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. 2023 Apr 25;10(8):5493–5499. doi: 10.1002/nop2.1788

Effect of online modified mindfulness‐based stress reduction training on the resilience of nursing interns in China

Yanqiu Wang 1, Jingli Kou 1, Binru Han 2,✉
PMCID: PMC10333883  PMID: 37186462

Abstract

Aim

This study aimed to adopt online mindfulness‐based stress reduction (MBSR) training to increase the resilience of nursing interns and help them to achieve a smooth transition.

Design

A one‐group pretest‐posttest study design was used.

Methods

A total of 119 college nursing interns were recruited from 12 tertiary hospitals in Beijing on Feb.20, 2021. The MBSR training was organized into 4 weeks of courses, conducted online using Tencent Meeting and taught by a certified teacher at the Oxford Mindfulness Centre. Resilience was assessed before and 2 weeks after the training, respectively, using Resilience Scale for Chinese Adolescents via an online questionnaire tool.

Results

Seventy‐nine college nursing interns finished both of the resilience questionnaire surveys. The mean resilience values before and after the training were 98.7 ± 13.69 and 104.57 ± 16.64 respectively. The 4‐week online MBSR training considerably increased the resilience of nursing interns. This can be an effective measure to maintain a balanced state among nursing interns and help them smoothly transition from school to clinical practice.

No Patient or Public Contribution.

Keywords: mindfulness‐based stress reduction, nursing interns, online, resilience

1. INTRODUCTION

A study showed that 83.3% of nurse interns felt stressed about their internship experience (Woo & Newman, 2020). Stress is a common experience that a nursing student will be exposed to in clinical practice. It can be motivated by work burden, patients, charging of pain management, or other challenging things, and lead to emotional stress, moral distress and burnout (Delgado, 2017). In China, every nursing student needs to complete an internship in the last year of the course. It will last for 8 months or more but less than 12 months. Usually, they will rotate most kinds of departments of hospital. An internship facilitates the transition from being a nursing student to being a clinical nurse role. It aims to help interns to apply theory into practice and gain competencies in nursing skills before graduation. Unlike experienced nurses, nursing interns lack social and clinical experience and thus are particularly vulnerable to high levels of stress. They will face many professional events, such as long working hours, numerous theory and skills learning, nursing critical patients, conflicts with colleagues or patients, and pain and psychological distress. These events are stressful and challenging for young nursing students to deal with these things. Nursing students tend to experience high levels of stress and anxiety (Turner & McCarthy, 2017), and was higher than general students (Bartlett et al., 2016). Stress is more likely to lead to longer‐lasting emotional and psychological adverse effects if the individual is unprepared for the event, they felt powerless to prevent the event, or it occurred repeatedly. Thus, it is essential for nurse leaders or teachers to consider stress reduction programmes for nursing interns (Cowden et al., 2011).

2. BACKGROUNDS

Psychological resilience is a positive adaptability or the ability to “bounce back” when confronted with new and predominantly negative situations involving adversity, stress and trauma (Tugade & Fredrickson, 2004). It represents a complex set of various protective factors and processes. A resilient nurse can ‘bounce back’ quickly and effectively from stressful events. This is significantly associated with burnout among nurses (Guo et al., 2018). People's responses to adversity substantially vary (Smeeth et al., 2021). Early identification and targeted intervention for low resilience will help nursing interns achieve a smooth transition. The pandemic of COVID‐19 and the prevention and control measure to mitigate the spread of the virus have significantly affected the students' learning, especially the clinical practice nursing internships.

Mindfulness is defined as moment‐to‐moment non‐judgmental awareness and a skill that can be learned through practice (Brown & Ryan, 2003). MBSR is a structured group programme that employs mindfulness meditation to alleviate suffering associated with physical, psychosomatic and psychiatric disorders (R., 2002). Fostering mindfulness is one strategy for cultivating resilience among nurses (Wei et al., 2019). Mindfulness‐based stress reduction (MBSR) has been widely evaluated in mental, physical and healthy populations (Sharma & Rush, 2014). It is a widely disseminated and frequently cited example of mindfulness training to reduce stress, depression and anxiety. Studies of mindfulness interventions displayed a high level of evidence, and transcended stress, anxiety and depressed mood among various interventions for reducing stress of nursing students (Aloufi et al., 2021). It can increase awareness and response optimally to adverse events. However, except for the clinical staff, the MBSR training should focus more attentions on nursing interns in clinical practice. Former study demonstrated that MBSR was effective when it was used with nursing students in reducing measures of depression, anxiety and stress, and increasing their mindful awareness (Song & Lindquist, 2015). For the epidemic of COVID‐19, nursing students are under tense stress and the offline intervention was limited to adapt for them. In order to identify whether the online modified MBSR training could increase resilience of nursing interns or not, we designed this programme.

