Nurse Education Today 76 (2019) 222–227

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Nurse Education Today

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T
Decreasing stress and supporting emotional well-being among senior
nursing students: A pilot test of an evidence-based intervention
Heather Beanlands , Elizabeth McCay, Suzanne Fredericks, Kristine Newman, Donald Rose,
⁎

Elaine Santa Mina, Lori Schindel Martin, Jasna Schwind, Souraya Sidani, Andria Aiello,
Angel Wang
Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, Canada

A B S T R A C T

Background: Nursing students can experience stress related to their academic

and practice experiences, which can have deleterious effects on physical and emotional well-being.
Objectives: To pilot test an evidence-based intervention, Dialectical Behavior Therapy-Skills Group, designed to promote emotional well-being among nursing stu-
dents.
Design: A single group, pre-posttest design, mixed-method approach.
Setting: A large university situated in a multicultural urban setting.
Participants: Senior undergraduate nursing students (n = 31).
Methods: Students participated in an 8-week modified Dialectical Behavior Therapy-Skills Group (DBT-SG) intervention. Quantitative and qualitative data were
collected to explore the interventions' feasibility, acceptability, and students' perceptions of its applicability to practice. Students also completed standardized
outcome measures of psychological distress and emotional well-being pre- and post-intervention to evaluate preliminary effectiveness.
Results: Overall feedback was positive, with participants describing how skill modules helped them establish relationships and manage stress in clinical, academic,
and personal settings. Significant reductions in stress and improvements in well-being were also reported.
Conclusion: Results suggest that DBT-SG offers a promising approach for mitigating nursing students' stress by helping them acquire practice-relevant strengths and
self-care strategies. Further research is required to examine the effectiveness of DBT-SG among other nursing student groups, as well as to explore optimal approaches
to delivering this intervention in conjunction with nursing curricula.

1. Introduction Gustavsson, 2012). Therefore, there is an urgent need for interventions

to minimize distress and to support emotional well-being for this stu-
Students pursing higher education experience significant expecta- dent population.
tions and demands which can result in stress and anxiety, as well as Despite the high levels of stress and negative emotional sequelae
compromising academic success and personal well-being (Hassed and reported by nursing students, limited attention has been given to de-
Chambers, 2014). This is most evident among nursing students, who are veloping strategies to mitigate them. Accordingly, an intervention that
required to manage academic demands; social and personal stresses supports students to develop skills in emotional regulation may increase
associated with attending university; as well as additional stresses ex- their capacity to navigate the stressful aspects of clinical practice. One
perienced in the clinical environment (Pulido-Martos et al., 2012; such intervention is Dialectical Behavior Therapy (DBT) (Linehan,
Timmins et al., 2011). Specifically, emotional challenges associated 1993). DBT is based on an understanding that difficulties in coping with
with patient or family suffering and death, as well as difficult inter- a diverse range of life challenges are related to inadequate emotional
personal relationships in the practice environment, contribute to the regulation. It is an empirically supported intervention designed to ad-
high degree of stress experienced by students (Moridi et al., 2014; dress a variety of mental health challenges, such as anxiety, mood
Pulido-Martos et al., 2012). Of particular concern is the negative impact disorders, disruptive and self-harm behaviors, among others (Miller
of stress and its effect on students' physical and emotional well-being et al., 2007). Despite evidence supporting the effectiveness of DBT in
(Jimenez et al., 2010), and future roles as clinicians (Rudman and reducing emotional distress among people managing a variety of

⁎
Corresponding author at: Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, 350 Victoria St., Toronto, Ontario M5B 2K3,
Canada.
E-mail address: hbeanlan@ryerson.ca (H. Beanlands).

https://doi.org/10.1016/j.nedt.2019.02.009

0260-6917/ © 2019 Elsevier Ltd. All rights reserved.

