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The use of Anxiety Reduction Strategies to Decrease Stress in Nursing Students

Alexandra Haluska, Brittany Latimer, Justyn Madick,

Taylor Martin, Hayden Sloan, Kacie Tekach

April 8, 2020

NURS 3749: Nursing Research

Dr. Kim Ballone

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Abstract

The research done on stress reduction in nursing students is very important in order for nursing

students to understand how to overcome moments of tension. It is well known that nursing

students have an intense curriculum. It is apparent that there are multiple things that lead to high

anxiety and stress in nursing students such as: clinicals; lab experiences; exams; and lectures.

They all require time and effort for students. With that being said, students must learn how to

balance their workload while trying to retain the abundant amount of information thrown at them

during each semester of school. The good thing is that there is research that shows which stress

and anxiety reduction techniques can be done to lessen the chances of stress.
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Stressors in Nursing Students

Stressors

For many, choosing to study nursing in college was an easy decision based on their desire

to help individuals and provide optimal care for those who are ill; however, over the course of

their learning, nursing students often find that their levels of stress are increased due to a variety

of different factors. “Nursing students experience higher levels of stress than students in other

health science” (Rafati et al., 2017, para. 1). Nursing programs at universities throughout the

world can often be very competitive for students. Due to the fact that the lives of individuals are

put in the hands of nurses, it is critical that students aspiring to be in this profession are provided

adequate education and taught the appropriate skills. While increasing their knowledge on

caring for individuals with different health problems in the classroom setting, nursing students

also spend many hours in the clinical setting for a hands-on experience with patients. Between

the two settings, nursing students experience an abundance of stressors relating to different

aspects of their education.

Being full time students, the workload can be quite cumbersome based on the course

requirements for each semester. Research shows that assignments and workload are the most

common causes of stress amongst nursing students (Shdaifat et al. 2018, p. 35). As mentioned

above, programs can be competitive when it comes to nursing majors. Grading scales may be

different compared to other majors, causing the percentage to achieve a passing letter grade to be

much higher. Based on this grading policy, the stress levels of many students increase as they

begin to worry about their grades and receiving bad ones (Shdaifat et al., 2018, p. 36).

Stemming from the stressor of the overwhelming workload, student nurses also worry whether
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their performance meets the expectations of their professors and other faculty members (Shdaifat

et al., 2018, p 36). Students confirmed that they cope with this situation simply by avoiding their

professors (Shdaifat et al., 2018, p. 37). While avoiding may seem like the easy way out in some

circumstances, it is not always the most beneficial mechanism. Nursing students often struggle

with managing their time in a manner that allows them to study for exams, complete any

assignments, and to also maintain a life outside of nursing school. In response to this, nursing

students cope by making plans, prioritizing assignments and events as well as using problem

solving skills in stressful situations (Shdaifat et al., 2018, p. 37).

Clinical Setting Stress

Nursing students experience a great deal of stress when it comes to being in the clinical

setting. Skills that are necessary in the nursing field are often taught in the classroom and

different skill lab settings that provide students with hands-on experiences. Although the

hands-on experience is extremely beneficial to a nursing students’ studies, this also causes a

great deal of anxiety. First year nursing students often do not have much experience dealing with

patients prior to clinicals; therefore, it can be understanding as to why it may be overwhelming.

In general, the student is working with the public trying to stand out from the rest while making

wise decisions in the medical field, as well as demonstrating their knowledge and their abilities

to their professors and mentors. As their education continues, however, many students still

experience stress in clinical settings for a number of reasons. Common stressors experienced by

nursing students in this setting include, “the fear of unknown events, working with equipment...

the fear of making a mistake and communication with staff’ (Rafati et al., 2017, para. 1).

Evidence shows that nursing students also cope with stress by obtaining a sense of well-being
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through mind and body practices (Rafati et al., 2017, para. 3). Instead of avoiding situations,

students deal with caring for patients by having “confidence in overcoming difficulties”

(Shdaifat et al., 2018, p. 37). Finding strategies to cope with stress is especially important in the

clinical setting, because how students react to situations can not only affect them, but can affect

the patient as well.

