Stress and Sleep Deprivation Among Nursing Students
High Level of Stress
Nursing students experience a high level of stress and sleep deprivation due to the nature of the profession, especially the demands of caring for patients. Although they are yet to transition to practice, nursing students train in a demanding environment to become effective professionals. The situation creates a need for implementation of a program to support them to reduce the levels of stress and improve their quality of life as they train and transition to nursing practice. The purpose of this study is to implement a mindfulness program for undergraduate nursing students to improve their sense of well-being and mindfulness, as evidenced by decreasing levels of stress and enhancing sleep caused by stress.
Stress is common within the nursing career, among students and practicing professionals. Sleep plays an essential role in ensuring optimal development and body functioning. It helps to achieve an equilibrium of human psychosocial conduct. Biological rhythms, such as the sleep-wake cycle, are wired into the human mind, and any disruption can have adverse effects (Menon, Karishma, & Mamatha, 2015). However, stress caused by high demands on the mind and body can cause a lack of quality sleep.
Stress can have detrimental effects on human beings. However, it can also have positive effects. One useful effect is that stress can force people towards achievement (Behere et al., 2011). Stress can also have a negative impact on the body. Harmful impacts of stress could be categorized into three classes: physical problems such as infections, headache, insomnia, and ulcers; psychological problems, such as anxiety, anger, and burnout, and behavioral problems, such as isolation, smoking, and drug abuse (Boyd, 2012). In addition, nursing students may also encounter sleep deprivation during their studying years. Sleep deprivation results in psychosocial stress, psychiatric disorders, decreased work effectiveness and learning disability. Nursing is a demanding profession with occupational stress which involves academics, shift duties, and sleep deprivation (Hughes & Rogers, 2004, McGrath, Reid, & Boore, 2003 &McVicar, 2003). Therefore, it would be appropriate to implement interventions to reduce stress and improve the quality of sleep.
Mindfulness represents one method of coping with stress and enhancing sleep. Mindfulness increases awareness of the present moment by blocking past and future thoughts (Kabat-Zinn, 2013). An integrative literature review found that the most effective evidence-based intervention to increase the productivity and well-being of health care providers was mindfulness training (Koren &Purohit, 2014). Studies have suggested that mindfulness training may be an effective intervention for nursing students as well (Song & Lindquist, 2015; Spadaro & Hunker, 2016; Vander Riet et al. 2015).
Research Questions and Hypotheses
The study will answer the following research questions: 1) Is there a difference in population mean sleep score change from pre-test to post-test between intervention group and control group? 2) Is there a difference in population mean stress score change from pre-test to post-test between intervention group and control group? It will test the following hypotheses: 1) After MBSR training undergraduate nursing students will report lower levels of stress as well as sleep pattern improvement caused by perceived stress. 2) Without MBSR training undergraduate nursing students will report no change in levels of stress as well as sleep patterns caused by perceived stress. (NULL).
H0: μ1 = μ2 H0: μ1 ≠ μ2
Experimental design with randomization will be used in this study. Nursing students in their first year will be assigned randomly. There will be two groups of nursing students (control group and intervention group). For this study, all the groups will have to fill out both the Pittsburgh Sleep Quality Index (PSQI) and Perceived Stress Scale (PSS) via Redcap (pre& posttest). The control group will receive a delayed training in this study. The researcher will consider their student status (to minimize harm). To ensure the confidentiality, any publications, presentations, or reporting of the study data in any way will be done in aggregate form with no identifying information so that there will be no way to link participants with the study.
The inclusion criteria for the study include undergraduate nursing students in the first year of their academic year. They should be English literate to respond to research questions. The exclusion criteria for the study will be students that are currently enrolled in any form of mindfulness, stress management or mediation classes. However, there will be no excluded volunteers based on race, ethnicity, or gender.
