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A Mindfulness Workshop for Health Science Graduate Students: Preliminary Evidence for Lasting Impact on Clinical Performance

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Introduction. Health science graduate students take high stakes examinations and experience stress and burnout, which can negatively influence performance in clinical courses. The intent of this study was to pilot a curriculum in mindful practice for graduate health science students under high levels of perceived stress. The purpose of this study was to determine the effectiveness of an abbreviated mindfulness workshop to determine if it would provide lasting benefit for students during clinical experiences 9 months later. Methods. Twenty-three graduate students across 4 health professions participated in a 6-week workshop for stress management in March 2017. Students were executed to practice mindfulness activities for 15 minutes daily over the 6 weeks. Weekly meetings included meditation, mindful movement, and small group discussion. A mixed methods approach incorporated pre- and postworkshop measures exploring students' levels of worry, perceived stress, feelings of isolation, self-judgment, self-kindness, overidentification, and mindfulness. Additional survey data were collected 9 months later to determine if the tools learned in the workshop influenced clinical performance. Qualitative comments were coded using generic qualitative analysis, and member checking confirmed themes. Results. Overall, students demonstrated improvements in all measures of stress over the 6-week workshop. Additionally, they reported positive influences on clinical performance in the affective and cognitive domains 9 months later. Four main themes were extracted from the data. These were I Have Tools; Think, Pause, Allow; Silence the Critic; and, I Am Not Alone. Overall, the participants experienced significant improvements in mindfulness scores and self-compassion, and showed improvements in perceived stress and worry (Cognitive-Affective Mindfulness Scale-revised). Discussion and Conclusion. Altogether, these data suggest that (1) graduate students can learn to manage worry, feelings of isolation, and self-judgment using tools and strategies from mindful practices; (2) students who practice mindfulness in a 6-week workshop report lasting effects during clinical performance 9 months later; and (3) students benefit from a community of peers and a shared space to share their thoughts and feelings as emerging health professionals. Suggestions are made for integrating mindful practices into graduate health science education.
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RESEARCH REPORT
A Mindfulness Workshop for Health Science Graduate
Students: Preliminary Evidence for Lasting Impact on
Clinical Performance
Annette Willgens, PT, MA, EdD, and Kerstin Palombaro, PT, PhD, CAPS
Introduction. Health science graduate
students take high stakes examinations
and experience stress and burnout, which
can negatively inuence performance
in clinical courses. e intent of this study
was to pilot a curriculum in mindful
practice for graduate health science stu-
dents under high levels of perceived stress.
e purpose of this study was to determine
the eectiveness of an abbreviated mind-
fulness workshop to determine if it would
provide lasting benet for students during
clinical experiences 9 months later.
Methods. Twenty-three graduate students
across 4 health professions participated in
a 6-week workshop for stress management
in March 2017. Students were executed
to practice mindfulness activities for 15
minutes daily over the 6 weeks. Weekly
meetings included meditation, mindful
movement, and small group discussion. A
mixed methods approach incorporated
pre- and postworkshop measures exploring
studentslevels of worry, perceived stress,
feelings of isolation, self-judgment, self-
kindness, overidentication, and mindful-
ness. Additional survey data were collected
9 months later to determine if the tools
learned in the workshop inuenced clinical
performance. Qualitative comments were
coded using generic qualitative analysis,
and member checking conrmed themes.
Results. Overall, students demonstrated
improvements in all measures of stress
over the 6-week workshop. Additionally,
they reported positive inuences on clin-
ical performance in the aective and cog-
nitive domains 9 months later. Four main
themes were extracted from the data. ese
were I Have Tools;ink, Pause, Allow;
Silence the Critic;and,I Am Not Alone.
Overall, the participants experienced signif-
icant improvements in mindfulness scores
and self-compassion, and showed improve-
ments in perceived stress and worry (Cog-
nitive-Aective Mindfulness Scale-revised).
Discussion and Conclusion. Altogether,
these data suggest that (1) graduate stu-
dents can learn to manage worry, feelings
of isolation, and self-judgment using tools
and strategies from mindful practices; (2)
students who practice mindfulness in a 6-
week workshop report lasting eects dur-
ing clinical performance 9 months later;
and (3) students benet from a commu-
nity of peers and a shared space to share
their thoughts and feelings as emerging
health professionals. Suggestions are made
for integrating mindful practices into
graduate health science education.
Key Words: Graduate health professions,
Students, Stress, Mindfulness, Mixed
methods.