These stressors may impact students in a variety of ways. Unfortunately, many of the

common stressors amongst students in nursing school are unavoidable; therefore, it is important

that students find ways to manage their stress in order to maintain good health and to do what

they can to avoid jeopardizing their academic performance. Reflecting back on different coping

strategies used previously, allows nursing students to see whether it was beneficial or not. Over

the years of schooling, students may also find other coping mechanisms to decrease their stress

levels. There is a variety of research that provides different techniques that are most beneficial in

relieving stress in students’ lives and performance as a prospective nurse that could certainly be

beneficial.

Test Anxiety

Interventions for Test Anxiety

Test taking is another big stressor that a lot of nursing students face. In the article,

“Interventions for Test Anxiety in Undergraduate Nursing Students: An Integrative Review”

written by Lisa D. Brodersen (2017), she states, “Although tests were not the most frequently

used method to assess learning, they carried the most weight in the determination of final course

grades” (as cited in Oermann, Saewert, Charasika, & Yarbrough, 2009). Examinations play a big

part in whether or not a student will pass the nursing education course; in addition, clinical
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attendance and student assignments contribute to this. With that being said, if a student does not

pass their tests, failure to successfully complete the course will be the end result. Since the

assessments carry the most weight when it comes to determining final grades, this makes sense

that nursing students feel an extreme amount of anxiety and stress around test time. Brodersen

(2017) discusses an integrative review done to find interventions related to test anxiety in

undergraduate nursing students. This review followed the Matrix Method. The study began with

a comprehensive search of the literature on interventions for test anxiety in nursing students

(Broderson, 2017, p. 131). The number of students in the studies throughout the articles ranged

from 14 to 483. Thirty-three different publications were found and nineteen interventions were

found within these thirty-three publications. Interventions were broken up into two different

sections: intratest interventions, interventions that were used while students were testing, and

peritest inventions, interventions used outside of test taking (Broderson, 2017, p. 132). These

types of interventions were both shown to be successful when it comes to nursing students and

test taking. The most common intratest intervention was collaborative testing. This type of

testing included double testing, group testing, and paired testing (Broderson, 2017, p. 132). Even

though most professors do not allow this type of testing to happen, it would help most students

when it comes to test anxiety. This type of intervention allows for students to work together on

tests which can increase their chances of improving their exam scores. Overall, passing the

course with a higher GPA. If the students know they will be able to have help from their peers,

this will alleviate stress levels while preparing for the test and increase performance during the

assessments.
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Another intratest intervention that decreased test anxiety in students was the use of a crib

sheet. Broderson (2017) defines a crib sheet as, “... a single sheet of paper with notes to be used

during an exam to facilitate recall of information” (p. 132). The crib sheet could allow a student

to write down certain information that they are having trouble memorizing or understanding

before an exam. So instead of the student focusing on a section that they can't seem to

understand, the student can focus and get more studying done on different topics. A third form

of an intratest intervention included humorous exam questions throughout tests. Examples of

humorous questions included funny or silly questions not counted toward the actual exam score

or serious exam questions with obvious answers that were not correct, but funny. This strategy is

shown to lower test anxiety in students (Broderson, 2017, p. 132). With this strategy, it shows

the students that professors are human and enjoy a sense of humor and that their goal is to see

that you succeed. Aromatherapy and music therapy have also been looked at to reduce the

anxiety of nursing students while they are taking their exams. Broderson (2017) states, “In

Turkey, students randomly assigned to take an exam in a room infused with lavender aroma had

significantly lower stated anxiety scores after the exam than students in a room without

aromatherapy” (p. 132). Aromatherapy helps the students to relax while test taking therefore

decreasing anxiety and stress. A crossover study in China showed that music therapy resulted in

decreased test anxiety, decreased finger temperature, and decreased pulse rate (Broderson, 2017,

p. 132). The intratest interventions have shown to be very successful with nursing students in

these studies.

