Abstract
Introduction
Challenges of academic life are major sources of stress and anxiety for students, often manifesting as various psychological disorders. These disorders could adversely impact students’ performance, leading to multiple negative consequences. This risk is of particular importance among nursing and midwifery students due to their critical role in promoting mental health and well-being in the community. Despite the impact of certain educational and psychological interventions on coping with academic challenges, studies focusing on self-compassion training remain limited. Therefore, the present study aims to investigate the effectiveness of self-compassion training on resilience and reflective thinking among nursing and midwifery students.
Materials and methods
This clinical trial, utilizing a pretest-posttest design with a control group, was conducted on 90 nursing and midwifery students at Bushehr University of Medical Sciences in 2023. Participants were selected through convenience sampling and then randomly assigned to either the intervention or control group (n = 45 per group). The intervention group underwent self-compassion training in eight 90-minute sessions over the course of one month, while the control group received no intervention. The instruments used included a demographic form, the Connor-Davidson Resilience Scale (CD-RISC), and the Groningen Reflection Ability Scale (GRAS). Data analysis was performed using SPSS 20.0.
Results
Most of the participants were female nursing students. Data analysis indicated that the self-compassion intervention significantly increased students’ resilience (p < 0.001). However, while overall reflective thinking did not show a significant improvement in the intervention group (p = 0.057), it declined over time in the control group (p < 0.001).
Conclusion
Self-compassion training could effectively enhance students’ resilience, suggesting that implementing self-compassion workshops at the beginning of students’ academic programs may help strengthen their resilience. Although the intervention did not significantly increase reflective thinking, the decline observed in the control group indicates that without such interventions, reflective thinking may decrease over time. These findings highlight both the potential practical applications of self-compassion training and the need for further studies to explore strategies to actively improve reflective thinking.
Trial registration
This trial’s protocol was registered in the Iranian Clinical Trials Registration system on September 28, 2022 (Trial Number: IRCT20220830055827N1). This Protocol is available in https://irct.behdasht.gov.ir/trial/65728.
Keywords: Self-compassion training, Resilience, Reflective thinking
Background
Transition from adolescence, which coincides with the student years, is often accompanied by significant stress and anxiety, along with challenges such as emotional dysregulation, maladaptive behaviors and even harmful actions, which are among its most important difficulties [1]. Research has indicated that medical sciences students, including nursing and midwifery students, experience multiple stressors during their education, which may lead to physical illnesses, sleep disturbances, headache and reduced capacity for problem-solving. Increased stress could negatively affect learning outcomes and professional success in clinical settings, ultimately impairing their performance [2].
Declined learning in clinical settings may influence the development and enhancement of professional competencies, critical thinking, clinical decision-making and reflective thinking. Reflective thinking plays a crucial role in fostering self-awareness and promoting self-directed learning by organizing knowledge in the mind [3]. It is a metacognitive phenomenon that could occur before, during, and after the learning process. Its goal is to enhance understanding of a topic or situation, ultimately leading to more accurate and informed decision-making and orientation in the future [4].
Learning in clinical settings is particularly challenging because it involves uncontrollable conditions influenced by various factors. Neglecting metacognitive reflection in these settings limits the opportunity to correct mistakes and rectify incorrect experiences [3]. Such neglect may result in academic underachievement. Scientific evidence indicates that stress is a significant barrier to reflective thinking [5]. Reflective thinking is not a spontaneous process. It can be deliberately developed through educational strategies [6].
Stress affects students in different ways. Their coping process, and especially the skill of resilience, plays an important role in shaping individual responses [7]. Resilient students use self-awareness, self-care, and reflective thinking to manage internal stress and cope with difficult situations. They are able to recognize their emotions, demonstrate empathy by managing patients’ emotions, and prevent abnormal behaviors through logical thinking [8]. Nevertheless, effective management of emotions can remain a challenge for some students [9].
Recently, psychologists have found that many psychological disorders and social deviations arise from difficulties in self-assessment, lack of personal control and efficacy in facing challenges, and insufficient preparation for coping with life’s problems [10]. Psychological traits can be improved through various methods. Among these, third-wave psychotherapy approaches, such as self-compassion training, are considered particularly important [11].
Self-compassion training is a relatively new approach in psychological education that has shown effectiveness in regulating emotions [12]. Compassion consists of emotional, cognitive, and motivational components that support personal growth, emotional change, and self-care [13]. By influencing self-regulation, self-compassion helps individuals manage their experiences more effectively [14]. This skill can also be taught to others, and practicing it produces positive effects on physiological, nervous, and immune systems [15].
Therefore, by implementing effective interventions, decision-making and planning to select coping strategies, preventive measures, as well as control and management of psychological disorders could be facilitated to prevent academic decline and the waste of young and active human resources [4]. Considering the importance of professions in medical sciences, such as nursing and midwifery, this study was conducted to investigate the effectiveness of self-compassion training on resilience and reflective thinking among nursing and midwifery students.