INTRODUCTION
Health science graduate students take high
stakes written and performance-based exami-
nations and feel high levels of stress and
worry.
1
Without easily accessible resources,
this may lead to anxiety, depression,
2,3
com-
passion fatigue, and burnout before they even
graduate.
4,5
In fact, empathy has been shown
to decrease in graduate physical therapy edu-
cation, likely due to burnout.
6
Students are
also learning to adjust to a new professional
identity. ey must integrate didactic informa-
tion with clinical learning, and they are con-
cerned about future plans and growing debt.
7
When experiencing distress, students can
seek out counseling services on university
campuses. However, not all students who may
benet from mental health care take advan-
tage of it due to long days in class, limited
time, stigma, and shame.
7
Many university
counseling centers are overowing with in-
creasing numbers of referrals, and students
have to wait for services.
8
According to the
Centers for Disease Control, suicide rates
have increased 30% between 1999 and 2016,
and it is the second leading cause of death in
students aged 1825 years.
9
Among medical
students, 300400 take their lives each year,
with male suicide rates higher than female
suicide rates.
9
Data on physician assistant,
nursing, and physical therapy students are not
available, but students aged 1825 years were
among the highest to strongly considerbut
not perform suicide.
9
Students who participate in supervised
mindfulness practice, as in a workshop, cur-
ricular thread, online course, or course series,
have improved mental health as compared
with those who have singular educational
experiences (ie, one lecture).
10,6 5
Recently, it
has been shown that stand-alone mindfulness
workshops are highly benecial for student
stress, anxiety, and depression, even without
being integrated into a larger therapeutic pro-
gram.
11
It is becoming clear that traditional
models of mental health care in the university
setting are not reaching enough of the pop-
ulation
12
and that mindfulness is an evidence-
based solution in graduate student education.
13
is is the rst study to explore the in-
uence of a brief mindfulness workshop on
graduate health science studentsstress and
subsequent clinical performance.
66
Research
questions included the following: (1) Does
a mindfulness workshop positively inuence
health science graduate studentslevels of
stress? (2). Does a mindfulness workshop
provide lasting stress management skills
during clinical coursework 9 months later? (3)
How does the multidisciplinary nature of the
workshop inuence students, if at all?
Annette Willgens Associate Clinical Professor,
College of Public Health, Department of Physical
erapy, Temple University, Cecil B. Moore Ave,
Philadelphia, PA 19122 (annette.willgens@temple.
edu). Pleaseaddress all correspondence to Annette
Willgens.
Kerstin Palombaro Associate Professor, In-
stitute for Physical erapy Education, Widener
University, Chester, PA.
e authors declare no conicts of interest.
Received June 16, 2018, and accepted November
10, 2018.
Supplemental digital content is available for this
article. Direct URL citations appear in the
printed text and are provided in the HTML and
PDF versions of this article on the journals Web
site (www.aptaeducation.org).
Copyright © 2019 Academy of Physical erapy
Education, APTA
DOI: 10.1097/JTE.0000000000000089
Vol 33, No 2, 2019Journal of Physical Therapy Education144
Copyright © 2019 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
LITERATURE REVIEW
Student Stress
Stress and anxiety in health science graduate
students has been linked to decreased aca-
demic performance, decreased condence,
and poor professionalism in the clinic.
4,13
Graduate school is a time of personal growth,
but excess stress can negatively inuence
clinical performance.
4,13,14
In physical ther-
apy education, the concept of self-care is often
left to the student, or it is addressed using
cognitivebehavioral approaches that limit
the personal insight needed to dampen the
sympathetic nervous system.
14,15
It appears
that the brainbody connection is not yet
a deliberate addition to health science grad-
uate education. However, the hypothalamic
pituitaryadrenal axis
16,17
and, more recently,
the neuralhematopoeticarterial axis
18
il-
lustrate the need to develop a lifelong practice
of self-care to minimize the eects of stress
over the lifespan. Health science graduate
students often exercise to address distressing
thoughts and emotions, but without tools to
address maladaptive thought patterns, exer-
cise becomes a temporary solution for the
ongoing rumination and worry.
18,19
Mindfulness
Mindfulness is dened as paying attention,
in a particular way, with nonjudgmental
awareness.
19,2 0
It includes meditation, which
has been shown to enhance attention by way
of the anterior cingulate cortex and improve
emotion regulation by way of the fronto-
limbic network.