Received 6 October 2018; Received in revised form 23 January 2019; Accepted 12 February 2019
H. Beanlands, et al. Nurse Education Today 76 (2019) 222–227

challenging life situations, to our knowledge, this intervention has not Therapy (DBT). DBT has demonstrated effectiveness in reducing emo-
been tested, as yet, among nursing students. Thus, the purpose of this tional distress, including depression, anxiety, and self-harm, in adult
study was to pilot test a modified DBT intervention designed to support and adolescent populations (Dimeff and Koerner, 2007; Miller et al.,
nursing students in managing stress. It was anticipated that the inter- 2007). As such, it promises to improve the well-being of undergraduate
vention would reduce psychological distress and improve emotional nursing students. Further, two studies have shown DBT to be effective
well-being among this group. in alleviating university students' psychological distress. Specifically,
one study where the full multi-component DBT intervention was im-
2. Background/literature review plemented demonstrated significant improvements in emotional dis-
tress (Pistorello et al., 2012). An additional study (Rizvi and Steffel,
Nursing students can experience high levels of stress (Alzayyat and 2014) tested an abbreviated 8-week version of DBT skills group, which
Al-Gamal, 2014; Moridi et al., 2014). While sources of stress may vary, focused primarily on emotion regulation and demonstrated improve-
experiences with clinical practice are identified consistently as among ments in emotion regulation, skills use and functioning. Thus, im-
the most stressful situations that nursing students encounter. Several plementing and evaluating one DBT component specifically, the DBT
studies have specifically examined the practice sources of students' skills group (DBT-SG), with undergraduate nursing students extends the
stress (Alzayyat and Al-Gamal, 2014; Jimenez et al., 2010; Moridi et al., research previously undertaken in this area and has potential to effec-
2014; Pulido-Martos et al., 2012; Timmins et al., 2011) and three broad tively address stress experienced by these students.
areas of stressors have been reported 1) concerns related to providing DBT is a theory-based intervention that decreases distress and en-
care for patients including confidence in nursing skills and knowledge, hances individuals' capacity to cope with life difficulties by learning to:
and perceived discrepancies between theory and practice; 2) witnessing withstand emotional distress and regulate emotions; as well as to be
pain and suffering, including not knowing how to help patients and more mindful in order to enhance interpersonal relationships and
families with psychosocial problems; and 3) interpersonal relationships overall sense of self (Linehan, 1993). A critical component of the DBT
with patients, families, staff and educators. intervention is the skills group (DBT-SG) that is offered on a weekly
Experiences of stress can have a profound impact. Several deleter- basis. DBT-SG operates through two mechanisms important to under-
ious outcomes have been associated with high levels of stress among graduate nursing students: 1) actively engaging participants in learning
nurses and nursing students. Negative effects of stress include poor to manage emotional distress, and regulate emotions over a relatively
physical and mental health (Jimenez et al., 2010), limited self-care, short time frame; as well as 2) emphasizing problem solving skills, and
engagement in potentially harmful behaviors (Timmins et al., 2011) the development of relationship skills applicable to other life situations.
and burnout (Rudman and Gustavsson, 2012). Additionally, mental Theoretically, DBT (Linehan, 1993) is based on the idea that a diverse
well-being has been reported to be worse in senior students (Timmins range of difficulties in coping with life challenges can be understood in
et al., 2011), reinforcing the importance of addressing stress in this terms of inadequate emotional regulation. DBT consists of cognitive
group. Of concern is the increasing level of burnout symptoms, such as behavioral methods in combination with acceptance-based approaches,
emotional exhaustion, as students progress through the program which originated in mindfulness Zen philosophy (McMain et al., 2001).
(Rudman and Gustavsson, 2012). Notably, higher levels of burnout Accordingly, mindfulness skills are an important component of the
have been associated with poorer individual (mood and life satisfac- DBT-SG intervention.
tion) and occupational outcomes (turnover intentions and reduced In addition, DBT emphasizes a dialectical philosophy, which high-
mastery of tasks), both at graduation and one year later (Rudman and lights the need for synthesis of natural tensions between opposing
Gustavsson, 2012). These results underscore the need to develop stra- forces to achieve a sense of balance (Chapman, 2006). Dialectical phi-
tegies to assist senior nursing students to manage stress, particularly losophy is realized in DBT through the recognition of the need for si-
associated with clinical practice. multaneous acceptance of the self, as well as striving for continued
While some attention has been given to exploring strategies to re- growth and change (Chapman, 2006). Specifically, DBT focuses on
duce stress in undergraduate nursing students, much of the research has validating the individual's challenges within the context of supporting
focused on curriculum development, with mixed findings (Turner and needed change. Thus, by assisting nursing students to understand and
McCarthy, 2017). However, it has been observed that the extent to learn to regulate their emotional response to stressful experiences, as
which nursing curricula “prepare students to deal with emotional as- well as developing effective interpersonal skills, it was anticipated that
pects of nursing is unclear” (Timmins et al., 2011, p. 765). Further, the DBT-SG would reduce psychological distress and improve emotional
number of studies addressing how best to reduce stress in nursing stu- well-being.
dents is limited, with few being grounded in a theoretical perspective
(McCarthy et al., 2018). Several studies have explored mindfulness- 3. Methods
based approaches to decrease stress among nursing students. Specifi-
cally, these studies have demonstrated that mindfulness-based pro- A single group, pre-posttest design, mixed method approach was
grams are effective in reducing depression, anxiety, negative thinking, used to pilot-test a modified DBT-SG intervention among senior un-
and stress, as well as increasing mindful awareness, sleep and con- dergraduate nursing students. The Research Ethics Board at the
centration (Song and Lindquist, 2015; Van der Riet et al., 2015). Al- University approved the study and all participants provided written
though these preliminary positive results suggest that mindfulness consent. The specific aims were to: 1) examine the feasibility and ac-
practices are helpful in alleviating the experience of distress for nursing ceptability of the DBT-SG intervention in an educational setting; 2)
students, there is some evidence to suggest that mindfulness alone does explore students' experiences with the intervention and their percep-
not provide students with sufficient breadth of skills to learn how to tions of its applicability to practice and 3) evaluate the preliminary
effectively deal with stress at the personal and professional level. In effects of the DBT-SG on the outcomes of psychological distress and
particular, a systematic review of interventions to reduce stress in emotional well-being.
nursing students concluded that stress interventions should be theory-
based and multi-faceted, including skills for dealing with stressful si- 3.1. Sample and recruitment
tuations and changing problematic thoughts (Galbraith and Brown,
2011). Thus, given the complexity of stress experienced by nursing The sample was recruited from students in the final year of the
students, novel interventions are needed to assist students to mitigate Bachelor of Science in Nursing (BScN) program at a large university
stress and its effects. situated in a multicultural urban setting. There are two undergraduate
One such evidence-based intervention is Dialectical Behavioral nursing programs: 1) a 4-year BScN collaborative program between two