Methods
Study design
This was a randomized controlled trial with a parallel design, including a pretest-posttest approach and a two-month follow-up period. The measured outcomes included resilience and reflective thinking. This trial’s protocol was registered in the Iranian Clinical Trials Registration system on September 28, 2022 (Trial Number: IRCT20220830055827N1). This Protocol is available in https://irct.behdasht.gov.ir/trial/65728.
Sample size and sampling method
The sample size was estimated to be 60 individuals (n = 30 per group) based on the study by Naemi and Faghihi (2019), considering an effect size of 0.8 [16], alpha of 0.05, and power of 85%. Subsequently, a total of 90 individuals (n = 45 per group) were selected, taking into account a 30% attrition rate. Sampling was conducted using a convenience sampling method, considering the inclusion and exclusion criteria.
Due to the limited number of first-year students who met the inclusion criteria and were willing to participate in the study, the required sample size could not be achieved by recruiting from this group alone. Therefore, to obtain an adequate sample size and ensure proper representation, second- and third-year students (2nd, 4th, and 6th academic semesters), who were still engaged in structured theoretical and clinical education, were also included. Fourth-year students (interns), who perform independent clinical duties and participate in night shifts, were excluded to maintain sample homogeneity and reduce potential bias in the results. The number of third-year student volunteers was limited; however, to achieve the required sample size, they were not excluded from the study. Then, the participants were randomly assigned to either the intervention or control group using simple randomization. Each participant was assigned a unique number, and these numbers were entered into SPSS software. Using random selection, half of the participants were randomly allocated to one group, and the remaining half were assigned to the other group.
Inclusion and exclusion criteria
The study’s inclusion criteria were enrollment in a Bachelor’s program in nursing or midwifery, willingness to participate in the research, and ownership of a mobile phone. The exclusion criteria were self-reported use of psychiatric medications, addiction to narcotics or psychoactive substances, transfer to another university during the study, and experiencing a loss within 6 months before or during the study.
Data collection tools
Data were collected using a demographic form, Connor-Davidson Resilience Scale (CD-RISC), and Groningen Reflection Ability Scale (GRAS). The demographic form was developed to collect data on age, gender, housing status (dormitory or not), academic years, level of education, field of study, cumulative grade point average, place of residence, marital status, employment status, economic status, and interest in the field of study.
The 25-item Connor-Davidson Resilience Scale (CD-RISC) was developed by Connor and Davidson (2003) to measure resilience. The items are scored based on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree”, with a score of 4 assigned to “strongly agree” and a score of 0 assigned to “strongly disagree”. The score ranges from 0 to 100, with higher scores indicating greater resilience. Connor and Davidson reported a Cronbach’s alpha coefficient of 0.89 for the resilience scale. Additionally, a reliability coefficient of 0.87 was obtained through the test-retest method over a 4-week interval [17]. This scale was translated into Persian by Khoshnazari et al. (2015), and its content validity was reported to be adequate, with a content validity ratio of over 0.62 for each item and a mean content validity of 0.84. Furthermore, the scale’s reliability was found to be desirable, with a Cronbach’s alpha coefficient of 0.94 [18].
The Groningen Reflection Ability Scale (GRAS) (2007) was used to assess reflective thinking. This scale consists of 23 items in three domains: Self-reflection with 10 items (individuals’ capacity to learn from experiences and events), empathic reflection with 6 items (the motivation behind a behavior rather than the appearance of the behavior), and reflective communication with 7 items (examining one’s behavior in the context of social interactions). The items are scored based on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). Five items of the questionnaire have reverse scoring (items 14, 17, 18, 22, and 23). The scores of all items are summed to calculate the total score. The total score of reflective thinking ranges from 23 to 115, with higher scores indicating greater reflective thinking [19]. This questionnaire was first translated into Persian and psychometrically tested in Iran by Rostami et al. (2018). The content validity of the questionnaire was quantitatively assessed, with the content validity ratio for all items being above 0.6. The mean content validity ratio was 0.76. The scale’s reliability was confirmed using internal consistency and calculating the Cronbach’s alpha of 0.7 [20].
Implementation
At the beginning of the study, the researcher obtained the necessary approvals from the Research Deputy and the School of Nursing and Midwifery at Bushehr University of Medical Sciences. Class representatives were then contacted to assist with participant recruitment. With their help, information about the study was shared, informed consent was obtained, and the names and contact numbers of interested students were collected.
Due to low initial participation, additional recruitment efforts were undertaken. Meetings were held at the end of classes, attended by the professors and the researcher, to explain the purpose of the study. It was clearly emphasized that participation was entirely voluntary and would not affect students’ grades or academic standing, and informed consent was obtained after providing verbal reassurances.
After reaching the required sample size, eligible participants were randomly assigned to control or intervention groups. Reminder text messages were sent 24 and 12 h before the introductory session, which was held separately for each group to explain the study objectives and process and to address students’ questions. Written consent was obtained, and all participants completed the demographic form, CD-RISC, and GRAS. To maintain anonymity, each participant was assigned a unique code, which was kept confidential by the researcher.