20
Mindful practices teach
the student to self-regulate so that the auto-
nomic nervous system can be restored
to its proper function.
1820
Without self-
awareness, students perceive threat based on
uncertainty and anticipation (clinical cour-
ses, examinations, laboratory practicals).
21,22
Table 1. Relationship Between Research Questions and Methodology
Research Question Methodology Method
1. Does a mindfulness workshop positively
inuence health science graduate students
levels of stress?
Descriptive statistics 1. Examine scores on measures of stress,
worry, mindfulness, and self-care
Generic qualitative analysis 2. Ensure that qualitative comments support
quantitative data analysis
2. Does a mindfulness workshop provide
lasting stress management skills during
clinical coursework 9 months later?
Generic qualitative data analysis 3. Analyze qualitative comments in response
to an online survey sent after the students
have completed clinical practice courses
Survey data
3. How does the multidisciplinary nature of
the workshop inuence students, if at all?
Generic qualitative data analysis 4. Determine whether qualitative comments
support, remain neutral to, or deny the inuence
of a multidisciplinary approach to stress
management in health care graduate students
Survey data
Table 2. Measures Used in Data Collection
Measure Description Rationale Psychometric Properties Sample Questions
The Cognitive Affective
Mindfulness Scale-
Revised
58
A 10-item self-report
measure that is scored on
a Likert scale of 1 (rarely
or not at all)to4
(almost always)
Used to determine the
level of mindfulness
before and after the
workshop
Strong internal
consistency and
structural, convergent,
discriminant validity in
college students
59
I can accept things I
cannot change
Perceived Stress Scale
60
A norm-referenced test
of 10 items in which
students are compared
to one another using
criteria from 0 (never) to
4 (very often)
Used to determine levels
of stress reactivity
Solid internal
consistency, reliability,
factorial validity, and
hypothesis validity on
college students (high
specicity)
61
In the last month, how
often have you been
upset because of
something that
happened
unexpectedly?
Penn State Worry
Questionnaire
62
A 16-item, self-report
measure using a Likert
scale of 1 (not at all
typical of me)to5
(very typical of me)
Used to determine levels
of worry and preferred
the word worryto the
word anxiety
High internal
consistency, reliability,
and convergent and
criterion-related validity
with high specicity in
college student
samples
63
My worries
overwhelm me
How I typically act
toward myself in
difcult times
64
A compassion scale of 26
items that include the
following subscores: self-
kindness, self-judgment,
isolation, mindfulness,
and overidentication. It
is scored on a Likert scale
of 1 (almost never)to5
(almost always)
Used to determine levels
of self-compassion in the
context of everyday
occurrences
High internal
consistency, reliability,
and criterion-related
validity
65
When I fail at
something important
to me, I become
consumed by feelings
of inadequacy
(overidentication)
Vol 33, No 2, 2019 Journal of Physical Therapy Education 145
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Students often admit to feeling hypervigilant
and experiencing excess negativity,
20,21
which
can create a snowball eect in the clinical
setting.
In contrast, students who practice mind-
fulness may develop more insight through
decentering and reperceiving,
22,23
is creates
a broader view of one self to be able to see the
contents of the mind (self-criticism, self-
judgment, negativity bias) more clearly.
2325
Meta-analysis has shown that mindfulness
meditation practices bring about signicant
eects in reducing physical and psychological
symptoms of perceived stress, depression, and
anxiety.
2329
It also helps students cope better
with university life,
2,27,30,31
gain maturity,
32
develop resilience,
33
prevent burnout,
34
and
enhance cognitive performance.
35
Mindfulness practices include breath-
focused meditation and body scanning, which
activates lateralized neural circuits that involve
the somatosensory cortex
19
and thereby the
embodied self.
36
is internal shift allows two
critical elements of mindfulness to evolve. e
rst is self-regulation.
37,38
As the student learns
to meditate, they begin to notice thought pat-
terns and thereby gain wisdom to manage
these thoughts more skillfully.
15,37,38
With
practice, the student develops increased
objectivity and granularity of incoming emo-
tional data (ie, is there sadness or disappoint-
ment?).
19,2 2, 23
is allows for more exible
feeling states and reinforces the transient na-
ture of emotion.
22,23,25,29,36,37
esecondele-
ment of mindfulness teaches students how they
relate to personal experience.
22,23,3640
Using
nonjudgment and self-compassion, the student
can dampen the sympathetic nervous
system
22,23,3640
to establish more accurate self-
assessment
37
and a heightened sense of personal
control.
