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Anxiety and a Mindfulness Exercise in Healthcare Simulation Prebriefing

      Highlights

      • A short mindfulness exercise during simulation prebrief may reduce anxiety in Simulation for Nursing Students.
      • Students reported “feeling more in the moment” after the short mindfulness exercise.
      • Students had heightened concern about other students’ perception of the mindfulness exercise.

      Abstract

      As nursing education searches for ways to advance the simulation experience for students, improving methods of prebriefing are essential. Student anxiety is commonly reported in and around the simulated learning experience. The aim of this study was to determine if a brief mindfulness exercise could influence anxiety for students entering the simulation laboratory. In this mixed-methods study, a visual analog scale (VAS) was used for students to self-report anxiety. Data analysis revealed that a brief guided meditation in the simulation prebriefing decreased self-reports of anxiety in the simulated learning experience. Students reported lowered anxiety, reported a feeling of “being in the moment”, but were also distracted by what others thought about the exercise. As we work towards a theoretical framework for the prebriefing phase of simulation, incorporating mindfulness may be as important as some of the other established best practices.

      KEYWORDS

      Introduction

      The International Nursing Association for Clinical Simulation and Learning (INACSL) best practices guide the use of simulation in nursing education (
      INACSL Standards of Best Practice: SimulationSM
      ), including prebriefing. Prebriefing is defined as an information session to prepare the student for the scenario. This is usually a five-to-ten-minute preparation period for the student immediately prior to the simulated experience. Prebrief is essential to “establish a psychologically safe environment for participants” (
      INACSL Standards of Best Practice: SimulationSM
      ) to promote a positive learning environment. The prebrief may include a number of activities, including a review of simulation objectives and establishing a fictional contract with participants.
      Often students report feeling anxious in the simulation lab setting despite faculty efforts to provide a psychologically safe environment. This is an area of concern as anxiety can affect clinical judgment in nurses (
      • Ferguson L.M.
      • Day R.A.
      Challenges for new nurses in evidence-based practice.
      ). The literature has suggested many strategies to reduce anxiety, among them, the practice of mindfulness has been found to be beneficial (
      • Moscaritolo L.M.
      Interventional strategies to decrease nursing student anxiety in the clinical learning environment.
      ). The aim of this study was to determine whether a two-minute guided meditation in the prebrief had an impact on anxiety levels in the simulated learning experience.

      Literature Review

      Prebriefing

      The National League for Nursing (NLN) and others have recommendations related to prebriefing practices. The suggests the inclusion of the following: The Basic Assumption is a statement about learning, confidentiality related to the simulation experience, the fiction contract which describes the context of the simulated experience, logistics related to the simulated experience, psychological safety of participants, and an environmental orientation to the setting of the simulation.
      • McDermott D.S.
      The prebriefing concept: A delphi study of CHSE experts.
      has suggested that prebriefing occurs in three phases, describing prebriefing as “vital” to the success or the simulated experience. This three-pronged approach to prebriefing includes planning, briefing, and facilitating. Planning incorporates the simulationist offering a variety of learning materials to participants specific to the simulation. In the second phase of prebriefing, the “tone” of the simulation and expectations are set. In the facilitating phase, there is an opportunity for participants to ask questions and clarify muddy points. While not clearly spelled out, these three phases have been incorporated into best practices supported by INACSL, NLN, and others.
      Page-Cutrara's (
      • Page-Cutrara K.
      Prebriefing in nursing simulation: A concept analysis.
      ) prebriefing concept analysis found that it is a unique term not traditionally used outside of simulation settings and that it can hold different meanings for different simulationists. She concluded that further research on prebriefing “could strengthen prebriefing's contribution to the simulation experience, provide a clearer evidence-based understanding of the activity, and address questions about the optimal delivery of simulation for learning” (
      • Page-Cutrara K.
      Prebriefing in nursing simulation: A concept analysis.
      ). She also suggested expanding the definition of prebriefing, recommending theoretical frameworks for simulation might be expanded to include methods for prebriefing (
      • Page-Cutrara K.
      Prebriefing in nursing simulation: A concept analysis.
      ). Similarly,
      • McDermott D.S.
      The prebriefing concept: A delphi study of CHSE experts.
      recommended further study of the topic, “comparing strategies, time frames, and settings” (p. 226), and that “future areas of prebriefing research are needed to develop evidence-based prebriefing methods” (p. 224). Though it is widely agreed upon that prebriefing should be done, there is limited data on best practices in a prebriefing session. Currently, there is no commonly used theoretical framework to drive the prebriefing process, leaving the experience open to interpretation, and creating variable experiences for students that have the potential to affect student learning.