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college partners and one university, and 2) a post-diploma degree Likert response format capturing personal competence and acceptance
program for Registered Nurses, bridging Registered Practical Nurses of self and life. In our study, Cronbach's alpha for the RS was ≥0.89. 4)
and bridging internationally educated nurses; all of whom are up- WHO-FIVE Well-Being Index (WHO-5) (World Health Organization,
grading to a BScN degree. All students in the final year of both BScN 1998): A 5-item questionnaire using a 6-point rating system from 0 to 5,
programs were eligible to participate. Prior to the start of each seme- based on how individuals have been feeling in the past two weeks.
ster, students were informed about the study via the list-serves of the Cronbach's alpha ranged from 0.67 to 0.84.
respective programs, through information posted on the online an- Descriptive statistics were used to characterize the demographic
nouncement page for the clinical placement courses, and class talks profile of participants, as well as responses to the study questionnaires.
conducted by the Research Assistant (RA). The target sample size for Total scale and subscale scores were computed (as the mean across
the study was a minimum of 30 participants. Sample size estimation respective items) to quantify the outcomes and paired t-tests were
considered the pilot nature of the study and its focus on testing the performed to examine changes in outcomes from pretest to posttest.
feasibility and acceptability of DBT-SG in a student population. Cohen's d statistic was computed to estimate the effect size of the
change.
3.2. The DBT-SG intervention