3840,54
Training in meditation may provide more
ecient access to executive control centers
during the type of cognitive demand experi-
enced in the clinic.
41
When competing with
alternate sources of attention (mind-
wandering, stress, feedback), the experienced
meditator can volitionally return to the task or
situation with more clarity and emotional
stability. For example, as a student sits in class,
their focus naturally shifts over the course of
several hours. e mind wanders in a self-
reective state, often tied to negative pro-
cessing, past focus, and future focus.
41
As the
student steadies the mind, returning it to the
lecturer, s/he creates a habit of shifting be-
tween mind-wandering and focused atten-
tion. In contrast, the student who practices
meditation trains the mind for focused
awareness. So, when the mind wanders, they
become aware of the change in mind states
more quickly, allowing for volitional control
and return to attention.
41
It is suggested that
the prefrontal cortex acts as a hubthat can
couple with neural networks more eciently
based on the student clinicians needs in the
moment (classroom vs clinical setting).
However, a restless mind that does not prac-
tice mindfulness meditation has less de-
veloped regions (and therefore connections)
associated with focused awareness (anterior
insula) and open monitoring (prefrontal
cortex).
42,43
During clinical performance, the
student who has not practiced mindfulness
meditation may struggle more with mind-
wandering, mood/aect, and skillful shifting
between brain states, especially under cogni-
tive load.
4144
Another way that mindful awareness can
be useful is amid a students strong achieve-
ment orientation often found in health sci-
ence graduate students.
45
With meditation,
the student can become aware of attachment
to grades, maladaptive perfectionism, and
worry, so that they can lter the eects of
these during clinical performance. As the
neural attention networks are no longer
hijacked by negativity, students may gain
condence from increased self-regulation.
46
Interdisciplinary Communication
In health sciences education, graduate stu-
dents have little opportunity to communicate
across disciplines.
47
Active listening, reective
responses, tolerating uncertainty, managing
conict, and practicing authenticity are rarely
practiced as part of the formal curriculum,
which may create a culture of isolation. In
physical therapy curricula, for example, stu-
dents practice regular communication with
other physical therapy students and some-
times practice interprofessional communica-
tion, but rarely do they have the opportunity
to speak about worry, fear, stress, conict, and
shame.
Mindful communication
48
involves joint
attention, deep listening, and personal
awareness so that students begin to notice the
desire to interrupt or turn the conversation
toward themselves. ey practice tolerance to
distress and awareness of how it feels to be
a listener. Having been trained to be concise
(as compared to descriptive or elaborative),
health care graduate students exhibit short-
ened and more objective communication.
49
is may limit their ability to express
thoughts and feelings within a clinical envi-
ronment, relate to the perspective of another
health care provider, or communicate their
own needs and expectations in the workplace.
METHODS
e Drexel University Internal Review Board
approved this study. Using convenience
Figure 1. Summary of study method and process.
Table 3. Student Discipline and Clinical Coursework 9 Months After the Workshop
Discipline/Major # Of Students
Clinical Coursework 9 Months After
Workshop
Physical Therapy 9 Full-time clinical experience of 6 wk
Creative Arts Therapy 5 Full-time clinical experience of 3 mo
Nutrition Sciences (PhD) 5 Full-time clinical experience of 6 wk
Physician Assistant 4 Full-time clinical experience of 3 mo
Vol 33, No 2, 2019Journal of Physical Therapy Education146
Copyright © 2019 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
sampling within the Drexel University Col-
lege of Nursing and Health Professions,
graduate students were recruited to volun-
tarily participate in a 6-week workshop for
stress management. Table 1 represents the
relationship between research questions,
methodology, and method.
Process and Recruitment
A workshop yer titled, Got Stress?was sent
to all students in the College of Nursing and
Health Professions in the following programs:
nurse anesthesia, creative arts therapies,
physician assistant, physical therapy, couple
and family therapy, and nutrition science. As
a physical therapy faculty member, the
scheduling for the workshop most easily met
the physical therapy studentsschedules and
therefore their ability to participate in the
workshop. e scheduling did not match
nurse anesthesia or other nursing disciplines
because they are mainly online programs.
