Model Development of a Resilience Promotion Program to Reduce Stress in Nursing Students

Abstract

Introduction Stress in nursing students is a significant mental health problem, particularly in the digital age, where rapid societal changes can exacerbate its impact. Nursing students experience intense academic pressures in theoretical and practical courses and high levels of stress during clinical practice. Additionally, adjusting to professional roles in patient care is a key factor contributing to stress. The lack of real-life experience and external pressures, such as expectations from family members, can further elevate stress levels. Teaching and learning process, relationships with peers and instructors, and other factors may amplify these stressors. The existing student support systems may not always be sufficient to mitigate stress effectively. One potential approach to helping students manage stressful situations is the development of resilience and mindfulness practices. This study aims to develop a resilience promotion program to reduce stress among nursing students, contributing to their well-being. 

Objectives 1) To describe stress and develop a resilience promotion program to reduce stress in nursing students, and 2) To examine effects of the program on stress in nursing students. The research hypotheses are: 1) There is a difference in stress between the experimental and control groups, 2) There is a difference in stress before and after participating in the program, and 3) The interaction between time and the program affects the stress in nursing students.

Design This Research and Development used Grothberg’s “I have, I am, I can” concept of resilience and Kabat-Zinn’s mindfulness practice through meditation. The researchers developed the program by exploring the stress situation in nursing students and exploring the concepts of resilience and mindfulness through meditation. The program included three modules: preparing knowledge, preparing mind, and resilience. This approach helped students navigate crises that led to stress reduction.

Methodology The participants consisted of first-year to fourth-year nursing students at a private university under the Office of the Higher Education Commission, enrolled in the second semester of the 2023-2024 academic year, from February to June 2024. Participants were selected through purposive sampling. The sample size was calculated using the G* Power program, consisting of two parts: 1) Exploring the stress situation in 141 nursing students and 2) Developing and testing the program in 30 students experiencing moderate to high stress, divided into an experimental group (15 students) and a control group (15 students) using a matched-pair design. The research tools included: 1) a demographic questionnaire, 2) The Suanprung Stress Scale with a Cronbach’s alpha coefficient of .90, 3) An open-ended questionnaire regarding stressors and stress management, and 4) The resilience promotion program, including a program manual, mindfulness meditation training videos, and activity worksheets for three modules. The program’s content validity index (CVI) was .89. Data were collected in three phases: Phase 1: The stress levels of nursing students were assessed, and the causes and coping strategies were identified through a stress questionnaire and open-ended questions distributed via QR codes. Phase 2: The resilience promotion program was developed based on findings from Phase 1, integrating with mindfulness meditation and reviewing relevant research. The program consisted of three main modules: preparing knowledge, preparing mind, and resilience. Phase 3: The developed program was implemented with the experimental group, while the control group received regular counseling services. The program consisted of six activities over six weeks, each lasting 90 minutes. The stress levels of both groups were measured immediately after the program and one month later. Data analysis employed Descriptive statistics, Two-way repeated measures ANOVA, and Bonferroni.

Results In Phase 1, 141 nursing students participated, with 95.7% female. The highest proportion (30.5%) was in the third year. Most students reported positive relationships with their families (54.6%) and supportive friendships (34.8%), while 48.9% felt they needed help from their instructors but were reluctant to approach them. Stress was most commonly severe (54.6%) and associated primarily with academic demands (72.3%). Strategies to manage stress were mostly self-initiated (44.7%), followed by consulting family members (29.8%) and non-family external sources (25.5%). In Phase 2, a six-session program was developed to promote resilience, covering understanding resilience, identifying stressors, setting goals, fostering supportive relationships, improving communication skills, and building resilience through mindfulness. In Phase 3, the control group revealed high-stress levels before and after the intervention (M = 49.1, SD = 8.8 and M = 50.0, SD = 8.8, respectively), with levels remaining high one month after the program (M = 51.4, SD = 8.7). The experimental group showed significantly lower stress levels, from high levels before the program (M = 45.7, SD = 6.8) to moderate levels after the program (M = 41.5, SD = 5.1) one month later. Two-way repeated measures ANOVA revealed no significant differences in time within group (F = 1.167, p = .304). However, interaction between time and program significantly affected stress (F = 4.413, p = .032). Analysis between groups also found significant differences (F = 9.936, p = .004), with the experimental group showing a statistically significant reduction in stress immediately after the program (MD = -8.733, p = .002) and one month later (MD = -9.933, p = .001).

Recommendation The findings indicate that the resilience promotion program effectively reduces stress among nursing students. It is recommended that the curriculum coordinator and relevant stakeholders integrate this program into existing student support systems and conduct long-term follow-up studies to assess its sustained impact. Further research could extend the application of this program to other educational contexts.