      Nursing Student Anxiety in Simulation

      Nursing education is high stakes given the ability to positively or negatively impact health outcomes based on clinical judgment and practice. As such, anxiety among nursing students is not a unique phenomenon, whether that anxiety relates to class assignments, exams, simulation, or clinical practice.
      • Shearer J.
      Anxiety, nursing students and simulation: State of the science.
      explored the state of the science related to simulation and found that nursing students experience anxiety related to simulation because of three main factors: the unknown, critique by peers and faculty, and fears of making mistakes. The unknown presented the greatest influence on anxiety (
      • Shearer J.
      Anxiety, nursing students and simulation: State of the science.
      ). These findings are further validated by
      • Yockey J.
      • Henry M.
      Simulation anxiety across the curriculum.
      who found anxiety in simulation is common and can negatively impact learning during the simulation. Labrague et al's (
      • Labrague L.
      • McEnroe-Petitte D.
      • Bowling A.
      • Nwafor C.
      • Tsaras K.
      High-fidelity simulation and nursing students’ anxiety and self-confidence: A systematic review.
      ) systematic review of the literature identified anxiety related to simulation is common and that anxiety negatively influences self-confidence. While the literature validates anxiety in simulation, limited research has been conducted to assess the effectiveness of interventions aimed at reducing anxiety.

      Mindfulness

      Mindfulness is the ability to be present “in the moment”, using one's senses to be aware of surroundings and feelings, without becoming overwhelmed by them. Mindfulness practices aim to incorporate techniques that promote such awareness and can vary. There are several techniques such as breathing exercises, guided meditation, purposeful pauses to think before engaging to name a few. White's (
      • White L.
      Mindfulness in nursing: an evolutionary concept analysis.
      ) concept analysis of mindfulness in nursing described mindfulness as a “transformative process” where one develops an increasing ability to ‘experience being present’, with ‘acceptance’, ‘attention’ and ‘awareness’.” (p. 282). Further,
      • White L.
      Mindfulness in nursing: an evolutionary concept analysis.
      suggests mindfulness is important to investigate for nurse self-care practices, development of therapeutic nursing qualities such as empathy, being fully present in their relationships with others, and to support the development of mindfulness practices with patients and families in a holistic manner.
      • Smith S.A.
      Mindfulness-based stress education: An intervention to enhance the effectiveness of nurses coping with work-related stress.
      found that nurses practicing mindfulness techniques had less burnout, anxiety, and improved the quality of the patients for whom they care.
      • Jerath R.
      Physiology of long pranayamic breathing: Neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system.
      describes how purposeful breathing has a direct effect on the autonomic nervous system to provide a sense of calm as well as a decrease in blood pressure and pulse. An Australian study of mindfulness techniques in undergraduate nursing students found that their interventions “enhanced the participants’ sense of wellbeing” (
      • van der Riet R.
      Piloting a stress management and mindfulness program for undergraduate nursing students: Student feedback and lessons learned.
      , p. 44). The study also reported a positive impact on concentration, clearer thinking, and overall positivity. (
      • van der Riet R.
      Piloting a stress management and mindfulness program for undergraduate nursing students: Student feedback and lessons learned.
      ). These studies suggest mindfulness is an important concept to research for nursing practice and nurse self-care, further supporting White's (
      • White L.
      Mindfulness in nursing: an evolutionary concept analysis.
      ) analysis.
      There is limited data on practicing mindfulness in the nursing profession and less on using mindfulness techniques in nursing education. Data about the influence of mindfulness in student learning and practice is sparse. When coupled with nursing student reports of anxiety related to simulation, incorporating mindfulness as a component of prebriefing is a novel idea worthy of investigation.