Many students expressed interest but were in
class during the workshop and could not
participate, causing an unequal distribution of
disciplines.
eyer provided program goals for stress
management, the time commitment, and the
need to collect data before and after the work-
shop and again after the student attended clin-
ical coursework. Clinical coursework was
dened as any period of immersion in a clinical
setting for at least 6 weeks that would require the
student to perform skills and be evaluated using
a formal assessment process. A yoga studio was
secured on campus for the 6 weekly, noon-time
meetings of 50-minute duration. eworkshop
(Appendix, Supplemental Digital Content 1,
http://links.lww.com/JOPTE/A46) was de-
livered in the Winter term and studentsclinical
coursework occurred in the Fall term, 9 months
later. Data were collected at 3 points: 1-week
before the start of the workshop (4 outcome
measures), immediately after the nal day of
workshop (4 outcome measures), and immedi-
ately after the studentsclinicalexperience
(Qualtrics survey link sent by email). ecur-
riculum for the workshop was modied from
the authors previously published mindfulness
curriculum,
50
to t into the reduced time frame
(Appendix, Supplemental Digital Content 1,
http://links.lww.com/JOPTE/A46). Students
were required to maintain daily practice logs. If
students showed evidence of less than 5 days of
practice, they were invited to complete the
workshop, but their data were not used.
Each session began with breath-based
meditation and body scan,
51,52
followed by
a brief teaching moment.
49,52
Additional ac-
tivities included mindful eating
54
and mindful
movement
52
in the form of slow, intentional
walking and gentle yoga. e theory is that
attention moves with movement of the body
with direct connections within neural circuits
for motor planning and spatial attention.
52,55,57
Because health science graduate students are
often required to sit still for long periods and
because they are often distracted, the yoga and
mindful walking provided an integrated way to
channel attention.
5557
Each session also in-
cluded mindful communication in dyads or
small groups, with someone you have not met
before.
Participants
Twenty-ve students emailed the author
within the rst day, and a waitlist was created
for another 17 students. One student dropped
out of the workshop on the day before the start.
Waitlisted students were contacted, but they
chose to defer citing no timeto participate or
did not respond in time for the start date of the
workshop. One student did not submit the
practice log, so his or her data were not used.
Participants were asked to complete 15
minutes of mindfulness practice every day.
ey could choose from one or more of the
following practices: meditation with focus on
the breath, body scan, mindful movement/
walking, mindful eating, and yoga. Practice
logs encouraged students to document their
time spent on a specic activity and briey
journal their thoughts and feelings. At rst,
Web-based resources were emailed to stu-
dents (meditation and body scan), but as the
workshop progressed, they shared additional
resources with one another and discovered
resources that worked best for them. Twenty-
three of 24 practice logs were collected, and all
students documented a daily practice of 15
minutes.
53,66
Table 4. Frequency of Mindfulness
Practices From Student Practice Logs
Mindfulness Practice
Practice
Frequency
Body scan: guided n=21
Seated meditation: guided n=19
Mindful meals (silent) n=19
Yoga group class n=9
Mindful walking (silent) n=6
Seated meditation: not
guided
n=4
Yoga home video n=3
Body scan: not guided n=2
Table 5. Pre- and Posttest Means and Standard Deviations of Quantitative Measures
a
Measure (n= 23)
Pretest Posttest
Mean SD Mean SD
The Cognitive Affective Mindfulness Scale-
Revised
58
24.7 4.4 29.2
a
5.0
Perceived Stress Scale
60
25.9 4.0 20.9
a
2.4
Penn State Worry Questionnaire
62
55.6 10.9 44.8
a
10.0
How I typically act toward myself in difcult times
64
Kindness subscale 13.6 3.4 18.0
a
3.3
Self-judgment subscale 17.3 2.6 12.6
a
2.1
Isolation subscale 15.3 2.7 10.5
a
2.4
Mindfulness subscale 11.9 3.1 15.8
a
2.1
Overidentication subscale 14.3 3.2 10.3
a
2.6
a
P#.001.
Vol 33, No 2, 2019 Journal of Physical Therapy Education 147
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It was important to ensure that all students
pretest, posttest, and survey data were collected
anonymously because the position of one of the
authors as Director of Clinical Education may
have biased studentscomments. Survey data
were collected using Qualtrics, an online survey
tool that allows researchers to design, collect,
and analyze participant responses using anon-
ymous methods. All pretest and posttest qual-
itative data were collected using this
encrypted software.
Data Collection
A mixed methods approach included pre-
workshop, postworkshop, and postclinical
measures to determine studentslevels of
worry, perceived stress, feelings of isolation,
self-judgment, self-kindness, overidentication
(rumination or magnication of negativity),
and mindfulness. See Table 2 for information
on outcome measures used.