DBT-SG is a manualized intervention (Linehan, 1993), which the 3.4. Qualitative Data Collection and Analysis
research team adapted by (i) decreasing the total number of sessions
from 16 to 8, in order to facilitate student involvement and (ii) in- Upon completion of the DBT-SG sessions, participants had the op-
corporating examples relevant to nursing students. The adapted inter- portunity to participate in a focus group interview to share their ex-
vention included three modules, each offered over 2 sessions and cov- periences. A semi-structured interview guide was developed to elicit
ering core DBT skills (distress tolerance, interpersonal effectiveness, students' perception of DBT-SG (e.g., its usefulness, challenges and fa-
emotion regulation), along with an orientation and closing session. cilitators to its use in practice, and its effectiveness in enhancing stu-
Skills modules were comprised of didactic content, role play and take- dents' ability to initiate and sustain therapeutic relationships with pa-
home work sheets. All modules included a review of the principles of tients). Additionally, students were asked to comment about the impact
DBT and core mindfulness was repeated at the beginning of each. of DBT-SG on academics, personal well-being and professional practice.
Weekly sessions were 1.5 h in duration and were co-led by two facil- Three focus groups were held with 25/31 students (group sizes ranged
itators. Participants were given the option of counting session atten- from 6 to 12). Focus group interviews were facilitated by a study RA
dance as a professional development activity, which was credited to- and audio-recorded and/or documented by the facilitator with detailed
ward clinical hours. Upon completion of the sessions, participants were notes. Sessions lasted approximately one hour. Qualitative comments
offered a $25 gift card in acknowledgement of participation. were also provided by 26 participants in response to two open-ended
questions embedded in the SWTM. Focus group recordings/facilitator
3.3. Quantitative data collection and analysis notes and students' written comments were transcribed verbatim and
were analyzed using qualitative content analysis (Schreier, 2014) to
To assess feasibility, data were collected regarding the numbers of categorize patterns in the responses according to interview questions.
students who: (i) expressed interest, (ii) enrolled (consented), (iii) de-
clined enrollment and reasons for refusal (if available), and (iv) com- 4. Results
pleted the intervention; including total number of sessions attended.
Students' ratings of acceptability were assessed with adapted ver- Recruitment began in Fall 2015 and was completed in Winter 2017.
sions of 1) Treatment Acceptability and Preference (TAP) scale (Sidani During this time, a total of 87 students contacted the RA to learn more
et al., 2009) where participants rated the appropriateness, effective- about the study; 40 students indicated they were interested and avail-
ness, and convenience of DBT-SG on a 5-point scale ranging from not at able to participate and 47 were interested, but unable to attend. Of the
all to very much, and 2) Satisfaction with Treatment measure (SWTM) a 47 unable to attend, 19 cited scheduling conflicts/availability and 1
27-item measure covering six domains a) suitability and utility of the cited personal reasons; the remaining 27 did not provide a reason.
DBT-SG modules, b) attitude toward and desire to continue with the Finally, we were unable to accommodate 3/40 students who were in-
treatment, c) competence and interpersonal style of therapist, d) im- terested and able to attend, due to space constraints (this was based on
plementation of treatment, e) improvement in stress and in everyday a first-come first-serve basis). As such, 37 students were enrolled in the
functions, and f) attribution of the experienced outcomes to the treat- study across three waves (Fall 2015; Fall 2016; Winter 2017). Initial
ment(Sidani et al., 2017). group sizes ranged from 10 to 15 across the waves and of the 37 stu-
To evaluate preliminary effectiveness, outcomes were measured at dents who were enrolled (consented), 31 (84%) completed the inter-
baseline (pretest) and after completing the DBT-SG (posttest). Five es- vention.
tablished self-report questionnaires with sound psychometric proper- Demographic characteristics of participants are displayed in
tieswere used to assess psychological distress and emotional well-being. Table 1. They ranged in age from 20 to 35 years (M = 23) with the
Psychological Distress. Depression Anxiety Stress Scales (DASS)-21 majority of participants identifying as female (97%) and single (84%).
(Antony et al., 1998; Lovibond and Lovibond, 1995): A 21 item in- Most participants indicated that they did not have any previous post-
strument used to measure depression, anxiety and stress within the past secondary education (68%) or previous healthcare experience (65%).
week. Cronbach's alpha ranged from 0.67 to 0.90 in the present study.
Emotional Well-being. 1) Toronto Mindfulness Scale (TMS) (Lau et al.,
2006): A 13-item measure with a 5-point Likert response format to 4.1. Acceptability
assess the acquisition of curiosity and de-centering (from thoughts and
feelings); core characteristics that are cultivated with mindfulness Scores for the TAP and SWTQ scales are reported in Table 2. Re-
practice. Cronbach's alpha in this study was > 0.80. 2) Self-compassion sponses on the TAP revealed that overall, participants found the in-
Scale (SCS) (Neff, 2003): A 26-item scale measuring self-compassion tervention to be effective, appropriate and convenient. Similarly, re-
with a 5-point Likert response format. This scale assesses self-kindness, sponses to the SWTQ reflected overall high ratings of satisfaction across
self-judgment, common humanity, mindfulness and over identification. most domains. Overall, participants reported a positive attitude toward
In this study Cronbach's alpha was ≥0.90. 3) Resilience Scale (RS) the intervention and high levels of satisfaction with the suitability and
(Wagnild and Young, 1993): A 25-item self-report scale with a 7-point perceived benefits of DBT-SG.