Ethical Considerations (Human Subject Approval)
IRB will be acquired before the study starts. An explanatory letter about the study will be sent to obtain permission to conduct the study. Additionally, the purpose of the study was explained to the participants before they completed the online survey. The nursing students were recruited for this study voluntarily and they were assured that their decision to participate or not to participate would not have any effect on their student status. Participants were informed that they had the right to withdraw from the study at any time and could choose not to answer any of the questions (see Appendix). The anonymity of the participants was guaranteed after they completed the online survey, and they were informed that all the data will be kept in a secure place. Any publications, presentations, or reporting of the study data in any way will be done in aggregate form with no identifying information so that there will be no way to link participants with the study. After acquiring the needed results, all the surveys were destroyed. An explanatory letter will be sent to the participants along with the consent form. Students will be recruited for this study voluntarily and they will be assured that their decision to participate or not to participate will not have any effect on their student status
Non-probability sampling (i.e., convenience sampling) will be employed in the present study. Participants include first-year undergraduate students who are enrolled in nursing college will be recruited. Undergraduate college students will be solicited for participation in this study because research evidence demonstrates that a substantial portion of college students suffer from stress and poor sleep quality, therefore, using convince sampling will ensure recruiting more participants.
Simple Random Assignment. Simple Randomization (intervention and waitlist control) will be conducted once participants have been consented, screened, and baseline data collected. Group assignments will be determined using computer-generated random numbers. On receiving the randomization outcome, the PI will notify participants of their group allocation. Those in the MBSR groups will be offered a date for their first session. Participants allocated to the wait-list control group will not receive anything for 8 weeks, at which point they will cross over to the intervention arm and receive the MBSR intervention. They will be discouraged from seeking any mindfulness-related activities during this time.
Required Sample Size. Gpower was used to determine the sample size. The total sample size will be 128 (64 participates on each group). T-test (means- difference between two independent groups), power (1−β) sets on 0.8, medium effect size 0.5, and α sets on 0.05 was used to find the suggested sample size. The assumed attrition rate is %10. Therefore, sample size will be increased to 142 participants.
Data Collection and Measurement:
The following measurements will be used: PASQI: The Pittsburgh Sleep Quality Index (PSQI) is an effective instrument used to measure the quality and patterns of sleep in older adults. The client self-rates each of seven areas of sleep: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Scoring of the answers is based on a 0 to 3 scale, whereby 3 reflects the negative extreme on the Likert Scale.
Validity and Reliability. The PSQI has internal consistency and a reliability coefficient (Cronbach’s alpha) of 0.83 for its seven components. Numerous studies using the PSQI in a variety of older adult populations internationally have supported high validity and reliability. The Perceived Stress Scale (PSS) is the most widely used psychological instrument for measuring the perception of stress. It is a measure of the degree to which situations in one’s life are appraised as stressful. It is a 10-items tool is rated on a 5-point scale from 0-4. The total score is a summation of individual scores, higher score means greater perceived level of stress. Cronbach’s alpha values (0.82 for the full scale).
Measures. PSQI and PSS will be collected three times. They will measure before MBSR program start (T1) and After the end of the 8 week sessions (T2). To reduce participant burden, the PI will notify participants when questionnaires are due. If participants fail to complete questionnaires within one week, a phone call will be made to verify receipt of the email or if there are any technical difficulties
Data will be analyzed using SPSS version 20. Demographic data will be analyzed by using descriptive analysis. T-test will be used to find the mean differences between the intervention and the control group. T-test will be used as an inferential statistic in determining the potential of a significant difference the experimental and control groups when testing the effect of the intervention on stress levels and sleep deprivation (***********). The statistical method is used when testing hypothesis in statistics.
Intervention for the experimental and control groups. The intervention group will undergo the mindfulness program, while the control group will not undertake any intervention. The goal is to compare the outcomes.