The self-compassion training intervention, based on Gilbert’s method [21], was conducted by the researcher, a master’s student in psychological nursing with a Master’s in Clinical Psychology and certified in Gilbert’s self-compassion training under the supervision of a university professor. The intervention was delivered to the intervention group, while the control group received no training. All participants completed the CD-RISC and GRAS questionnaires immediately after the intervention and again two months later. After data collection, the self-compassion training materials were provided to the control group. The sampling process began on January 21, 2023. The intervention started on February 15, 2023, and was completed on March 15, 2023.
Intervention
In this study, Gilbert’s self-compassion training program was implemented following his standard guidelines. The intervention consisted of eight 90-minute in-person sessions, conducted twice a week over one month. The first session was delivered as a lecture, while sessions two to eight included lectures, question and answer discussions, homework assignments, and role-playing activities as an active learning method. PowerPoint presentations were used to support the instruction. Session schedules were coordinated with students in advance, and reminder messages were sent 12 h before each session. A summary of the session content is provided in Table 1.
Table 1.
Overview of self-compassion training sessions
| Session | Session objectives and activities | Teaching method | Platform | Mode of Delivery | Homework expectations |
|---|---|---|---|---|---|
| Session 1 | An initial overview, formation of groups, a review of the session’s framework, and an introduction to the fundamental principles of self-compassion training. | lecture | PowerPoint | In-person | Participants will identify and record situations in their environment where compassion appears to be needed, as a way to increase awareness of suffering and the relevance of self-compassion. |
| Session 2 | Introduction and instruction of several mindfulness techniques aimed at enhancing present-moment awareness. Participants were taught six specific techniques: mindful breathing, mindful observation, mindful awareness, mindful listening, mindful reflection, and mindful appreciation. | Lecture and Questions and Answers | PowerPoint | In-person | Practice mindfulness exercises including breathing, observation, awareness, and active listening. Additionally, identify situations in the surrounding environment that require compassion and suggest possible ways to address them. |
| Session 3 | Introduction to the characteristics of self-compassionate individuals and the cultivation of compassion towards others. Participants learned about the stages of compassion, developed warmth and kindness towards themselves, and practiced acceptance and wisdom. Emphasis was placed on recognizing that others also experience suffering. For homework, participants were asked to practice acceptance and understanding of themselves and others, and to reflect on and discuss the feelings experienced during this practice. | Lecture and Questions and Answers | PowerPoint | In-person | Practice acceptance exercises focused on oneself and others. Additionally, engage in compassion visualization techniques. |
| Session 4 | Review and summarize the previous session. Encourage participants to engage in self-awareness by assessing their personality to determine whether they perceive themselves as self-compassionate based on the educational material. Focus on cultivating a compassionate mind, including empathy and sympathy toward oneself and others. For homework, participants were asked to practice self-soothing techniques and to explore the relationship between mood, thoughts, feelings, and events | Lecture and Questions and Answers | PowerPoint | In-person | Participants are asked to practice non-judgmental awareness by observing their thoughts, feelings, and experiences without criticism or evaluation. This exercise aims to foster greater self-acceptance and reduce self-critical tendencies. |
| Session 5 | Review of exercises from the previous session. Teaching and performing activities that promote self-compassionate thinking. Homework assignments related to the topics covered during the training were provided. | Lecture and Questions and Answers | PowerPoint | In-person | Identify unhelpful emotions and reflect on their impact on the practice of self-compassion |
| Session 6 | Review of exercises from the previous session. Practice in creating compassionate imagery. Instruction on verbal and practical compassion techniques. Application of these methods in clinical settings and daily life to support others. Homework assignments related to the training topics were provided. | Lecture and Questions and Answers | PowerPoint | In-person | Participants are asked to practice compassionate responding skills in real-time situations, focusing on applying self-compassion and compassion towards others in the present moment. This exercise aims to enhance mindfulness and empathy during daily interactions. |
| Session 7 | Review of exercises from the previous session. Instruction on how to write compassionate letters to oneself and others. Training on recording and documenting real-life situations with an emphasis on compassion. | Lecture and Questions and Answers | PowerPoint | In-person | Write a compassionate letter to oneself. |
| Session 8 | Summary of all key points covered throughout the training. Providing approaches to support the ongoing practice of self-compassion exercises. Guidance on applying these therapeutic approaches in both clinical settings and daily life. | Lecture and Questions and Answers | PowerPoint | In-person | Read aloud the compassionate letter and share the experiences and insights gained from the class. |
Data analysis
Initially, the data was cleaned, and no outliers were observed. For the main variables, a maximum of 3% of the data was missing, which was replaced with the mean value of the respective variable. The mean, standard deviation, frequency and percentage were reported to address to the research questions and describe the variables. Normal distribution of the quantitative data was assessed using the Shapiro-Wilk test. Demographic variables were compared between the intervention and control groups using independent t-tests, Mann-Whitney tests, Chi-square tests and Fisher’s exact tests. Within-group comparisons of resilience and reflective thinking were conducted using repeated-measures analysis of variance (ANOVA). Post-hoc pairwise comparisons were conducted using the Bonferroni correction to adjust for multiple comparisons. Independent-samples t-tests were conducted to compare the intervention and control groups at pre-test, post-test, and follow-up on the main study variables. To control for type I error due to multiple comparisons, the Bonferroni correction was applied, yielding an adjusted significance threshold of α = 0.017 (tests were considered statistically significant if p ≤ 0.017).