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Table 1 Table 3
Participant characteristics at baseline (n = 31)a. Scores on outcome measures and t-test results (n = 31).
Variable Range M SD Psychological distress

Age 20–35 22.97 3.08 Time 1 Time 2

Measure Possible M (SD) M (SD) t(30) p Effect sizea

Frequency Percentage range range range

Sex Depression, 0–100 38.72 32.26 1.41 0.168 0.025

Male 1 3.2 anxiety & (23.22) (17.31)
Female 30 96.8 stress total 8.38–92 6–86
score
Marital status Depression 0–42 8.39 7.61 0.43 0.669 0.08
Single 26 83.9 (8.16) (5.45)
Married/commonly law 5 16.1 0–28 0–22
Previous post-secondary education Anxiety 0–42 12.26 11.03 0.77 0.450 0.14
Yes 10 32.3 (8.26) (8.18)
No 21 67.7 0–32 0–36
Stress 0–42 18.08 13.61 2.23 0.033 0.40
Highest level of post-secondary educationb (10.52) (7.33)
Diploma 3 9.7 4–38 2–38
Partial degree 3 9.7
Degree 6 19.4
Other 1 3.2
Emotional well-being
Previous healthcare experience
Yes 11 35.5
Time 1 Time 2
No 20 64.5

Role and practice areab Measure Possible M (SD) M (SD) t(30) p Effect size
Receptionist/unit clerk 3 9.7 range range range
Student intern/extern 4 12.9
Registered practical nurse 1 3.2 Mindfulness 0–52 25.48 34.29 −6.95 < 0.001 1.25
Other 4 12.9 (9.91) (7.13)
a
4–42 20–46
Some missing data. Self-compassion 26–130 73.03 87.95 −5.64 < 0.001 1.01
b
Respondents could select more than one response. (16.77) (13.53)
42–110 58–123
Table 2 Resilience 25–175 129.21 137.45 −3.49 0.002 0.63
(21.04) (15.38)
Descriptive statistics of treatment acceptability measure and satisfaction with
82–166 106–163
treatment questionnaire subscales (n = 31).
Well-being 0–100 56.13 63.48 −2.00 0.054 0.36
Subscale Possible range Range M SD (18.05) (12.89)
16–88 36–88
Treatment Acceptability Measure (TAP) a
Cohen's d.
Effectiveness 0–8 2–7 5.00 1.44
Appropriateness 0–8 2–8 5.65 1.68
Convenience 0–12 3–11 6.39 2.22 4.3. Participant experiences with DBT-SG
Total 0–28 8–25 17.03 4.32