Peritest interventions were also studied in this article and had significant results when it

comes to test taking anxiety and nursing students. Broderson (2017) states, “Peritest
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interventions were pet therapy, a test-taking skills workshop, exam analysis, and various

cognitive behavioral (CB) interventions” (p. 134). These interventions were used outside of

class time and helped the students prepare for their upcoming exam. Pet therapy was studied

using a quasi experimental study and showed a decreased test anxiety level by 10 points

(Broderson, 2017, p. 135). Some of the cognitive behavioral interventions included

hypnotherapy, guided imagery, counseling on nutrition, exercise, relaxation, study skills, and

test-taking strategies (Broderson, 2017, p. 135). The exam analysis was held between the

professor and the student. The professor reviews the test with the student and goes over any

incorrect answers. The teacher then gives the student advice on how to improve for the next test.

All of these peritest interventions have been shown to decrease test anxiety in nursing students

while they are preparing for their exams.

Awareness of Stress

Mindfulness of Stress

Nursing is known for being a well-respected field. Many students go into nursing with

the goal in mind of wanting to help others; as well as holding a career which can potentially

provide a solid income. As we’ve discussed, in order to become a nurse, it requires many

stressful times throughout nursing education. Without some type of stress management, it can

cause nursing students to develop physical and emotional stress symptoms. This can then be

reflected amongst their academic and clinical performance (Lua et al., 2019, p.41). One way to

see if reduction of stress can occur in nursing students is the training of mindfulness.

Mindfulness is bringing one’s attention to the present moment experiences including body

sensations, emotions, and thoughts (Lua et al., 2019, p.42). In order to see this correlation, a
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study was done at a university in south-eastern United States. Ninety-nine undergraduate

nursing students from a Bachelor of Nursing program completed this study ranging from ages 18

to 24. The students were asked to fill out a questionnaire which collected their trait mindfulness,

compared to their psychological stress on a Perceived Stress Scale-10 (Lua et al., 2019, p.41).

The Stress Scale ranged from 1 (never) to 5 (very often) to depict their stress that day in

correlation to how mindful they were to the situations. The results of this study showed little

correlation between acting with awareness and the reduction of stress. This means that

observing with mindfulness the physical (e.g. headache) and psychological (e.g., worrying)

symptoms had no correlation with reduction of stress (Lua et al., 2019, p.44). Although this did

not reduce stress, it allowed the participants to become more aware of their stress and had more

acceptance and understanding of their stress levels. It can also be helpful for nursing educators

to adopt and teach mindfulness-based training to their students. This is because it can help them

as they become a nurse in the field by not showing their patients their stress related responses,

and not reacting to others ways of responding to stress. Nurse educators can play a vital role in

how nursing students deal with stress by acting with awareness of their students and being

non-judgmental to help promote reduction of psychological stress.

Interventions and Strategies

Distraction Focused Interventions

An additional way to decrease stress is use of distraction focused interventions. Nursing

students experience high levels of stress which in turn cause negative impacts on their health,

emotional state, and performance in class and during clinical settings (Gebhart et al., 2019, p.1).

Academic stress can have a negative impact on the well-being of nursing students which can
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cause delay in their schooling, switching majors, or even dropping out of college. This stress can

also lead to unhealthy behaviors such as smoking, eating disorders, and substance abuse

(Gebhart et al., 2019, p.2). The highest stressor of the nursing student is predominantly

examinations. This study focuses on distraction focused methods used to see their effects on

nursing students of examination stress and test anxiety. Fifty-seven nursing students participated

and were assigned to a random group. The groups included animal therapy, music therapy,

mandala painting, and the control group. Each of the distraction interventions lasted 45-60

minutes in the morning. The researchers collected sociodemographic data as well, including sex,

age, and educational background. Also, they asked what they did in order to relieve stress and

how effective it was to them. Psychological stress was assessed using the well-validated State