Intervention. MBSR program will be based on the program developed by Jon Kabat-Zinn at the University of Massachusetts. The program includes 8 weekly classes and daily home assignments (with accompanying CDs) to enhance mindfulness in everyday life. The study will emphasize mindfulness-based meditation practices that enhance acceptance and self-compassion. To maintain the fidelity of the interventions, data will be collected after each session on whether the mindfulness practices and movement exercises were helpful or if modifications need to be made to guide development. The instructor (psychologist) will provide MBSR sessions, also, an orientation session will be provided prior to the initiation of the 8-week sessions. The time will be used to familiarize the participants on the content of each of the eight weeks, expectations related to weekly homework and practice, and brief mindfulness practice. Possible challenges or barriers to practice and solutions will be discussed. There will be time for participants to engage in questions.
Measures. PSQI and PSS will be collected three times (1 before MBSR program start (T1), 2 after the end of the 8-week sessions (T2), and the 3 follow-ups 3 months (T3 ) by using REDCap, to reduce participant burden. The PI will notify participants when questionnaires are due. If participants fail to complete questionnaires within one week, a phone call will be made to verify receipt of the email or if there are any technical difficulties.
The results of the study will include a comparison of the outcome of the level of stress and sleep deprivation among nursing students in the experimental and control groups. In the experimental group, the students will have undergone the mindful exercise program to reduce the level of stress and improve the quality of sleep. In the control group, the students will not undergo any intervention and are expected to experience the usual level of stress just like in the normal days of the individuals’ academic endeavors. The outcome of the study is expected to prove the effectiveness of the program in reducing the stress levels and improving the quality of sleep. Therefore, the stress level in the experimental group will be lower than the level in the control group. Furthermore, students will have improved sleep-wake cycles in the experimental group compared with the control group. The table in the appendix is a dummy table of the expected outcome. It will be used to input the results from data collected and analyzed before and after the program implementation in the experimental and control groups. It will provide the means and standard deviations for each outcome measure.
Self-Critiques on Internal and External Validity
Possible Threats Internal Validity
Threats to internal validity affect researchers’ confidence in confirming that the association between the dependent and independent variables exist. The following factors will affect the internal validity of the study:
Threats Due to Attrition. According to the Institutional Review Board’s ethical approval of the study, participation is voluntary, there will be no coercion used. Therefore, participation and participants are given the freedom to withdraw from the study at any time. As a result, there will be a risk of participants withdrawing from the study before completion (Saunders, Lewis, & Thornhill, 2007). In case some participants decide to leave the study before completion, the researcher will run the risk of remaining with a biased sample of the people who decided to remain and complete the research. Besides, it can be possible that all (or most of the participants) have something in common that allows them to remain and continue with the study, such as a high level of motivation. The solution to the threat is to recruit more participants to minimize the risk. The more the participants, the lower the risk because even if some of the participants will decide to leave, the researcher will still be left with a sufficient sample of individuals with representative characteristics. The solution will also prevent the threat of having results that cannot be generalized.
Confounding. The threat relates to a situation in which any change in the outcomes of the research is due to a third variable that could emanate from the intervention that the participants undertake (Saunders, Lewis, & Thornhill, 2007). For example, the outcome of the intervention could be due to the unexpected effect of the mindful exercise program to intervene in stress and quality of sleep among nursing students. The outcome could be caused by the level of expertise of the implementers of the program and not the actual effect of the intervention. Although it might be hard to control the threat, the researcher will ensure moderation in all aspects of the intervention, including the choice of the mindful exercises and the expertise level of the implementer.
Lack of Blinding. Blinding is necessary for the study to eradicate bias in the study as well as the situation in which participants are aware of the different conditions that they are exposed to in the research (Page & Persch, 2013). The research has not addressed the process of blinding the participants to the conditions of the intervention because of ethical considerations. As a result, the experimental and control groups might act in such a way that affects the outcome of the study due to the knowledge of their different treatments in the course of the study. For example, the intervention group members could be aware that they have undergone the mindful exercise program, while the control group members are not involved in any intervention. The threat can be prevented by blinding the participants to the two conditions of the study or explaining the reasons for the differences (McShane & Gal, 2015). However, due to the need to comply with the ethical standards that require disclosure, the researcher could give sufficient details of the conditions the two groups will undergo during the study. However, the researcher will prevent information regarding the differences in the treatment and control to the extent that it does not affect the outcome of the study. Hence, it will prevent participants from behaving differently due to their different situations in the study.