      Design and Methodology

      This study utilized a mixed-methods cross-over approach among a convenience sample of 46 junior-level BSN students. The setting was a small pre-licensure baccalaureate nursing program in the southeastern United States. The study was conducted during a traditional fall term, over a two-week period as part of an adult health course that incorporates multiple ungraded clinical simulations as a required component of the course. Prospective participants were informed of the study after Internal Review Board (IRB) approval was received. All junior-level BSN students and were given the option to participate or not, without any penalty by simply choosing to participate or not on both days of data collection. Of the 47 junior-level students, all but one participated because of participant absence, and that participant was excluded from the study.
      In this study, participants engaged in two simulations throughout the data collection. Each simulation in the study setting typically incorporates five to 10-minutes for the prebriefing, 15 to 20 minutes for the simulation, and 15 minutes for debriefing, including those in this study. The prebriefing, simulation, and debriefing conducted by the same faculty members. As is customary in the study setting, participants were scheduled in groups of four to five, with roles assigned at the time of prebriefing. Prebriefing was conducted by the same faculty for all groups and included a review of information shared online ahead of the session as well as expectations. Each group was offered the opportunity to ask clarifying questions before beginning and participants were then informed of their roles. This prebriefing protocol is the one customarily utilized by the study setting.
      Standard debriefing utilizes Rudolph et al's (
      • Rudolph J.W.
      • Simon R.
      • Rivard P.
      • Dufresne R.L.
      • Raemer D.B.
      Debriefing with good judgment: combining rigorous feedback with genuine inquiry.
      ) Debriefing with Good Judgment model, which was led by a CHSE simulationist. Groups were identical for time periods one and two, although roles may have been different between these time periods. Likewise, the mindfulness activity and location were delivered by the same researcher for the duration of the study. To measure anxiety, participants self-reported their anxiety using a 10-point visual analog scale (Figure 1), similar to a pain scale, with higher scores associated with higher anxiety levels. Participants were asked to report their anxiety immediately prior to prebrief and after the simulation, before the debriefing on two separate occasions with two different simulations.
      During time-period one, half of the students participated in a mindfulness exercise immediately prior to prebriefing (Group A) while the other half served as a control (Group B), experiencing the usual prebriefing prior to the simulation. Neither group of participants was informed ahead of time whether they would initially experience the mindfulness exercise with prebriefing or the traditional prebriefing. During time-period two, the groups were reversed so that at time-period one or two, all participants had engaged in a traditional prebriefing and a prebriefing with a mindfulness exercise. The mindfulness exercise involved a scripted guided meditation which included deep-breathing techniques, delivered to groups of four to five participants. The environment in which this exercise was conducted was a quiet, lowly-lit room located directly adjacent to the simulation lab, with chairs forming a circle. Participants were directly led into the prebriefing or to a two-to-three-minute scripted guided meditation immediately prior to prebriefing.
      Approximately two weeks after time-period two, participants were invited to a focus group to discuss their experiences with simulation anxiety and the intervention. The two-week gap between time two and the focus group provided additional time for participant reflection with the experience yet have it still be “fresh” in their minds. The discussion was guided by five open-ended questions to promote dialogue. The focus groups were led by the researchers and recorded, with one researcher serving as the primary facilitator and the other recording field notes. A qualitative descriptive approach was used to examine data derived from the focus groups. Raw data collected from field notes and transcripts were analyzed by both researchers and mutually identify themes shared by participants.

      Results

      Quantitative Data Analysis

      Participants generally reported a decrease in pre-sim vs. post-sim VAS scores during the two simulations (Table 1). A confounding variable is that unbeknownst to the researchers, a course exam was rescheduled on the same day as time-period one. Group A participated in time-period one of the study before the exam while Group B participated post-exam. During the debriefing, Group B expressed anxiety about the exam affecting self-perceived poor performance during the simulation. This may explain the difference in Group B pre-sim vs. post-sim score during time-period one. Regression analysis demonstrated this offers a modest explanation of differences (R2 = 0.51). Despite this, the intervention was found to significantly influence post-sim Anxiety VAS score with a larger difference pre-sim vs. post-sim (p < .0001) (Table 2). Overall, participants' pre-sim Anxiety VAS score significantly influenced post-sim Anxiety VAS score, with those reporting higher pre-sim Anxiety VAS scores experiencing a smaller decrease in post-sim Anxiety VAS scores (p < .0001) regardless of intervention or control. Since groups crossed over, the significance of the sequencing of the intervention was analyzed. Data demonstrated no significant change in post-sim Anxiety VAS scores, whether participating in the control or intervention (p = .13); however, sequencing of receiving control or intervention first was significant (p = .002).
      Table 1  
      Time Period OneTime Period Two
      VAS Anxiety Score (0 – 10)Group A ControlGroup B InterventionGroup A InterventionGroup B Control
      Mean Pre-Sim5.383.413.236.41
      Mean Post-Sim2.083.861.383.91
      Mean Difference-3.29+0.45-1.85-2.5
      Table 2  
      VAS Anxiety Score (0 – 10)Control (All)Intervention (All)
      Mean Pre-Sim5.873.32
      Mean Post-Sim2.962
      Mean Difference-2.91-1.32 (p < .0001)
      Data analysis of participant role in the simulation did not influence post-sim Anxiety VAS score (p = .98), suggesting a non-graded simulation invokes anxiety, regardless of role. The researchers presumed groups were similar as part of the same cohort of students in a single study site. Post-study course grades determined there was no significant difference in grades between the two groups (Table 3), supporting the researcher's assumption.
      Table 3  
      Group AGroup BLevel of Significance
      82.8783.41p = .30