Anxiety Inventory (STAI-State). This uses a 4-point scale ranging from 0 (not at all) to 4 (very

much so). Psychological stress was also calculated through a visual analogue stress scale

(VASS) ranging from 0, no stress, to 10, most stress imaginable along with faces (Gebhart et al.,

2019, p.2). Physiological stress was measured with testing the salivary biomarker levels, Cortisol

and Immunoglobulin A, because it is the main way to assess stress responses in the body. The

researchers collected baseline scores on a normal under stressful day, as well as, on a day prior to

an examination. The data collected next was on a day where an intervention was carried out on a

non examination day. Lastly, data was collected on an examination day with an intervention

carried out. The results came to show that on days a distraction-focused intervention was put in

place on a non examination day, stress levels significantly reduced compared to days with no

interventions. Contrarily, on days of examinations the stress level was not decreased by the

distraction interventions. This study showed that examinations are outstanding stressors that
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some interventions cannot intervene this (Gebhart et al., 2019, p.2). With the use of these

distraction methods it helps to decrease stress the nursing student goes through on a daily basis

and should be used.

Clinical Setting Stress Reduction

When it comes time to go out into the actual clinical settings such as hospitals, nursing

homes, schools, etc., instructors and professors have a goal in mind and that is to fully prepare

their students for this time. As with almost everything in nursing, anxiety comes along with this

big move. Prior to going out into these real life experiences, students go through patient care

simulation scenarios to prepare them even more; however, this can still generate high levels of

anxiety working with a computerized patient. Mills (2016) states in his article:

“An experimental investigation into the extent social evaluation anxiety impairs

performance in simulation-based learning environments amongst final-year

undergraduate nursing students”, “Stimulation has been defined by Gaba as “... a

technique, not a technology, to replace or amplify real life experiences with guided

experiences, often immersive in nature, that evoke or replicate substantial aspects of the

real world in a fully interactive fashion” (p. 9).

Going through these simulations should decrease the anxiety of going into a real patient’s room

by giving the student an opportunity to get comfortable with the equipment, medication

administration, and overall patient care. Research shows that simulation lab experiments should

follow a “low to high-fidelity simulation, where students are first exposed to basic scenarios void

of extraneous distraction allowing focus to be narrowed to the application of clinical skills alone”

(Mills, 2016, p.9). The three components Mills describes are equipment, environmental, and
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psychological fidelity. Equipment fidelity is described as the reaction and function of the

patients, manikins, and medical instruments. Environmental fidelity, meaning if these

simulations match the demands of patients in the real world. Psychological fidelity provides a

uninterrrupted patient care flow compared to a student being in the room with the patient's family

or friends with questions during procedures. Mills believes that this strategy “allows early-stage

students to learn new skills with minimal stress until proficiency of a clinical skill is mastered,

after which time they can practice those skills in increasingly stressful simulated environments

that replicate real-world demands” (Mills et al., 2016, p. 10). In this study, students were

randomly assigned to complete one of the three same simulation-based scenarios to obtain

different levels of social evaluation anxiety by changing the number of people present with the

student during simulation. Stress and anxiety levels were measured by continuous heart-rate and

salivary cortisol. Different increases were found within the first minute of the simulation

between students who had one versus three people in the room with them. “The first study

hypothesis predicted that more confederate actors in the room during a SLE-conducted scenario

would result in increased anxiety in students due to SEA” (Mills et al., 2016, p. 13). Students

reacted worse to an increased number of instructors or researchers in the room than an increased

number of other students. They felt less pressure knowing they had the support of their

classmates to help each other. Results of this study show that students with only one person in

the room with them significantly outperformed those with three other people in the room with

them. Greater numbers in the room with the student increases their anxiety and can make them

perform poorly. Heart rate and salivary cortisol levels were significantly high between each
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study. Having multiple people in a patient's room causes great anxiety and nervousness not only

for the nurse or caregiver but the patient itself.