Experimenter Expectancies. The threat is the experimenter’s effects, which would happen when the researcher Explains the expectations to participants about how the participants should respond to the experiment. The knowledge might affect the way they react to the research. If the participants understand what is expected of them in the study, the information might affect their behavior and reaction to the intervention or control situations (Klein et al., 2012). Differential reactivity to measures results from systematic changes from pre- to post-intervention in how willing participants are to respond honestly or naturally during assessments. However, it might be hard to control the way subjects respond to questions, especially in self-report situations. For example, their behavior before intervention might be different from the way they respond after the program. This will be avoided by minimizing contacts between experimenter and participants (the psychologist will ably the MBSR session, the researcher will only observe with no direct interaction). Another solution is explaining the expectations of the research as much as possible to the participants. If the researcher is honest, it will increase their chances of being honest as well.
Extraneous variance in the experimental settings. Because the MBSR sessions will be conducted in nursing school, such distracting noises will affect the meditation necessary for successful implementation of the mindful exercise. It might be challenging to control the activities that go on within the nursing school because the rest of the community are not affected by the study. Besides, they might not be aware that the research is being conducted in their school. Therefore, the study might be affected by various interactions, including the noise (Whitley Jr & Kite, 2012). The researcher should ensure that a quiet room will be reserved for the sessions. The researcher will make sure that the space available for the study is as quiet as possible to avoid destructing participants. It will be necessary to ensure the calmness before beginning the intervention.
Possible Threats to External Validity
Threats to external validity in a study affects the possibility of generalizing the outcome to other similar groups. the following factors will affect external validity of the study:
Selection. This occurs when participants in the intervention and control groups react differently to the research measures because they have had different experiences with one or more aspects of the research. The issue occurs because although participants experience similar challenges, they are assigned to various interventions during the study. The researcher might experience problems of differences between the two groups in the study that could be related to the independent variable (such as the willingness to take part in the study or either of the two groups) (Drost, 2011). He might also face a challenge relating to the demographics of subjects willing to participate in the exercise program in the intervention group. The problem can be avoided by excluding any participants with previous MBSR experience, which I did not add in my inclusion and exclusion criteria. Such an omission will ensure that the participants included in the study are unaware of the intervention that they undergo because it will be their first time to participate (Page & Persch, 2013). The researcher could also provide only the necessary information to comply with the ethical requirements, such the participation in the two groups, but blind participants to the actual intervention that they will undergo.
Threats due to resentful demoralization. My study has two groups: one intervention and one control group. The study might face a threat due to ethical concerns or the potential for resentful demoralization among participants not receiving the new intervention. Consequently, participants might behave differently in the intervention and treatment groups because of the differences in their conditions. The situation might affect the outcome of the study considering that it will use self-reports of stress and sleep deprivation to determine the differences in outcomes in the two cohorts (Drost, 2011). Participants might fail to provide correct information due to demoralization. To solve the problem, the researcher may offer participants an alternative intervention, a placebo, or a delayed intervention. In my study, a delayed intervention will be applied. However, so long as there are voluntary consent and ethical codes that require full disclosure in research, there will be a chance that participants may refuse to live by the random numbers table and want to change to another group ex (from intervention to control). Solution: regular feedback and proper communication with close observation will be applied. Besides, giving participants adequate information regarding the nature of the study will help to eradicate the challenge of demoralization. The research will remain open to the two conditions and explain the reason why it is necessary to expose participants to intervention and control.