Satisfaction with Treatment Questionnaire (SWTQ) Results of the content analysis were grouped into three categories
Suitability 0–12 3–11 7.71 1.90 according the focus group questions. (1) Perceptions of the DBT-SG.
Utility 0–16 3–15 10.97 2.42 Most found the experience of participating in the program positive,
Attitude toward treatment 0–8 4–8 6.13 1.15
Desire to continue treatment 0–8 1–8 5.90 1.76
meaningful, and useful. Concepts and skills that participants found
Perceived benefits – health problems 0–24 7–23 16.68 3.71 particularly valuable included interpersonal effectiveness, stress man-
Perceived benefits – functioning 0–20 7–19 13.55 2.83 agement, and emotion regulation. The integration of mindfulness in all
Discomfort 0–4 0–3 0.19 0.60 the sessions was highlighted as especially helpful as it encouraged
Therapist – competence 0–12 7–12 11.10 1.40
participants to pause and reflect on how best to respond. Some content
Therapist – interpersonal style 0–12 11–12 11.74 0.44
Dose 0–8 2–8 6.35 1.62 was more easily accepted, with a few participants commenting that
Format 0–12 6–12 10.10 1.78 some new terms took time to get used to. In addition, a few felt over-
Group dynamics 0–8 3–8 6.32 1.42 whelmed with the amount of content in some weeks and suggested
increasing the amount of group time. (2) Applicability and relevance
of the intervention. Overall, participants felt that the content was
4.2. Outcomes valuable in helping manage stress more effectively and in promoting
their well-being, building capacity to provide better patient care and to
Table 3 displays the results of the t-tests examining pretest and effectively communicate with the healthcare team. Several participants
posttest scores for psychological distress and emotional well-being. No described an increased awareness of their own responses to challenging
statistically significant changes were found in depression (p = 0.669) situations; allowing them to be more empathic to the responses of
or anxiety scores (p = 0.450), however a statistically significant im- others (e.g., patients and families). Many participants also reported
provement was noted in levels of stress (p = 0.033) with an effect size adopting self-care strategies which enabled them to handle academic
of 0.40. Statistically significant improvements were found for all four demands more effectively. In addition, a majority of participants de-
measures of emotional well-being. A large effect size was observed for scribed developing skills in mindfulness and as such were increasingly
the mindfulness (1.25) and self-compassion (1.01). The effect size for reflective regarding managing challenging situations. (3) Factors that
resilience (0.63) was medium and for well-being was small (0.36). influenced participation. Most participants felt that the facilitators'
ability to create a supportive, trusting and accepting atmosphere