On the last day of the workshop, students
were asked to respond to an anonymous
survey link that was sent with the following
three questions: How has the program
changed the way you manage daily stress, if at
all? What were the most valuable lessons or
tools for you and why? How did the presence
of other health professions students inuence
you during this workshop, if at all?
Upon completion of the posttest survey,
students were sent a nal list of resources for
continued practice. ese included the Head-
space app, Insight Timer app, and Sound
Cloud for free online access to meditation and
body scans. It was recommended that students
subscribe to a daily e-magazine, Mindful.org,
which includes short tips, practices, and arti-
cles on a variety of mindfulness topics.
Post Clinical Survey
Postclinical survey data were collected at the
9-month postworkshop mark, which varied
minimally across students. is anonymous
survey contained the following question: How
did the tools you learned in the mindfulness
workshop support your performance in the
clinical setting, if at all?
Qualitative comments from all three peri-
ods were coded and categorized using generic
qualitative analysis.
67
Generic analysis requires
an inductive process of reading (survey) data,
code meaningful statements related to the re-
search question, cluster codes to create themes,
and return to the data to ensure that support-
ing text is consistent across participants. In the
nal step, the themes are synthesized to form
interpretations that inform the quantitative
data. Creswell
68
called this the equivalent status
design in which both methodologies are used
to understand and uncover the research ques-
tions. Study participants agreed to member
check by responding to an email to verify
statements and nal themes. All participants
agreed with the themes identied. Figure 1
illustrates the study method in a visual format.
SPSS version 23 was used for quantitative
data analysis. Descriptive statistics were run
foralldemographicvariablesaswellason
the variables of interest. A Wilcoxonssigned
ranks test was performed on all pretest and
posttest data, due to the use of convenience
sampling.
RESULTS
Fifteen female and 8 male subjects completed
the workshop. Mean age was 26.2 (63.0)
Table 6. Generic Qualitative Analysis: Post Workshop
Theme Examples of Data Support for Theme
I have tools I Have more resources to address it rather than
feeling helpless when presented with high stress
circumstances.
I Really enjoyed the meditation for working with
difculties because mystress usually manifests itself in
very real physical ways that effect my body, and this
meditation helped me recognize where in my body
the stress was, helping me to label it and relieve it.
All of the techniques taught in this workshop were
valuable to create a toolbox for me to try out
different things and see what worked best for me. I
took the most value from the body scanning and
watching the breath.
Pause, think, allow I Have been able to approach situations that may
overwhelm me one step at a time.
I dont get as anxious when things dontgoas
planned and I am not upset for as long. I liked the
concept of being withwhatever arises. And
attend and befriendis now stuck to my frig, as
a daily reminder.
I Started to stop and think before responding. I now
know that my anxious brain tries to trick me and I
have to check if the story I am telling myself is true or
not.
Silence the critic By stopping the (self) judgment, I reduced my levels
of self-doubt. Treating yourself like you would treat
a puppy or small child was a powerful visual for me.
One of the biggest takeaways was the concept of not
allowing fear to run your life. When I stopped
studying out of fear and began to study with the
intention of becoming a better practitioner,
everything shifted and my anxiety before high-
pressure situations decreased signicantly. Stopping
the mean voice in my head was huge.
I Am not alone I liked the activity in class where we partnered up with
students we didnt know. After 2 y with the same
group, you forget to be anything but a PT student.
When we partnered and got to speak freely I thought
that was incredibly interesting to speak to someone
outside my major because they had the same stress as
me, the same examination anxiety. You get such
tunnel vision. Knowing that complete strangers feel
the same way as me helped me not feel so alone.
I Used to think it was only me, I must be the student
with the lowest GPA so I lacked condence but the
partner and group work helped me to see-literally
looking at a new partner each week and hearing how
they had the same feelings as me was so helpful.
Vol 33, No 2, 2019Journal of Physical Therapy Education148
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years. Table 3 includes student numbers by
discipline and clinical experience time.
Student practice logs were collected and
analyzed for frequency, duration, and the type
of mindfulness practices. Table 4 represents
the data collected in order of most to least
frequent. During the workshop, students were
encouraged to practice mindfulness medita-
tion and body scan daily, eat one mindful
meal daily, and walk mindfully without talk-
ing or listening to music. Students were told to
experiment with what worked best for them in
the rst week, then continue with that method
for the duration of the 6 weeks. erefore,
analysis only included weeks 26.