Due to the sampling method, which included students from academic years 1 through 3, additional analyses were performed to address potential variability. Given the small number of third-year students, participants were grouped into two categories: first-year students and a combined group of second- and third-year students. We compared the pre-test scores of resilience and reflective thinking between these two groups and found no statistically significant differences. Furthermore, all analyses were conducted twice: once including all participants and once including only first- and second-year students (with 37 participants in the control group and 39 in the intervention group). The results were consistent across both analyses; therefore, we reported the findings based on the entire sample. Marital status was assessed as a potential demographic variable; however, since all participants were single, no further analysis was performed on this variable. Data analysis was performed using SPSS 20.0. The significance level was considered to be less than 0.05 in all tests.
Results
In this study, 90 nursing and midwifery students participated. Ultimately, 6 students (5 from the control group and 1 from the intervention group) withdrew at the beginning of the study, and the analysis was conducted on 84 nursing and midwifery students (Fig. 1). The mean age of participants was 21.34 ± 1.84 in the intervention group and 21.65 ± 1.98 in the control group. The median age in both groups was 21 years. There were no statistically significant differences between the two groups in terms of age and other qualitative and quantitative demographic variables (Table 2).
Fig. 1.
CONSORT flow diagram. This figure illustrates the flow of participants throughout the study, from initial assessment for eligibility through enrollment, allocation, follow-up, and inclusion in the final analysis
Table 2.
Comparison of demographic variables between intervention and control groups
| Quantitative Variables | Groups (Total number = 84) | ||||
|---|---|---|---|---|---|
| Control (n = 40) | Intervention (n = 44) | t* or Z** | P value (ES) | ||
| Mean ± SD ormedian (IQR) | Mean ± SD ormedian (IQR) | ||||
| Age/Years | 21.65 ± 1.98 | 21.34 ± 1.84 | −0.626** | 0.532 (0.16 a) | |
| Grade Point Average (0–20) | 17.32 ± 0.86 | 17.00 ± 1.15 | 1.312* | 0.194 (0.31a) | |
| Birth order | 2(1–3) | 1(1–3) | −0.771** | 0.441(0.10 b) | |
| The degree of interest in the field of study (1–5) | 3(2–3) | 3(2–3) | −0.551** | 0.553 (0.20 b) | |
| Qualitative variables | N(%) | N(%) | X2*** or Fisher**** | P value | |
| Gender | Men | 13(32.5) | 21(47.7) | 2.016*** | 0.156 (0.15b) |
| Women | 27(67.5) | 23(52.3) | |||
| Residing in a student dormitory | Yes | 31(77.5) | 37(84.1) | 0.590*** | 0.442 (0.8 b) |
| No | 9(22.5) | 7(15.9) | |||
| Being employed | Yes | 8(20.0) | 11(25.0) | 0.299*** | 0.584 (0.06 b) |
| No | 32(80.0) | 33(75.0) | |||
| Residence | City | 37(92.5) | 38(86.4) | 0.825*** | 0.364 (0.1 b) |
| Village | 3(7.5) | 6(13.6) | |||
| Economic statues | Weak | 3(7.5) | 4(9.1) | 1.589**** | 0.491(0.14b) |
| Moderate | 23(57.5) | 30(68.2) | |||
| Good | 14(35.0) | 10(22.7) | |||
| Academic years | First | 19(47.5) | 21(47.7) | 0.001 | 0.983(0.002) |
| Second and third | 21(52.5) | 23(52.3) | |||
* Performed test: Independent t test, ** Performed test: Mann-Whitney, *** Performed test: Chi square, ****: Performed test: fisher exact
a Effect size is Cohen's d, b Effect size is Cramer’s V
N Number, SD Standard deviation, IQR interquartile range, ES Effect size
Between-group comparisons of means between the intervention and control groups revealed no statistically significant differences in pretest scores of resilience or in reflective thinking and its three domains (self-reflection, empathic reflection, and reflective communication).
However, the mean posttest and follow-up scores of resilience and reflective thinking, including its three domains (self-reflection, empathic reflection, and reflective communication), were significantly higher in the intervention group compared to the control group.
Within-group comparisons showed that the mean score of resilience changed over time in both groups. There was a difference in the mean scores of self-reflection, empathic reflection, reflective communication and overall reflective thinking in the control group across the three time points. However, there was no statistically significant difference in the mean scores of these variables in the intervention group across the three time points (Table 3). The post-hoc test conducted for pairwise comparisons of time points showed the mean posttest and follow-up scores of resilience in the control group were significantly lower than the mean pretest scores. Additionally, the mean follow-up score of resilience was significantly higher than the mean posttest score. In the intervention group, the mean posttest and follow-up scores of resilience were significantly higher than the mean pretest score. There was no statistically significant difference between the mean posttest and follow-up scores of resilience. Comparing reflective thinking across the three time points in the control group was significant. The post-hoc test showed the mean posttest and follow-up scores of the overall reflective thinking and its domains were lower than the mean pretest scores of these variables. The mean follow-up scores of the overall reflective thinking, and its reflective communication domain were significantly lower than the mean posttest scores of these variables. There were no statistically significant differences between the mean posttest and follow-up scores of self-reflection and empathic reflection (Table 4).