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resulted in an environment whereby participants felt comfortable and a time and space to share with their peers in a nonacademic context,
safe, supporting the adoption of a non-judgmental attitudes toward one suggesting nurse educators may want to consider building time in the
another. As well, the facilitators' knowledge of the content was per- curriculum for peer support activities. The importance of peer caring
ceived by participants to be a positive and worthwhile aspect of the and support is also highlighted by researchers who found that it can
intervention. Further, some participants expressed that other commit- improve subjective well-being (Zhao et al., 2016), as well as enhance
ments, sometimes hindered their ability to participate or learn effec- professionalism, increase engagement in socialized learning, and facil-
tively in the intervention. itate transition from student to professional nurse (Jacobs, 2017).
Overall, our preliminary results suggest DBT-SG offers a promising
5. Discussion approach for mitigating nursing students' stress by helping them ac-
quire a range of practice-relevant strengths, and learn self-care strate-
Currently, there is limited research addressing the effectiveness of gies, which may have a positive impact on their future careers.
evidence-based interventions, such as DBT-SG, to support nursing stu- However, these findings need to be considered in the context of study
dents in managing their own emotional responses to caregiving, despite limitations. Although appropriate for the pilot nature of this study, our
the high levels of stress associated with clinical practice reported by sample was relatively small and comprised of nursing students who
nursing students. The preliminary results from this pilot study suggest were interested in and able to participate in a weekly group interven-
that DBT-SG is a promising intervention for nursing students experi- tion. Results may therefore not apply to students who prefer not to be in
encing stress within the context of a demanding academic and clinical a group or who are unable to participate in such an intervention due to
program. Overall participants found participation in the DBT-SG ses- competing academic, personal and/or employment demands. Further
sions to be a positive experience and found the intervention effective, research is required to examine the effectiveness of DBT-SG among
appropriate and convenient. Results reflect overall high ratings of sa- other nursing student groups, as well as to explore optimal approaches
tisfaction with the intervention. Participants highlighted how the skills to delivering this intervention and/or subcomponents of the interven-
modules helped in establishing relationships and managing stress in tion (e.g., mindfulness) in conjunction with nursing curricula. While
clinical, academic and personal circumstances. overall participation in the DBT-SG was good in our study, some par-
Content analysis of qualitative data revealed that DBT-SG offered ticipants indicated that competing demands sometimes interfered with
participants the opportunity to gain concrete and transferable skills and their ability to full participate. Thus, future research could also explore
to develop a repository of coping strategies, which should help position alternate delivery modes to increase accessibility for students by con-
them to be more effective and compassionate practitioners. Thus, DBT- sidering various forms of technology, such as mobile applications.
SG has the potential to support students to acquire a range of practice-
relevant strengths, alleviate stress and learn self-care strategies, which
6. Conclusions
may have a positive impact in their future careers.
Participants experienced decreased levels of stress, after partici-
The consequences of not preparing students to navigate the new
pating in DBT-SG, providing preliminary evidence the intervention
territory of challenging emotional work of caregiving can be deleterious
supports senior nursing students in managing stress. This is consistent
for students and can leave them vulnerable to ongoing stress and
with previous research supporting the effectiveness of mindfulness in-
mental health challenges. Nurses cannot effectively care for patients
terventions in reducing depression, anxiety and stress (Chen et al.,
and their families if they cannot first care for themselves. DBT-SG offers
2013; Song and Lindquist, 2015). However, in our study overall anxiety
a promising approach in assisting students to learn self-care strategies
remained at moderately high levels after the intervention. Although
that can have an impact throughout their careers. The strength of DBT-
related, stress and anxiety may be associated with different personal
SG resides in its wide applicability to a range of practice-based situa-
and situational characteristics, suggesting the need to consider com-
tions that students will encounter. Through the acquisition of concrete
plementary strategies to support students; for example, peer mentoring
and transferable skills, students can develop and hone a repository of
and biofeedback-assisted relaxation training (Turner and McCarthy,
coping strategies that will position them to be more effective in es-
2017). A systematic review of interventions to reduce stress in nursing
tablishing and sustaining patient-centered relationships.
students concluded that stress interventions should be theory-based and
multi-faceted (Galbraith and Brown, 2011), as is the case in this study.
Further, consideration should be given to increasing the support pro- Funding source
vided to students so that they can better manage the stress that is fre-
quently associated with clinical practice. This project was supported with funding received from the National
Given the increasing level of burnout symptoms, such as emotional League for Nursing (NLN) Research in Nursing Education Research
exhaustion reported by nursing students (Rudman and Gustavsson, Grant.
2012), supporting students' ability to positively manage their own
emotional responses to caring is essential. Thus, the significant increase Conflict of interest
in resilience, self-compassion, well-being, and mindfulness reported by
our participants following the 8-week DBT-SG intervention, is very None declared.
encouraging. In addition to the DBT skills learned in the sessions,
participants described mindfulness as helpful, because it encouraged
Ethical approval
pausing and reflecting in a non-judgmental way when dealing with
challenging situations. This finding is comparable to previously re-
Approval for this study was obtained by the Ryerson University
ported benefits of mindfulness interventions for nursing students (Song
Research Ethics Board.
and Lindquist, 2015).
DBT-SG involves balancing acceptance of self with desire for growth
or change. Self-compassion encompasses mindfulness, self-kindness, Acknowledgements
and common humanity,; thus, the increase in self-compassion seen in
study participants suggests an increase in being kind toward oneself, We gratefully acknowledge the contributions of the following
being mindfully aware of one's painful feelings and seeing one's falli- graduate nursing students, advance practice nurses and research staff in
bility as part of a broader human experience. (Barnard and Curry, 2011; support of this project; Shara Ally, Celina Carter, Audrey Danaher,
Neff, 2003). Further, participants highlighted the importance of having Medina Esmail and Joanna Lynch.

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