Data from Table 4 illustrates that students
preferred to use guided meditation and body
scan, stating that it was preferred with the
support of an app. Several students stated
that they did not practice mindful eating
because they preferred speaking with
roommates and friends as a way to relieve
stress, and they forgotto walk mindfully
(slowly) because they would often walk with
friends to class or be in a hurry to get to class
on time. Students who did yoga often com-
bined this form of mindful movement with
focused breathing and body scan in a 30-
to 60-minute class or home video practice.
After the mindfulness sessions, participants
experienced signicant improvements in
mindfulness and self-compassion scores
and decreases in perceived stress and worry.
ey demonstrated increased Kindness and
Mindfulness subscales with decreases noted
in self-judgment, isolation, and over-
identication (Table 5).
Table 6 represents themes drawn from the
survey data and analyzed using generic
qualitative data analysis. Four themes are
represented with examples of data support
for each.
After clinical coursework (9 months post
workshop), students responded to one nal
open-ended, anonymous survey question:
How did the tools you learned in the mind-
fulness workshop support your performance
in the clinical setting, if at all? (Table 7).
DISCUSSION
is pilot study conrmed all three of the
research questions. Indeed, a brief mindful-
ness program can positively inuence gradu-
ate studentslevels of stress. Additionally, the
interdisciplinary nature of the workshop
conrmed for students that they have more in
common than they realized, diminishing their
feelings of isolation over time. e most sig-
nicant nding was that the mindfulness
workshop made a lasting impression, even 9
months later, to positively inuence students
self-care during full-time clinical coursework.
Having established a daily practice for 6
weeks, students not only retained the skills
they learned in the workshop but they also
applied them in the clinic. is nding is
consistent with studies that have demon-
strated positive results using mindfulness for
physician stress and burnout.
6971
LIMITATIONS
e limitations of this study included a small
sample size and limited prior research on the
connection between stress and clinical per-
formance in health professions students. A
control group would have added to the
trustworthiness of the study. Exploring dif-
ferences based on practice setting, age of the
student, GPA, and other data sources would
have added depth to this study. Open-ended
survey questions could have been posed in
a more neutral fashion. Variation in mindful
practices prevents generalizability. Biases may
have surfaced in the coding of the qualitative
survey statements, although students partici-
pated in member checking and agreed with
the results obtained. Additionally, tri-
angulation of data was achieved with the
mixed methods approach. In the future, cor-
tisol samples, heart rate, and blood pressure
logs would be helpful to determine the phys-
iological change.
CONCLUSION
Health sciences faculty members have a re-
sponsibility to provide easily accessible, evi-
dence-based strategies to support students
mental health.
Recent studies support the use of mindful
practices in university students,
2,8,13,27,30,31
but
this is the rst study to track the inuence and
application of stress management on physical
therapy, physician assistant, creative arts ther-
apy, and nutrition science graduate students.
Table 7. PostClinical Experience Survey Results
Response Options n=23
Percentages of Mindfulness Tools Used
During Clinical Immersion Representative Student Comments
The tools helped somewhat 2 Two students stated that they did not use
the tools specically but did benet from
the workshop
I was still very stressed but it did not
paralyze me like it usually does. Its
a process. If you dont put in the time, you
dont get the benets
The tools helped a great deal 21 Students used reframing of their thoughts
and feelings and decreased judgment of
themselves (self-compassion)
I remembered S.T.O.P. when I made
a mistake in front of my (clinical)
instructor, or when I wished something
would have gone more smoothly, I didnt
beat myself up as much
Students stated they remembered to
describe and label thoughts and feelings
I Used R.A.I.N. to ask myself: is this
thought true or is it my critic talking?
Students stated they approached thoughts/
feelings with more kindness, which
decreased worry
Just nding words to describe my
feelings was helpful
Students used body scan and breathing
space practices
I used my breathing and body scan every
day, especially in the beginning when I
wasnt getting much feedback from my
CI, it helped me stay positive
Students used a combination of recalling
their personal mantra,eating mindfully,
and moving mindfully
I used the mantra everything doesnt
have to be perfect or Itsok
Vol 33, No 2, 2019 Journal of Physical Therapy Education 149
Copyright © 2019 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
Anxiety and depression are increasing in prev-
alence in health science graduate students,
72
and
concepts such as maladaptive perfectionism,
18,19
maladaptive self-concept,
73
and imposter syn-
drome
74
must be openly discussed. Students
who experience these phenomena have an in-
creased risk of failure during clinical course-
work, may become unsafe during patient care,
and may struggle with critical thinking and
clinical reasoning.