Table 3.
Post-hoc comparisons of resilience and reflective thinking scores across time points
| Variable | Groups (Total number = 84) | T value | P value for between groups comparisons | Effect size (Cohen’s d) | ||
|---|---|---|---|---|---|---|
| Control (n = 40) | Intervention (n = 44) | |||||
| Mean ± SD | Mean ± SD | |||||
| Resilience | Pretest | 64.75 ± 14.64 | 64.52 ± 13.49 | 0.076 | 0.940 | 0.01 |
| Posttest | 42.74 ± 15.52 | 69.07 ± 12.79 | −8.515 | < 0.001 | 1.85 | |
| Follow-up | 50.88 ± 13.37 | 74.07 ± 19.01 | −6.407 | < 0.001 | 1.41 | |
| Within group comparison | F | 25.275 | 5.031 | - | - | - |
| P value (η2) | < 0.001 (0.393) | 0.009 (0.105) | - | - | - | |
| Self-reflection | Pretest | 40.05 ± 4.38 | 40.65 ± 4.72 | −0.597 | 0.552 | 0.13 |
| Posttest | 32.78 ± 7.01 | 41.80 ± 4.18 | −7.236 | < 0.001 | 1.56 | |
| Follow-up | 29.25 ± 8.20 | 40.30 ± 4.84 | −7.600 | < 0.001 | 1.64 | |
| Within group comparison | F | 29.319 | 1.598 | - | - | - |
| P value (η2) | < 0.001 (0.429) | 0.208 (0.036) | - | - | - | |
| Empathic reflection | Pretest | 21.99 ± 2.77 | 22.51 ± 3.04 | −0.814 | 0.418 | 0.18 |
| Posttest | 17.84 ± 2.91 | 22.36 ± 2.61 | −7.518 | < 0.001 | 1.64 | |
| Follow-up | 17.33 ± 3.28 | 21.49 ± 2.71 | −6.362 | < 0.001 | 1.38 | |
| Within group comparison | F | 33.798 | 1.772 | - | - | - |
| P value (η2) | < 0.001 (0.464) | 0.176 (0.040) | - | - | - | |
| Reflective communication | Pretest | 24.00 ± 4.37 | 24.80 ± 3.52 | −0.929 | 0.356 | 0.20 |
| Posttest | 21.53 ± 2.79 | 25.53 ± 3.48 | −5.764 | < 0.001 | 1.27 | |
| Follow-up | 19.27 ± 4.65 | 25.25 ± 4.76 | −5.820 | < 0.001 | 1.27 | |
| Within group comparison | F | 15.067 | 0.526 | - | - | - |
| P value (η2) | < 0.001 (0.279) | 0.593 (0.012) | - | - | - | |
| Overall reflective thinking | Pretest | 86.30 ± 9.42 | 88.07 ± 8.59 | −0.898 | 0.372 | 0.20 |
| Posttest | 75.92 ± 11.39 | 89.85 ± 8.26 | −6.457 | < 0.001 | 1.40 | |
| Follow-up | 66.81 ± 13.76 | 85.58 ± 10.27 | −7.028 | < 0.001 | 1.55 | |
| Within group comparison | F | 29.924 | 3.167 | - | - | - |
| P value (η2) | < 0.001 (0.434) | 0.057 (0.047) | - | - | - | |
Note: Repeated Measures ANOVA performed for within-group comparisons; Independent-samples t-tests were used for between-group comparisons
η2 = partial Eta squared
p-values are Bonferroni-adjusted for multiple between-group comparisons (α = 0.017)
Table 4.