Resilience Building Strategies

Resilience building strategies are a key part of a nursing student's ability to cope well

with the stress and workplace madness after they graduate from nursing school. Though there is

a plethora of stress and anxiety that comes with nursing school, there is also a lot of it when it

comes to the workplace setting which is different in its own way. According to Cochran et al.

(2020) “In health care settings, burnout is routinely attributed to high workloads, lack of support,

high intensity situations, moral distress, and low job satisfaction” (p. 105). In nursing school,

this can be overlooked and that could be due to the other pressing matters of lectures, exams, and

clinicals which ultimately take priority due to what the state board mandates for nursing

programs. Nonetheless, it should be something that is prioritized more in nursing programs

throughout the country, because it is the reality of the profession once accomplishing the status

of a registered nurse. This study emphasizes the importance of incorporating these strategies in

nursing school so nursing students may be better prepared when graduating nursing school.

Cochran et al. (2020) state “Resilience training is a promising approach to improving

health and well-being. Resilience is a psychological construct that involves innate and/or

modifiable capacities that allow an individual to adapt positively to adverse situations” (p. 105).

Being resilient in the workplace setting is critical because the nursing profession can be very

stressful. This study done by Cochran et al. (2020) was to see how many nursing schools

actually provide these resilience building strategies. They found that not many accredited

nursing schools offer that, Cochran et al. (2020) state “ In conclusion, resilience training and
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resources related to coping skills, self-care, and well-being are essentially absent from the

curricula of accredited nursing schools in the United States” (p. 109). This is alarming because

evidence shows that mindfulness, self care and coping skills improve the overall well being of a

person. This is especially true in those who experience a lot of stress in their schooling and

careers. The research Cochran et al. (2020) found stated:

A pilot study of a multimodal resilience intervention that included expressive writing,

event-triggered counseling, mindfulness based stress reduction, and exercise sessions

showed that building and practicing resilience strategies had the potential to significantly

reduce posttraumatic stress disorder and depressive symptoms and increase resilience

scores of intensive care unit nurses.

This shows that there is evidence that supports the fact that there are stress reduction techniques

that will lead to less workplace burnout. The research states it was recognized to help nurses in

intensive care units, which is significant because there is a lot of stress and burnout that comes

with this part of the nursing profession. It is usually very intense and can take a toll on many

nurses. This outlines the importance of having resilience building strategies nurses and

especially for nursing students, because if it is learned before they become nurses then they will

be able to avoid burnout and deal with the stress of the job much easier.

Reducing Stress in First Year Nursing Students

One thing that students should look at when going into nursing school is the amount of

stress that can come with it. There are countless examples of nursing students having a difficult

time with the workload that comes with the education. Research has been done to look at how it

might be important for students to recognize this and take the appropriate steps to reduce stress.
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As we may all agree, the intense curriculum of nursing school with the testing, clinical

experience and lectures all of which can take a toll on many students, especially students who

haven't taken the time to reduce their stress. Any nursing student can testify to that. As Peterson

(2016) states “It is important to consider sources and effects of stress on college students, in

particular nursing students” (p. 1).

There are several resources many colleges and/or universities may offer to help with

student wellness. It is important to look at what particular schools offer especially their strengths

and weaknesses as Peterson (2016) states “When determining the ability to successfully

implement a program to reduce student stress it was critical to evaluate the strengths,

weaknesses, opportunities, and threats affecting the organization”(p. 3). There must be a

baseline of what is offered and then we can see how this is helping students. We all talk about

what causes the stress but we then must look to what type of things lead to the reduction of

stress. If a school is well equipped with things that reduce stress then the stress reduction in

students will be that much better. Things a school can offer are gyms, access to a church or

temple, athletics, intramurals, and even different student activities such as yoga or spinning

classes. Peterson (2016) refers to these extra things as external stress reducers. Peterson (2016)

stated the following:

External to the organization were outside opportunities that could reinforce stress

management in students, such as regular prayer or meditation through attendance at a

church or temple. Other opportunities were gyms, athletic, recreational facilities, and

classes offering activities such as yoga. (p. 4)

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These sorts of activities and places to go help with stress reduction. For a first year nursing

student, having these things are substantial because they are things that are proven to relieve

stress in some capacity. It is also key to note that these are mostly physical activities that reduce

stress in several ways.