4
Individuals who practice
meditation may have more functional and
structural connectivity between the dorsolateral
prefrontal cortex, the insula cortex, and the
anterior cingulate cortex, which preserves ac-
curate self-assessment and critical thinking,
even under cognitive load.
41
Sharing these data with faculty members
may help to improve student safety, prevent
the need for remediation, and safeguard the
patient/client from errors associated with
faulty clinical reasoning. It may also help to
prevent chronic stress in future clinicians,
which benetsthehealthcareprofessionas
awhole.Researchinthisareaisneededto
implement training for faculty to integrate
these practices into everyday coursework
and to more intentionally provide resources
while students attend clinical rotations o
campus.
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... 2,9,15 e DASS-21 has been found to be valid in measuring depression, anxiety, and stress in the general adult population and among persons in the 4 most prevalent racial groups in the United States (White, African, Latino, and Asian). 28 Specifically, research on the DASS-21 has consistently shown to have very good psychometric properties, such as internal consistency, 28,29 concurrent validity, 29 construct validity, 30 and discriminant validity. 28 2. A written subjective history of mental health issues, stress management strategies, and current health behaviors was provided by the participant at each assessment time. ...
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Purpose: Mistakes are ubiquitous in medicine; when confronted by error, physicians may experience anxiety, guilt, and self-doubt. Feedback may be useful for navigating these feelings, but only if it matches a physician's self-assessment; self-doubt and the imposter syndrome are examples of inaccurate self-assessments that may affect receptivity to feedback. The impact of real or imagined underperformance on seemingly competent physicians is poorly understood. This study aimed to develop a deeper understanding in order to identify strategies to support all physicians who struggle. Method: In 2015, 28 practicing physicians were interviewed about their experiences with underperformance at an academic institution in Canada. Early in the data collection process, participants spontaneously identified the imposter syndrome as a feature of their experiences; questions about the imposter syndrome were probed in subsequent interviews. Results: Many participants-even those at advanced career stages-questioned the validity of their achievements; progressive independence and career advancement were variably experienced as "rising to the level of your incompetence." Not all participants identified as imposters; the imposter syndrome occurred at the extreme end of a spectrum of self-doubt. Even positive feedback could not buffer participants' insecurities, which participants rarely shared with their colleagues. Conclusions: Self-doubt variably affects clinicians at all career stages. Frequent transitions may cause a resurgence of self-doubt that may affect feedback credibility. Medical educators must recognize that it is not just the underperforming or failing learners who struggle and require support, and medical culture must create space for physicians to share their struggles.
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Background: Stress is a part of daily life for graduate students, including graduate nursing students. Contemporary graduate nursing students are facing unprecedented challenges to meet rigorous academic standards as they prepare for their advanced professional role to meet the demands of the nation's complex and ever-changing healthcare system. Empowering graduate nursing students to ease their perceived stress and minimize undesirable health effects may benefit their capacity to adapt and successfully manage perceived stress in their future healthcare role. Aims: To conduct a systematic review to evaluate the existing evidence with the aim of identifying evidence-based self-care interventions for coping with perceived stress. Methods: We conducted a systematic review, searching CINAHL Plus with Full Text, PsycINFO, and MEDLINE. Inclusion criteria included self-care, graduate students, perceived stress as measured by Perceived Stress Scale, quantitative analysis, conducted within the United States, English language, and peer reviewed. Two authors completed an asynchronous review of the articles, and one expert evidence-based practice mentor and one wellness expert conducted rigorous appraisal of the eight identified studies. Evidence was evaluated and synthesized, and recommendations for practice were determined. Results: Eight studies meeting the criteria for this systematic review were critically appraised. The interventions varied from a stress management course to mind-body-stress-reduction (MBSR) techniques, such as yoga, breath work, meditation, and mindfulness. All studies measured the outcome of stress with the Perceived Stress Scale. Each study demonstrated a reduction in perceived stress postintervention. Linking evidence to action: Most effective self-care MBSR interventions include (a) a didactic component, (b) a guided MBSR practice session, and (c) homework. Consideration should be given to a trained or certified MBSR instructor to teach the intervention.