Post-hoc comparisons of resilience and reflective thinking scores across time points
| Variables | Group | A | B | A- B | SE | P value | 95% CI for mean diferences | Effect size (Cohen’s d) |
|---|---|---|---|---|---|---|---|---|
| Resilience | Control | Posttest | Pretest | −22.01 | 3.39 | < 0.001 | −30.485; −13.540 | 1.026 |
| Follow-up | Pretest | −13.88 | 2.93 | < 0.001 | −21.214; −6.539 | 0.749 | ||
| Posttest | 8.14 | 3.06 | 0.034 | 0.493; 15.779 | 0.420 | |||
| Intervention | Posttest | Pretest | 4.55 | 1.65 | 0.026 | 0.434; 8.665 | 0.435 | |
| Follow-up | Pretest | 9.55 | 3.31 | 0.018 | 1.313; 17.786 | 0.456 | ||
| Posttest | 5.00 | 3.68 | 0.544 | −4.170; 14.171 | 0.215 | |||
| Self-reflection | Control | Posttest | Pretest | −7.28 | 1.22 | < 0.001 | −10.319; −4.236 | 0.943 |
| Follow-up | Pretest | −10.80 | 1.35 | < 0.001 | −14.175; −7.419 | 1.265 | ||
| Posttest | −3.52 | 1.70 | 0.137 | −7.783; 0.743 | 0.327 | |||
| Intervention | No significant in within-group comparison | |||||||
| Empathic reflection | Control | Posttest | Pretest | −4.15 | 0.58 | < 0.001 | −5.610; −2.691 | 1.131 |
| Follow-up | Pretest | −4.66 | 0.63 | < 0.001 | −6.228; −3.097 | 1.171 | ||
| Posttest | −0.51 | 0.65 | < 0.999 | −2.150; 1.125 | 0.124 | |||
| Intervention | No significant in within-group comparison | |||||||
| Reflective communication | Control | Posttest | Pretest | −2.47 | 0.84 | 0.017 | −4.574; −0.363 | 0.465 |
| Follow-up | Pretest | −4.73 | 0.87 | < 0.001 | −6.907; −2.552 | 0.860 | ||
| Posttest | −2.26 | 0.87 | 0.040 | −4.445; −0.077 | 0.411 | |||
| Intervention | No significant in within-group comparison | |||||||
| Overall reflective thinking | Control | Posttest | Pretest | −10.38 | 2.15 | < 0.001 | −15.765; −5.004 | 0.763 |
| Follow-up | Pretest | −19.49 | 2.33 | < 0.001 | −25.329; −13.654 | 1.32 | ||
| Posttest | −9.11 | 3.00 | 0.013 | −16.612; −1.602 | 0.480 | |||
| Intervention | No significant in within-group comparison | |||||||
Note: Post−hoc pairwise comparisons were Bonferroni−adjusted for multiple comparisons
CI Confidence interval
Discussion
This study was conducted to investigate effectiveness of self-compassion training on resilience and reflective thinking among nursing and midwifery students at Bushehr University of Medical Sciences in 2023.
The results indicated self-compassion training significantly increased the resilience of nursing and midwifery students, and this effect was lasting. Additionally, there was a significant difference in the mean scores of resilience between the intervention and control groups. These findings were consistent with the studies by Aghaali Tari et al. (2020), Tarkhan et al. (2020), and Saffari Bidhendi (2021) on high school students [13, 22, 23] as well as the study by Franco (2021) on pediatric nurses [24]. No studies contradicting the present study were found in the available literature. This may be due to the limited number of studies conducted in this field or the lower likelihood of publication for studies with negative results.
Self-compassion training is critical in facilitating positive emotional change among individuals. By building a compassionate and kind stance towards oneself, it results in increased self-care and self-support. This, in turn, inhibits self-criticism behaviors, promotes higher levels of self-acceptance, and alleviates motional suffering. Through these changes, individuals become better at managing their internal emotional states through self-soothing [25]. This enhanced capacity not only assists them in identifying sources of stress but also empowers them to develop and implement effective coping mechanisms to navigate those challenges more effectively [26].
In addition, self-compassion training allows individuals to recognize and reframe their negative, irrational self-criticisms with more balanced perspectives. As a result, they are better equipped to adopt effective coping skills when facing challenges, overcome obstacles, and, in the process, become more resilient. This resilience enables them to cope with life’s challenges with greater flexibility and ease [27].
In the present study, the intervention did not result in a significant improvement in students’ reflective thinking at the posttest. However, reflective thinking declined in the control group. Two months after the intervention, reflective thinking scores in the intervention group showed a slight, non-significant decrease, whereas the control group experienced a more pronounced decline. This pattern indicates that self-compassion training may have a lasting protective effect in sustaining reflective thinking over time.
Since the posttest questionnaire was administered concurrently with the final examinations, the observed decrease in reflective thinking may be associated with exam-related stress, which could have influenced participants’ cognitive and reflective abilities. The self-compassion training provided to the intervention group may have served as a protective factor against the decline in reflective thinking, potentially operating through multiple mechanisms. Self-compassion contributes to lowering stress and anxiety, as it enables individuals to respond with self-kindness rather than self-criticism. This shift not only alleviates psychological distress but also strengthens cognitive resources [28] for reflective thinking. Additionally, self-compassion enhances resilience, which promotes greater emotional regulation. As a result, negative emotions are reduced, allowing individuals to engage in deeper levels of cognitive processing [29]. In addition, self-compassion promotes cognitive flexibility [30], allowing students to reframe academic challenges as opportunities rather than threats, a perspective that helps them sustain reflective processing even under stressful conditions.
Additionally, the impact of the intervention may manifest differently in students as the duration of the training increases. Therefore, further studies with a longer duration of self-compassion training are recommended to achieve more accurate results. Moreover, using other training methods alongside self-compassion training and comparing them with this intervention, or employing a combined approach, would help identify the most effective intervention for reflective thinking.
Strength and limitation
The use of a randomized controlled trial design can be considered a methodological strength of this study, as it helps reduce potential sources of bias. Nonetheless, the present study has certain limitations that should be acknowledged.