First year nursing students being mindful of stress and the effects of it is important. The

research done by Peterson (2016) in which she conducted an 8 week mindfulness stress reduction

program (MSR), which was incorporated into their curriculum showed that stress was recognized

as a real problem. There were a total of 23 students that volunteered to be a part of the study and

only 16 of them finished through and took the post test to determine how effective the

mindfulness of stress reduction was. There were biweekly mindfulness practice sessions that

were 20-30 mins. Peterson (2016) says “The MSR practice involved listening to MP3 recordings

of MSR practices (p. 26). This study was to look more at the mental aspect of reducing stress.

Nursing students are able to be more mindful of stress and use mindful techniques to reduce their

stress in some way. With all of this being said Peterson (2016) did state that with the sample size

they had the intervention itself did not statistically support the effectiveness of MSR but it did

show that there are high levels of stress present in nursing students. Peterson (2016) states “In

conclusion, factors causing stress are not always controllable but learning techniques to manage

stress can improve overall student well-being through decreasing the physiological,

psychological, and spiritual effects of stress” (p. 50). At the end of the study, the students in a

post-questionnaire noted that there were positive effects that came with the intervention. There

were other good things to come out of the study that support the idea of educating first year

students on student wellness and the recognition of stress reduction. Peterson (2016) states “ It
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reinforced the need for integration of student wellness education including MSR into nursing

student education. Education on stress and its management emphasized the importance of

recognizing stress and its effects on health” (p. 48)

Energetic Modalities

Nursing school is highly demanding for its students. This difficult career path causes

students to experience high levels of stress, anxiety, and possibly even lead to depression. The

stress nursing students experience originates from a multitude of things. Examples of stressors

in nursing students include the large volume of information that is taught to them along with

clinical experiences. Luckily, stress and anxiety reducing techniques are now being used more

frequently. These effective modalities are also being taught to students through classes offered at

some colleges/universities. The benefits students receive from taking such courses are more than

just decreasing their stress and anxiety. Some of the techniques the students learned included

mindful dialogue breathing technique, meditation, chakras, Donna Eden’s energetic techniques,

William Tiller’s energy fiends, and Sharon Weiselfish-Giammaatteo’s integrative manual therapy

processing of energy. According to a study done by Kramer (2018), “Nursing students reported

decreased stress and improved concentration, academic performance, productivity, and

problem-solving while experiencing a greater appreciation of their clinical experiences,” after

taking such courses (p.366). The results from this study were confirmed by journal entries the

students wrote to reflect on changes they observed when using the various techniques taught to

them. This is a promising step that shows how the implementation of stress relieving strategies

can improve a nursing student's experience and performance.

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Self-compassion

A common and effective stress relieving strategy is that of self compassion. Self

compassion is described as how one can care or comfort themselves in a moment of failure or

difficult times. A study done by Lou and colleagues grouped 1,519 nursing students and

measured their anxiety and depression by using the Goldberg anxiety and depression scales. This

study revealed high levels of anxiety and depression in the nursing students in the study. By

implementing methods of self-compassion into the students regular schedule, their mental health

along with their performance in nursing school were positively impacted.

Improving college students' self-compassion through various feasible methods can reduce

their perceived pressure and thus reduce anxiety and depression. Interventionists should

consider self-compassion as an approach to alleviate perceived stress and thereby reduce

anxiety and depression in nursing students, such as through implementing training to

incorporate mindfulness into daily life. In this way, students can manage academic

pressure and challenges with a positive attitude and avoid adverse mental health

outcomes while transitioning from school to clinical professions. (Lou et al., 2019, p.8)

The findings from this study support the claim that self-compassion is an important and useful

way for nursing students to cope with their stress or anxiety. Self-compassion benefits nursing

students with more than just decreasing levels of stress, anxiety, and depression. This mindful

technique also enhances the students compassion for others.

