and exclusion criteria, leaving a total of twelve
publications for review. The inclusion criteria consisted of studies examining stress in relation to
medical learners, nursing students, graduate students, healthcare professionals, and associated
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mindfulness practice, as well as RCTs published between 2009-2020. Exclusion criteria
consisted of studies examining stress related to non-medical and non-graduate students, as well
as studies published prior to 2009. Throughout the refinement process of the literature review,
selected search terms were narrowed considerably to ensure applicability to the patient
population selected for this research project.
A longitudinal online wellness-intervention study at USC PNA was constructed with the
capstone committee chairperson and biostatistician to help measure the effects of mindfulness
implementation on reducing stress levels among second year SRNAs. Ethical approval for this
prospective cohort study was sought from the University of Southern California Institutional
Review Board (IRB), which approved The Mindfulness Project UP-20-00373. The process
began by application to the IRB to determine the appropriate level for human subject protections.
The study was approved as expedited with minimal risks to the participants by a member of the
IRB committee. Expedited approval required the study to fit in one of the federally designated
expedited review categories. Once approved, student demographics such as ethnicity,
employment status, and relationship status were collected using the Research Electronic Data
Capture (REDCap) (Table 1). Study participation was voluntary.
Procedures
A convenience sample of participants was recruited in a private and respectful manner,
free of coercion. The potential participants were assured that participation or lack of participation
would have no impact on any aspect of the student’s educational evaluation or experience at the
USC Program of Nurse Anesthesia. Informed consent was obtained by reading the informed
consent document to participants, answering any questions, followed by the participant signing
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 16
the consent form. The inclusion criteria were second year SRNAs enrolled at a three-year
doctoral training program (USC Program of Nurse Anesthesia), and currently participating in
clinical rotations. The exclusion criteria were students who chose not to participate in the study.
Based on the trained mindfulness instructor’s analysis, any individual with high scores,
determined to be at high risk, would receive a referral to the Counseling and Mental Health
department, on the Health Science campus of University of Southern California. Subsequently,
participants were enrolled after written and verbal consent from each student. No financial
compensation was provided.
The wellness program was taught by a trained and certified mindfulness instructor,
Reverend Jim Burklo. Rev. Burklo is a Senior Associate Dean in the Office of Religious and
Spiritual Life at USC and is a faculty mentor within the Keck School of Medicine. In addition,
he has several published works related to his Master of Divinity degree and has been teaching
mindfulness practice for over forty years. He previously served as a mindfulness instructor at
Stanford for ten years, and has been practicing at USC for twelve years, as the co-founder of
Mindful USC, which is a service offering ongoing training, practice groups, and special events
throughout USC. The mission of Mindful USC is to empower the USC community to make
positive change by building a culture of mindfulness and compassion and is readily accessible as
a phone application.
Student participants were enrolled in a longitudinal, five-week MBSR intervention
program. The mindfulness program included one-hour weekly classes held via private zoom
sessions. Students were given weekly “homework” assignments which consisted of practicing
mindfulness meditation at home and were encouraged by the instructor to access the Mindful
USC phone application available to all currently enrolled USC students. The mindfulness courses
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17
consisted of one-hour guided sessions that emphasized different themes each week. The first
week focused on an introduction of the instructor and students, as well as a primer on
mindfulness and the expectations of the 5-week course. The additional four weeks centered
around topics of progressive muscle relaxation, compassion for oneself, and attention to
emotions, thoughts, and bodily functions.
Perceived Stress Scale
The Perceived Stress Scale (Appendix A) was utilized as an anonymous electronic survey
instrument to measure responses to the intervention in this pre-test/post-test research design. This
instrument is aimed at measuring the students’ stress levels. The Perceived Stress Scale is an
economical tool that was designed for use in community samples and requires only a few
minutes to complete. The PSS has been used in studies of healthcare students, similar to this
investigation, and was found to be valid and reliable. It represents a way to assess psychological
stress and gauges an individual’s pattern of reacting to events (Erogul et al., 2014). Cohen and
Williamson (1988) reported that scores on the PSS scale demonstrated adequate internal
consistency of 0.85, reliability, and adequate convergent validity. The PSS is one of the most
widely used psychological instruments for measuring the perception of stress. This scale is in the
public domain and does not require permission for use in academic research.
REDCap
The authors provided an electronic link to the survey questionnaire before the first
week’s session, at the conclusion of the last session, and four-weeks following the last session.
All survey answers remained anonymous to the authors through the utilization of Research
Electronic Data Capture (REDCap), an application ensuring secure and Health Insurance
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 18
Portability and Accountability Act (HIPAA)-compliant data collection. It is important to
acknowledge that significantly high PSS scores may have warranted further investigation by our
mindfulness instructor and a referral to the Counseling and Mental Health department at USC.
Statistical Methods
Repeated measures analysis of variance (ANOVA) was used to analyze the data. The
Friedman one-way ANOVA was used to determine the overall change in median total PSS
scores from pretreatment to post-treatment and to 4-week follow-up. Bonferroni correction was
used to correct for multiple comparisons when assessing pairwise comparisons. All analyses
were two-sided with alpha = 0.05 and performed using SPSS Version 26.0 (SPSS Inc., Chicago,
IL).

MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS

19
Chapter 4
Results
Seventeen SRNAs initially attended the first mindfulness meditation session, however,
five participants were excluded from the study due to inability to attend follow-up sessions. A
total of 12 students participated in the five-week course. Of the participants, seven were female,
seven identified as White, four as Asian/Pacific Islander, and one preferred not to disclose their
ethnicity. Nine SRNAs were unemployed, six were partnered, and one married at the beginning
of the study (Table 1).
Table 1. Socio-demographic characteristics

N (%) Baseline (%) Post (%) 4-week (%)
All 12
Ethnicity
White 7 (58%)
Asian/Pacific Islander 4 (33%)
Prefer Not to Say 1 (8%)
Employment Status
Unemployed 9 (75%) 10 (83%) 10 (83%)
Employed 0-10hrs 0 0 0
Employed 11-20hrs 0 0 0
Employed >20hrs 1 (8%) 1 (8%) 1 (8%)
Prefer Not to Say 2 (17%) 1 (8%) 1 (8%)
Relationship Status
Single 4 (33%) 5 (42%) 4 (33%)
Partnered 6 (50%) 5 (42%) 6 (50%)
Married 1 (8%) 1 (8%) 1 (8%)
Prefer Not to Say 1 (8%) 1 (8%) 1 (8%)
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 20
Preliminary analyses found the total PSS scores differed over time by gender, and thus
analyses were stratified by gender (Table 2). The results of this pilot study showed no
statistically significant difference in median PSS scores amongst the collective group at baseline,
post-course, and at the 4-week follow-up (20.5, 16.5, and 13.5, respectively, p = 0.171). There
was a statistically significant reduction in median PSS scores among female students overall (p =
0.028) and between baseline scores and at the 4-week follow-up (21 vs. 14, adjusted p = 0.048).
Interestingly, male students experienced an increase in median PSS scores between the first and
second follow-up assessments, however this was not statistically significant (p > 0.05) (Figure
1).

Figure 1. Median PSS (IQR) score by gender

MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS

21
Table 2. Median (IQR) PSS scores at different timepoints for all subjects, as well as
stratification by gender.

N (%) Baseline Post 4-week p-value
All 12 20.5 (8-21.5) 16.5 (8.5-19.5) 13.5 (10-17.5) 0.171
Male 5 (42%) 9 (7-13) 9 (8-17) 12 (9-13) 0.662
Female 7 (58%) 21 (20-25) 17 (13-20) 14 (11-18) 0.028
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 22
Chapter 5
Discussion
Extraordinary world-wide circumstances occurred during the implementation phase of
this pilot study that may have contributed to elevated PSS scores. In December 2019, an
outbreak of a novel strain of coronavirus (SARs-CoV-2) was discovered in Wuhan, China.
SARs-CoV-2 rapidly spread across the globe and caused a fatal respiratory disease, later termed
Coronavirus Disease of 2019 (COVID-19). By March 2020, the World Health Organization
(WHO) declared COVID-19 a worldwide pandemic. Countries began closing their borders and
discontinuing international travel. Counties across the nation initiated “stay-at-home” orders in
an attempt to decrease disease transmission. Students were no longer able to attend classes in-
person, many individuals who had the privilege to work from home did so, and a transition to
virtual interactions (by means of video conferencing applications, such as Zoom) swept the
nation. During the COVID-19 pandemic, there was a surge in concerns for mental health
(Centers for Disease Control and Prevention, 2021; Droit-Volet et al., 2020). The new physical
distancing policies resulted in feelings of social isolation, the inability to engage in previous
coping strategies (i.e. socializing, exercising in gyms or outdoors, traveling, etc.), and completely
changed how people lived their lives. In addition, the United States quickly became the leader in
COVID-19 case prevalence and mortality. The stress of losing a loved one to this disease or even
fearing for the safety of a loved one can have a major impact on one’s mental health (Centers for
Disease Control and Prevention, 2021). Therefore, participating in nurse anesthesia school while
concurrently surviving a worldwide pandemic may have resulted in higher than normal PSS
scores found in this pilot study.
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS

23
To our knowledge, this was the first study to collect PSS scores among SRNAs. The
original mean PSS score of the study subjects at baseline was 20.5, which far exceeded the age-
matched normative mean of 12.9 (Cohen & Williamson, 1988). Perceived Stress Scores were
significantly higher in various populations during the COVID-19 pandemic. A recent
observational, cross-sectional study in Paraguay evaluated PSS scores to investigate stress levels
among the general public during the current COVID-19 pandemic. Their results from 2,260
subjects showed a PSS score of 18.10 (+/- 5.99) with women scoring higher than men (18.54 vs.
16.82, respectively) (Torales et al., 2020). A longitudinal case study of 19 participants made up
of students, post-doctoral fellows, and faculty at the University of Tennessee Health Science
Center, found overall PSS scores to be between 17.4 and 18.5 at the beginning of the COVID-19
pandemic. Possible explanations for this finding may have been due to multiple factors,
including that medical learners who are in clinical rotations are potentially at higher risk of
exposing themselves to COVID-19 and, therefore, face additional stressors.
Previous studies have documented higher stress levels among female medical learners
(Dahlin, Joneborg, & Runeson, 2005; Neufeld, Mossière, & Malin, 2020). Possible explanations
for this phenomenon may have stemmed from female students’ self-concept and paradigm of
their own skills and capabilities in a male-dominated field that may have resulted in more
stressors (i.e. higher evaluation anxiety, imposter syndrome, and social isolation) (Wyatt et al.,
2019). Additionally, mindfulness meditation has been shown to have a greater reduction in stress
among female students. Vibe et al. (2013) evaluated the effect of a seven-week MBSR program
on mental distress, study stress, and burnout among 288 medical students (76% female) by
utilizing the Perceived Medical School Stress (PMSS) scale. They found only female students
had a significant intervention effect on the three outcome variables regarding stress.
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 24
Interestingly, similar to this pilot study, the male students in the study by Vibe et al. experienced
higher PMSS after the intervention. The authors hypothesized biological and gender-specific
socialization processes affected how students experienced and expressed stress. Therefore, it was
possible that mindfulness meditation helped male students become more aware of their stress,
while helping female students handle their stress better (Vibe et al. (2013).
The female students in this study had an overall reduction in self-perceived stress when
averaging the three PSS scores taken at baseline, post-course, and 4-week follow-up. Results also
showed a significant decrease in the female students’ baseline PSS scores compared to the four-
week follow-up scores, but not the post-course scores (baseline vs post, p=0.135). This may have
suggested that the longer the female participant practiced mindfulness, the greater reduction in
stress levels. The authors could not support this hypothesis beyond the study conditions because
there was no follow-up with these participants to ensure that they continued their mindfulness
practice after the course was completed. It could be speculated that the sample size of males
(n=5) was too small to detect a statistically significant difference between pre and post-
intervention data.
This study confirmed findings from previous research demonstrating elevated stress in
SRNAs (Chipas and McKenna, 2011; Chipas et al., 2012). In these national cross-sectional
observational survey studies, multiple causes of stress in this population were elucidated.
Important stress-causing factors included entering school, time in training, stress increased in
association with senior students, changing careers, moving residence, and minority identity
students. Griffin et al. (2017) further elucidated sources of stress particular to this population,
including a sense of vulnerability, altered living routines, sleep deprivation, and lack of exercise
and leisure time.
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS

25
Attrition and fidelity were common issues found in previous studies. We expected our
pilot study to face similar issues. Although we started off with 17 students enrolled in our
program, we anticipated that some students would drop the program or skip some classes. It is
also worth noting that the authors could not force students to do their “homework”––mindfulness
meditation exercises––during their free-time. Therefore, it was anticipated that fidelity would be
an issue and may affect the results.
Limitations
Due to its exploratory nature, the study had many limitations resulting in the need for a
larger, more diversified investigation. This research used a non-randomly selected, convenience
sample of 17 SRNAs. There was significant attrition, and several factors may have been
responsible. Firstly, our mindfulness meditation program was augmented from an in-person
course to video sessions using the Zoom online platform as a result of the COVID-19 pandemic
infection control restrictions. This limitation of face-to-face access to participants may have
negatively impacted engagement, and thus contributed to the attrition rate. Secondly, we
acknowledge the participants of this study as classmates from a single educational program, and
this circumstance may affect not only their willingness to reveal or share personal stressors, but
also limits the comparability of these findings to other cohorts. Lastly, we acknowledge that the
paucity of high-quality data relevant to this student population may have produced bias in the
selection process of studies to review. The investigators spared no effort to assure that the
included studies represented the most robust evidence that was currently available.
Future studies on the effect of mindfulness on SRNA stress levels should include larger
group samples, and students from different programs in order to more accurately represent the
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 26
SRNA population. Including a control group can further strengthen any findings within the
study.
Conclusion
There is a growing body of research supporting the association between mindfulness and
stress reduction in student populations. Significant acute and chronic stress levels among medical
learners is a widely acknowledged factor affecting coping strategies, clinical performance, and
overall interpersonal interactions within the characteristically stressful work environments of the
perioperative theater. The incorporation of mindfulness may serve as a buffer to prevent adverse
events from occurring in students learning in such a stressful environment. Mindfulness can be
characterized as a “personal tendency to focus on the present time in a non-judgmental manner,
including the interior and exterior experience of feelings and events” (Alzahrani et al., 2020).
The aim of this prospective longitudinal cohort pilot study was to explore the relationship
between mindfulness meditation and stress levels in a population of second-year student
registered nurse anesthetists. We hypothesized engagement in mindfulness meditation would
show an inverse relationship with stress scores. Significant improvement in perceived stress
scores was demonstrated in female participants at the 4-week follow-up interval survey post-
intervention. The change in perceived stress scores among male participants during and after the
intervention was too small to detect any significant association. Explanations for this discrepancy
were unclear and warrant further investigation with larger and more diverse sample sizes. Further
publications regarding mindfulness meditation are necessary in order to better understand one’s
personal stress characteristics and how to better navigate and incorporate mindful practice within
the healthcare environment and workplace. Currently, there is great opportunity for healthcare
systems and graduate medical programs to prioritize wellness initiatives to enhance the
MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS

27
wellbeing of clinicians, improve healthcare quality, and decrease the odds of preventable medical
errors.
Disclosures
The authors of this prospective cohort pilot study declare that they have no competing
interest and obtained no external funding for this project.

MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 28
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MINDFULNESS AND STRESS IN STUDENT NURSE ANESTHETISTS 34
Appendix A

Abstract (if available)

Abstract Medical learners and healthcare professionals are susceptible to high levels of stress, which is associated with medical errors, poorer patient care, and negative psychological conditions. Twelve SRNAs in their second year of graduate school at USC participated in a five-week online mindfulness program that covered areas such as body scan meditation, sitting meditation, progressive muscle relaxation, loving-kindness meditation, and compassion for oneself, and attention to emotions, thoughts, and bodily functions. The Perceived Stress Scale (PSS) was used to quantify stress before, immediately after, and four weeks following the program. The median pre-intervention PSS score among the participants was 20.5. Male SRNAs demonstrated a trend toward increased PSS scores between the three-time intervals, however this was not statistically significant (9, 9, and 12, p = 0.662). Female SRNAs demonstrated a statistically significant overall reduction in PSS scores between the three-time intervals (21, 17, and 14, p = 0.028) and between baseline scores and at the four-week follow-up (21 vs. 14, p = 0.048). A five-week online mindfulness program significantly reduced stress among female SRNAs. The change in perceived stress scores among male participants during and after the intervention was too small to detect any significant association.

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Asset Metadata

Creator Lopez, Jorge (author)

Core Title The effects of mindfulness meditation on stress levels among student registered nurse anesthetists: a pilot study

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Publication Date 04/20/2021

Defense Date 04/20/2021

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Tag anesthesia,healthcare personnel,medical learner,Meditation,mindfulness,OAI-PMH Harvest,Stress,stress reduction

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Advisor Bamgbose, Elizabeth (committee chair), Burklo, Jim (committee member), Griffis, Charles (committee member)

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