One limitation pertains to the composition of the sample. Convenience sampling was used, and due to the limited number of first-year students who met the inclusion criteria and agreed to participate, students from the second and third academic years were also included. While this approach enabled us to reach the required sample size, it may have introduced variability related to differences in educational level, clinical experience, and academic responsibilities, and consequently may limit the generalizability of the findings. Restricting the sample to a single academic year or using stratified sampling could have resulted in more homogeneous and precise outcomes. This limitation has been acknowledged and addressed in the manuscript to ensure transparency regarding its potential impact on the results. For future research, we recommend stratifying participants by academic year or level of clinical experience and employing random or stratified sampling methods to enhance comparability and generalizability.
In addition, similar to other pedagogical interventions, there is a potential for information exchange between the control and intervention groups, which may have influenced the outcomes. The sample was also limited to midwifery and nursing students from a specific university, potentially restricting the generalizability of the findings to other student populations or educational settings. Furthermore, the study lacked blinding, meaning that both participants and researchers were aware of group assignments, which could have influenced behavior and responses. Finally, the posttest and follow-up were administered shortly before and after the students’ exams. The timing, coinciding with exams and potentially elevated stress levels, may have affected the results.
Conclusion
The findings demonstrated that the self-compassion training program enhanced the resilience of nursing and midwifery students. These results highlight the practical value of integrating self-compassion workshops at the outset of academic programs, as such interventions may better equip students to cope with the academic and emotional challenges of higher education.
Although the intervention did not significantly increase reflective thinking score, the decline observed in the control group indicates that reflective thinking may be particularly vulnerable during stressful academic periods when no protective strategies are in place. This highlights the role of self-compassion as a potential buffer, enabling students to preserve reflective processing in stressful situations. Considering the limited studies on the impact of self-compassion training on reflective thinking, it is recommended to conduct longer self-compassion training or integrate it with other training methods to achieve more accurate results.
Acknowledgements
This study was derived from an MS thesis approved and financially supported by Bushehr University of Medical Sciences in Bushehr, Iran. The authors sincerely thank the Research Deputy of the university, the administrators of the study setting, and all participating students for their valuable cooperation.
Authors’ contributions
Conceptualization and study design: FK, MB and RB. Intervention and quantitative Data collection: ZZ. Data analysis: RB. Writing original draft of manuscript: FK and RB. Prepared final version of manuscript: MB, RB and FK. All authors have read and approved the final version of manuscript.
Funding
This study was extracted from MS thesis approved and funded by Bushehr University of Medical Sciences, Bushehr, Iran (Grant number: 1401-90).
Data availability
The anonym zed datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethical approval and consent to participate
This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the Ethics Committee of Vice Chancellor for Research at Bushehr University of Medical Sciences with the ethics code IR.BPUMS.REC.1401.081.
Ethical considerations were thoroughly observed in this study. Participation was entirely voluntary. Although students were invited by their course instructors or advisors, it was explicitly explained that choosing to participate or not had no effect on their grades, academic evaluation, or relationship with the instructors. To minimize any perception of coercion, verbal assurances were provided. Written informed consent was obtained from all participants. Furthermore, confidentiality and privacy were carefully protected by safeguarding names and other personal information. In addition, participants were assured of their right to withdraw from the study at any stage without the need for explanation.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Valibeigi M, Moheb N, Abdi R. Explaining the structural model of the relationship between optimism and resilience with psychological well-being based on life satisfaction in students with symptoms of borderline personality disorder. J Mod Psychol Researches. 2022;16(64):236-53.
- 2.Poorheidari M, Delvarian-Zadeh M, Yahyaee S, Montazeri A. Study of the stressful experiences of midwifery students during clinical education in the labor room. Res Med Educ. 2017;9(4):66–58. [Google Scholar]
- 3.Vafadar Z, Parandeh A. Nursing Students` experiences of narrative Writing- reflection in clinical education: A qualitative study. Iran J Med Educ. 2019;19(0):78–89. [Google Scholar]
- 4.Kazemipoor M, Hakimian R. Evaluation of reflection level in the field of educational findings among dental students at Shahid Sadoughi university of medical science in 2017–2018. J Med Educ Dev. 2018;13(3):229–37. [Google Scholar]
- 5.Shirazizadeh M, Tajik L, Amanzadeh H, Reflection. Resilience and role stress among Iranian EFL teachers: A mixed methods study. Issues Lang Teach. 2019;8(2):1–24. [Google Scholar]
- 6.Rahimi M, Haghani F. Reflection in medical education: a review of Concepts, Models, principles and methods of teaching reflection in medical education. Res Med Educ. 2017;9(2):24–13. [Google Scholar]
- 7.Rashidi A, Amiri M, Mehravad Giglu S, Nodehi H. Examine the correlation between perceptions of class learning environment with educational tolerance. Teach Learn Res. 2016;12(2):189–98. [Google Scholar]
- 8.Modarres M. Student resilience. Iran J Med Educ. 2022;22(0):325–6. [Google Scholar]
- 9.Sharifi Rahnmo S, Sadeghi S, Fathi A. Developing a structural model for the role of mental health in high-risk driving behaviors of young people: the mediating role of resilience. Traffic Law Enforc Res Stud. 2021;1399(35):115–40. [Google Scholar]
- 10.Gross JJ, Uusberg H, Uusberg A. Mental illness and well-being: an affect regulation perspective. World Psychiatry. 2019;18(2):130–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Edalat A, DashtBozorgi Z, Talebzadeh Shoshtari M. The effectiveness of compassion training on health Hardiness, compassion and behavioral emotion regulation. Iran J Cult Health Promotion. 2022;6(3):562–9. [Google Scholar]
- 12.Dixon S, Chiang C-M. Promoting reflexivity and reflectivity in counselling, education, and research. 2019.