3. METHODS

3.1. Aim and design

A one‐group pretest‐posttest study was conducted to test whether online modified MBSR training could increase resilience of nursing students during internship. The principle of anonymity was adopted in data collection to protect student privacy, we did not collect the students' name or other identity information. It was a one‐group pretest‐posttest design but not a paired samples design.

3.2. Sample and recruitment

According to a former study (Song & Lindquist, 2015), the sample size was calculated by the formula of comparison of means between two samples, in which the significance level and power of the test were 0.05 and 0.9. The minimum number of participants was 53. The value of α was 0.05 and β was 0.1. were included in this study voluntarily, while students on leave were excluded. The inclusion criteria of this study were as follows: (1) nursing students during internships; (2) nursing student who was volunteering for the study. Nursing students who were on annual leave or sick leave during the intervention period were excluded.

A convenience sampling was used to recruit participants from 12 teaching college hospitals of grade 3 class A (In China, hospitals are designated as primary, secondary or tertiary institutions, and each of which contains three grades. Tertiary hospitals round up the list as comprehensive or general hospitals at the city, provincial or national level. Grade 3‐Class A hospital is on the top level). The principle of anonymity was adopted in data collection to protect student privacy, we did not collect the students' name or other identity information. It was a one‐group pretest‐posttest design but not a paired samples design. Informed consent was taken from the study participants before the training started.

3.3. 4‐week online modified MBSR training

Against the coronavirus disease (COVID‐19) pandemic, the 4‐week MBSR training was conducted online through Tencent Meeting. Tencent Meeting can allow for an online conference involving 300 people and has varied functions to meet our group intervention needs. The software enables real‐time screen sharing of the screen and supports online document collaboration. All participants participated in the programme in one training conference. Tencent meeting has a function of video recorded. We distributed the class schedules and reminded students to attend class via the WeChat group. The timing of the intervention was set at the midterm of the internship. At that time, nursing students have experienced most of the nursing work.

The trainer and participants could communicate and interact via video. The trainer is a certified teacher by the Oxford Mindfulness Centre. This package of 4 weeks of mindfulness practices focused on experiential training, including body awareness, yoga, breath‐focused attention, body scan‐based attention, walking meditation and eating meditation. Each class includes theoretical study and in‐class practice, followed by feedback and sharing per week. Each week, nursing students would be asked to finish the home practice. If any student could not attend the training at the set time, we would send a recorded video version to the student for self‐study and practice. The content and arrangement of the programme are shown in Table 1.

TABLE 1.

Overview of the online MBSR programme.

Week Theme Practice Home practice
1 Awareness and perception Body scan and mindfulness of breath Body scan
2 Power of presence and choiceless awareness Walking meditation and lying down yoga Lying down yoga
3 Identifying disgust and stress management Body scan, mindful eating and sitting with unpleasant sensations Mindfulness of breath
4 Intentional mindful responses and mindful communication Mindful communication techniques Practice mindful communication techniques
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3.4. Resilience assessment

Nursing interns' resilience was determined before the online MBSR training and 2 weeks after it. The Resilience Scale for Chinese Adolescents (RSCA) (Yueq & Yiq, 2008) was used to evaluate the resilience of nursing interns. The scale has 27 items, including workforce and support force dimensions. The former includes goal focus, emotion control and positive cognition, and the latter includes family support and interpersonal assistance. Each item adopts a 5‐point Likert scoring method, and a full score ranges from 27 to 135 points. Among them, 12 items are scored reversely: the higher the score, the better the level of resilience. Cronbach's coefficient of the scale was 0.832–0.851, and the retest reliability was 0.862.

3.5. Data collection and analysis

Participants' demographic characteristics and resilience were collected by a universal online questionnaire platform in China powered by www. wjx.cn. The online questionnaire was prepared in Chinese with a by QR code and distributed among participants through WeChat. Unified instructions were used to explain the manner of filling out the questionnaire and the purpose and significance of the programme. The questionnaires were filled out anonymously. Nursing interns scanned the QR code to complete the questionnaire and then submit it. The researcher obtained data from the background database. Data were collected separately before the MBSR training (Feb. 20, 2021) and 2 weeks after the training (April 3, 2021).

IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY, USA) was used for data analysis. Measurement data were described by the mean ± standard deviation. Differences in resilience before and after the MBSR group intervention were tested to verify the value of online MBSR group intervention. T‐test was used for comparison between groups. p < 0.05 was considered a statistically significant difference.

3.6. Ethics

The ethical committee has approved the study of REDACTED. All participants signed informed consent.