Compassion is one of the main pillars of nursing. A compassionate nurse can enhance

their patients' experiences tremendously by making them more comfortable and better with

administering the care they need. Nurses must also have this compassion for themselves. As
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described by Lou et al., (2019) “ too much and disproportional compassion dedicated to patients

(i.e., compassion fatigue), compassion dedicated to oneself, or self-compassion, is found to be

able to alleviate the negative emotions experienced by individuals” (p.2). This demonstrates the

importance of the implementation of self-compassion into nurses and nursing students' lives.

With the compassion directed to their patients, nurses often neglect themselves which becomes

detrimental to their mental health. The use of such mindfulness techniques will benefit nursing

students and nurses greatly. This will greatly enhance the student’s experience in school along

with their future.

Conclusion

Nursing is a well respected field filled with people who are compassionate and love to

care for others. This is why many college students pursue this major for their career. With great

reward comes great responsibility during the nursing student’s education. The stress among

these students can cause anxiety and decrease their ability to strive in lecture, labs, and clinical.

With this awareness though, there are many interventions and ways to decrease their stress.

Some methods include breathing techniques, meditation, physical activity, and animal therapy.

With these interventions nursing students will better thrive with less anxiety and be more

prepared and organized going into nursing as their career.

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References

Brodersen, L. D. (2017). Interventions for test anxiety in undergraduate nursing students: An

integrative review. Nursing Education Perspectives, 38(3), 131-137.

doi:http://eps.cc.ysu.edu:2089/10.1097/01.NEP.0000000000000142

Cochran, K. L., Moss, M., & Mealer, M. (2020). Prevalence of coping strategy training

in nursing school curricula. American Journal of Critical Care, 29(2), 104–110.

https://doi.org/10.4037/ajcc2020287

Gebhart, V., Buchberger, W., Klotz, I., Neururer, S., Rungg, C., Tucek, G., … Perkhofer, S.

(2019). Distraction‐focused interventions on examination stress in nursing students:

Effects on psychological stress and biomarker levels. A randomized controlled trial.

International Journal of Nursing Practice, 26(1), 1–11. https://doi.org/10.1111/ijn.12788

Kramer, D. (2018). Energetic Modalities as a Self-Care Technique to Reduce Stress in Nursing

Students. Journal Of Holistic Nursing: Official Journal Of The American Holistic

Nurses’ Association , 36(4), 366–373. https://doi.org/10.1177/0898010117745436

Lu, J., Mumba, M. N., Lynch, S., Li, C., Hua, C., & Allen, R. S. (2019). Nursing students’ trait

mindfulness and psychological stress: A correlation and mediation analysis. Nurse

Education Today, 75, 41–46. https://doi.org/10.1016/j.nedt.2018.12.011

Luo, Y., Meng, R., Li, J., Liu, B., Cao, X., & Ge, W. (2019). Self-compassion may reduce

anxiety and depression in nursing students: a pathway through perceived stress. Public

Health, 174, 1–10. https://doi.org/10.1016/j.puhe.2019.05.015

Peterson, K. K. (2016). Mindfulness education for stress reduction in nursing students.

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Nursing Theses and Capstone Projects.

https://digitalcommons.gardner-webb.edu/nursing_etd/260/

Rafati, F., Nouhi, E., & Sabzevari, S. (2017). Coping Strategies of Nursing Students for Dealing

with Stress in a Clinical Setting: A Qualitative Study. doi: 10.19082/6120

Shdaifat, E., Jamama, A., & Al-Amer, M. (2018). Stress and Coping Strategies Among Nursing

Students, 33–41. doi: 10.5539/gjhs.v10n5p33