- 13.Aghaali Tari S, Haghani R, Nikkhah B. The effectiveness of the therapy based on Self-Compassion on the aggression and resilience of female student with ODD. Med J Mashhad Univ Med Sci. 2021;63(6):2210–20. [Google Scholar]
- 14.Shakarami M, Latifi Z, Mosavi S. The effectiveness of compassion focused group therapy on aggression, emo-tion of self-regulation and school motivation about the Boy student of the el-ementary school. Res School Virtual Learn. 2020;7(2):77–87. [Google Scholar]
- 15.Khalajzadeh M, Hashemi N. The effectiveness of self-compassion training on the perception of competence and psychological flexibility of female caregivers. Q Educatinal Psychol Allameh Tabataba’i Univ. 2019;15(54):1–32. [Google Scholar]
- 16.Naemi A, Faghihi S. The effectiveness of cognitive self-compassion on resiliency, psychological well-being and distress tolerance of female teachers of elementary schools in Sabzevar. J School Psychol Institutions. 2021;10(3):134–47. [Google Scholar]
- 17.Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson resilience scale (CD‐RISC). Depress Anxiety. 2003;18(2):76–82. [DOI] [PubMed] [Google Scholar]
- 18.Khoshnazary S, Hosseini M, Fallahi Khoshknab M, Bakhshi E. The effect of emotional intelligence (EI) training on nurses’ resiliency in department of psychiatry. Iran J Psychiatric Nurs. 2016;3(4):28–37. [Google Scholar]
- 19.Aukes LC, Geertsma J, Cohen-Schotanus J, Zwierstra RP, Slaets JP. The development of a scale to measure personal reflection in medical practice and education. Med Teach. 2007;29(2–3):177–82. [DOI] [PubMed] [Google Scholar]
- 20.Rostami A, Keshmiri F, Askari R, Jambarsang S, Shafiei M. Validation of Groningen reflection ability scale questionnaire and evaluation of reflection ability level of health care management students. Evid Based Health Policy Manage Econ. 2019;3(4):293–302. [Google Scholar]
- 21.Gilbert P, Procter S. Compassionate Mind training for people with high shame and self-criticism: overview and pilot study of a group therapy approach. Clin Psychol Psychotherapy: Int J Theory Pract. 2006;13(6):353–79. [Google Scholar]
- 22.Tarkhan M. The effectiveness of compassion focused therapy (CFT) on academic resiliency and hopefulness in the academic procrastination of male students of the second degree of high school. Res School Virtual Learn. 2021;8(4):9–18. [Google Scholar]
- 23.Saffari Bidhendi S, Asadzadeh H, Farokhi N, Dortaj F. Efficacy of Self-Compassion training on educational resilience and mental vitality in high school students. J Appl Psychol Res. 2022;12(4):327–43. [Google Scholar]
- 24.Franco PL, Christie LM. Effectiveness of a one-day self-compassion training for pediatric nurses’ resilience. J Pediatr Nurs. 2021;61:109–14. [DOI] [PubMed] [Google Scholar]
- 25.Alirezaee F, Mardani Hamooleh M, Seyedfatemi N, Ghaljeh M, Haghani S. Effects of self-compassion training on the positive and negative emotions of nursing students: A quasi-experimental study. Iran J Nurs. 2021;34(132):21–32. [Google Scholar]
- 26.Pouresmaeel Niazi M, Farshbaf Mani Sefat F, Farshbaf Mani Sefat F, Meshgi S. The mediating role of coping strategies in the relationship between Self-compassion and adherence to treatment in cardiovascular patients. J Health Care. 2022;23(4):289–300. [Google Scholar]
- 27.Saghaee SS, Nasri M. The Effectiveness of Self-Conscious Therapy on Resiliency, Self-discrepancy, and Mindfulness of Patients with Type 2 Diabetes. 2022.
- 28.Han A, Kim TH. Effects of self-compassion interventions on reducing depressive symptoms, anxiety, and stress: A meta-analysis. Mindfulness. 2023;14(7):1553–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Rehman S, Addas A, Rehman E, Khan MN. The mediating roles of self-compassion and emotion regulation in the relationship between psychological resilience and mental health among college teachers. Psychol Res Behav Manage. 2024; (17):4119–33. [DOI] [PMC free article] [PubMed]
- 30.Cırcır O, Tagay Ö. The relationships between cognitive flexibility, perfectionism, optimism, self-compassion and psychological well-being: A mixed study. Curr Psychol. 2024;43(22):19830–46. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The anonym zed datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.