4. RESULTS

4.1. Participants' demographic characteristic

A convenience sampling of 119 college nursing interns was enrolled on 20 Feb 2021, from 12 tertiary hospitals in Beijing. Before training, a total of 119 college nursing interns participated in the survey. The mean age of the 119 participants was (20.74 ± 2.0) years old. 97.5% of them were female (116/119). 32.8% (39/119) were class cadres and 59.7% (71/119) were from one‐child families. Three nursing students were not of Han nationality. Students of the cadres or from non‐one‐child families reported slightly higher resilience level compared with others, but the differences were not significant. (Table 2).

TABLE 2.

Relationship between nursing students' demographic characteristics and resilience level.

Demographic characteristics x ± s/n Resilience t/r p
Age 20.74 ± 2.0 98.7 ± 13.69 −0.072 0.437
Class cadres
Yes 48 100.21 ± 13.14 −0.990 0.324
No 71 97.60 ± 14.04
One child
Yes 80 98.16 ± 13.86 0.609 0.544
No 39 99.79 ± 13.42
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4.2. The resilience level of nursing students

The mean level of resilience was (98.7 ± 13.69) of the 119 nursing students. The lowest scored dimension was positive cognition. The two dimensions and total score of resilience level are shown in Table 3.

TABLE 3.

Resilience level of the study participants (N = 119).

Variables Score
Manpower
Goal focus 18.29 ± 3.14
Emotion control 20.53 ± 4.58
Positive cognition 15.31 ± 2.81
Support force
Family support 22.37 ± 4.55
Interpersonal assistance 22.19 ± 4.67
Resilience 98.7 ± 13.69
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4.3. Intervention effects on resilience

After 2 weeks of training, 79 nursing interns were left because 40 students drop out of the training or resilience measuring. The mean level of resilience was (104.57 ± 16.64). The change in resilience differed significantly (p = 0.007) before and after training (Table 4). To better understand how MBSR training influences the resilience of participants, a sub‐analysis of the differences in five resilience factors differences before and after training was conducted (Table 5), and the differences were significant among emotion control and family support domains (p < 0.05).

TABLE 4.

Difference in resilience before and after online MBSR training.

Group N Resilience t p
Before training 119 98.7 ± 13.69 −2.710 0.007
After training 79 104.57 ± 16.64
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TABLE 5.

Difference in five resilience factors before and after online MBSR training.

Factors Before training After training t p
Goal focus 18.29 ± 3.14 19.23 ± 3.56 −1.941 0.054
Emotion control 20.53 ± 4.58 22.24 ± 5.50 −2.373 0.019
Positive cognition 15.31 ± 2.81 16.03 ± 2.67 −1.787 0.076
Family support 22.37 ± 4.55 24.08 ± 4.68 −2.557 0.011
Interpersonal assistance 22.19 ± 4.67 23.00 ± 5.00 −1.157 0.248
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5. DISCUSSION

Compared with before training, the resilience of nursing interns improved significantly after the online MBSR training.

5.1. The heterogeneity of nursing students' resilience was not significant

The results of this study show that there was no significant difference in resilience between the ‘only child or not’ group, which may be related to the change of The Times. At present, the number of multi‐child families is increasing, the proportion of only children is decreasing, the economic problems of multi‐child families are decreasing and the emotional regulation of children is gradually paid attention to by parents.

5.2. Nursing students need effective resilience intervention during internships

Resilience is an essential skill for nurses to deal with stressors confronted in clinical work environment (McAllister & Lowe, 2011). An internship is a critical transition period for a nursing student before becoming a registered nurse. This transition period will affect their decision whether they will pursue nursing or not. However, nurses must interact with patients and other health care professionals and experience conflicts and stress. As young students, nursing interns will confront stresses, such as knowledge deficit, lack of confidence and theory‐to‐practice gap, suffering and death (Sa et al., 2019; Woo & Newman, 2020). Seeing patients in pain and suffering is the most stressful experience during the internship, for they have rarely seen it before (Happell et al., 2021). Studies have revealed that a negative transition experience would lead to a high burnout rate among new registered nurses within their first year of practice (Flinkman & Salantera, 2015). Besides, the other negative events, such as natural disasters, or bullying‐related suicides, have shown the need to foster resilience in our students to better prepare them for future change and life challenges (Stephens, 2013). Young college students are unprepared to deal with complicated life events and challenges they faced with, as a result, many will adopt negative coping and adaptive responses.

This study has identified that an online MBSR programme can foster resilience in nursing students. Nurse leaders have been actively trying to find ways to help nurses build resilience and combat burnout. The strategies identified herein can promote resilience among interns by helping them shift their focus, cultivate positivity/optimism, connect with others, practice being in the moment and improve their physical health through appropriate sleep, exercise and diet.

5.3. Online MBSR group intervention is an effective tool in increasing resilience of nursing students

Resilience is the ability to bounce back or cope successfully despite adverse circumstances (Mahmoud & Rothenberger, 2019). It arises from the normative functions of human adaptational systems, and it can be taught and developed with practice (Herbers et al., 2021). It is a protective intervention for health care to persist in overcoming burnout and acquire the skills to handle challenges for nursing students (Cleary et al., 2018). Thus, adequate and early identification and programmes specific to resilience supported by nursing managers or universities are needed to facilitate the positive transition among nursing interns. Many studies have focused on occupational burnout among registered nurses. Younger nurses tend to have a high burnout rate. This study focused on identifying and improving the resilience of nursing interns when they are in a resource‐scarce state compared with registered nurses (Zeng et al., 2020). Thus, we implemented the online MBSR group training to support and build resiliency in nursing interns. We advocate the development of online MBSR as an effective resilience‐enhancing interventions to help nursing students for transition.

A meta‐analysis suggests that mindfulness interventions effectively address burnout on the individual level (West et al., 2016). We designed a 4‐week online MBSR training, which improved the resilience of nursing interns. The present study is similar to previous studies among undergraduate nursing students (McVeigh et al., 2021). There is a growing consensus that MBSR training has various benefits for people, both physiological and psychological (Marciniak et al., 2020). According to former study (Fang et al., 2010) reported, MBSR can achieve a decrease in anxiety and C‐reactive protein levels in patients. Concerning resilience, the mean score of nursing students has increased by 5.87 points, and a significant difference was found before and after the online MBSR training.

5.4. Online group intervention is effective for certain public events situations

The COVID‐19 pandemic has disrupted nursing education and proposed a challenge to a traditional educational model. From a report of a the prevalence of four health problems of nursing students during the COVID‐19 pandemic, the health problem with the highest prevalence in nursing students was depression (52%), fear (41%), anxiety (32%) stress (30%) and sleep disturbances (27%) (Mulyadi et al., 2021). The systematic review proposed that strategies such as modified distance learning are necessary to manage nursing students' teaching and learning during the COVID‐19 pandemic or similar future situations to prevent health problems related to certain situations. Study found that COVID‐19 was related to nursing students' stress (Aslan & Pekince, 2021). Study from Israel found that stronger resilience was associated with significantly lower anxiety levels during COVID‐19 among nursing students (Savitsky et al., 2020). They did also advocate nursing educators focusing on lowering student anxiety by maintaining a stable educational framework, providing high‐quality distant teaching and encouraging and supporting students through challenging periods.

Against the COVID‐19 pandemic, we adopted an online group intervention, which has a crucial advantage in that it can be conducted without location and time restrictions. Online meeting software helped achieve excellent online interaction. Nursing interns can communicate with the MBSR trainer timely through videos. The trainer can make timely adjustments for convenience. They can communicate with each other through the microphone or on the message board.

Online MBSR training can be a significant resilience aid for nursing interns and has been associated with improvements in resilience. Through MBSR skills, nursing interns can develop a repository of positive coping mechanisms that will increase their ability to navigate the more stressful aspects of academic and clinical practice.

6. LIMITATIONS

The study has several limitations. First, 119 participants were recruited from several hospitals, but 40 of them did not complete the second resilience assessment. We recruited the participants by convenience sampling from 12 hospitals in Beijing that might lead to a sample bias, so it may not be representative of other nurses in China, and for this reason, these results may not generalize well to other institutions. Second, our goal was to increase the resilience of nursing students by the online modified MBSR training. Thus, further studies comparing the efficacy of formal training with more accessible interventions in other formats are warranted. Finally, most nursing interns included in the study were females. Thus, the results may not be generalized to male nursing students.

7. CONCLUSIONS

Young nursing interns will face many stressful events. Administrators or universities must consider providing adequate mental support. The online modified MBSR group intervention aimed to assist nursing interns in focusing attention and accepting their present state oneself. The MBSR training equipped nursing students with positive coping strategies during the stressful transition internship, and it was influential in the resilience management of nursing interns. It provides an excellent opportunity for nursing students to transition from the campus to a clinical environment.

AUTHOR CONTRIBUTIONS

Yanqiu Wang carried out conceptualization, methodology, investigation and writing original draft. Binru Han carried out conceptualization, methodology, review and editing. Jingli Kou was involved in investigation, review, editing, and revising the article. Yanqiu Wang and Jingli Kou contributed equally to this manuscript.

FUNDING INFORMATION

The study was funded by the 2019 Teaching Model and Methods Promotion Project of Yenjing Medical College, Capital Medical University (2019yjjx045).

CONFLICT OF INTEREST STATEMENT

No conflicts of interest are declared by the authors.

ACKNOWLEDGEMENTS

The authors thank all the participants in the study for their time and willingness to participate in the study and providing the rich and valuable information.

Wang, Y. , Kou, J. , & Han, B. (2023). Effect of online modified mindfulness‐based stress reduction training on the resilience of nursing interns in China. Nursing Open, 10, 5493–5499. 10.1002/nop2.1788

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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