      Qualitative Data Analysis

      Feelings of anxiety, being “in the moment” and wondering what everyone else was thinking emerged as themes. These findings validate and add to quantitative data related to mindfulness exercises in prebriefing. Further, these findings add description to the experience as viewed by participants in a manner in which quantitative data could not capture.

      Feelings of Anxiety

      Participants generally reported a positive association with the mindfulness exercise. While some were new to guided meditation and other meditation practices, and some had used it before in various personal and academic settings. The participants who had prior experience expressed a comfort level with mindfulness practices. Those that had not voiced initial skepticism about whether or not it would be helpful, initially but reported they were able to see its merits. One participant indicated “I did not think this was going to help, but I really got into it and it made a difference” while another shared “I had never done a meditation before and I was surprised how calm it made me feel.” Paradoxically, a few participants verbalized increased anxiety after the simulation because they perceived their performance in the simulation to be poor, suggesting anxiety in simulation is triggered by many factors.

      Being in the Moment

      Participants were able to express a feeling of “being in the moment” after the mindfulness exercise that they had not encountered before. Several verbalized a sense of calm that came over them in the simulation which incorporated the mindfulness exercise, which was not typical of their experience in the simulation lab in the past. One participant illustrated this idea by stating, “I had tried meditation for anxiety before, but I never thought it would help me in the simulation lab with keeping me so focused.” Another participant shared, “I've never remembered being so focused in the sim lab before.” These statements align with the level of significance in anxiety scores with and without the mindfulness exercise.

      Wondering what everyone else is thinking

      Participants expressed concerns about how peers did or could view mindfulness practices. Some participants shared they had used mindfulness for years as suggested by a therapist and did not view it as awkward or embarrassing, while others were hyperaware of what others might view this practice in the academic or practice setting. This concern is evidenced by one participant who stated, “In my military background, this would not work because other soldiers would think it was silly” while another participant declared, “I was hyperaware of what the other students were looking at during the meditation.” Despite these concerns, participants did express the perceived benefits of incorporating mindfulness activities during a busy clinical day. A few expressed reluctance to openly do so, stating “I guess I could go into the break room or bathroom and do a quick meditation.”

      Discussion

      Overall, the brief guided meditation exercise had a positive impact on participants, validated by quantitative and qualitative data. Anxiety VAS scores were lower post-sim, which is consistent with what has been reported in the literature (
      • Labrague L.
      • McEnroe-Petitte D.
      • Bowling A.
      • Nwafor C.
      • Tsaras K.
      High-fidelity simulation and nursing students’ anxiety and self-confidence: A systematic review.
      ). Self-reported anxiety scores were lower pre- and post-sim in the intervention group and appeared to remain for the duration of the simulation through the debriefing session. There were a limited number of participants who voiced they were more anxious after the debriefing because of self-perceived performance, but that did not appear to negatively impact the use of the mindfulness exercise overall. Participants were also able to express appreciation at being emotionally more present throughout the whole exercise giving them a sense of calmness and ability to make better decisions and saw utility in using mindfulness techniques during other nursing school experiences. These findings add support to earlier studies exploring mindfulness in nursing.
      A confounding variable was a rescheduled exam during time-period one which was scheduled around the simulation groups so that some had taken the exam before simulation while others were scheduled to take after simulation. This was beyond the researchers’ control and was an additional consideration during data analysis. While the presence of a confounding variable is challenging, it also provides new information to further explore the influence of abrupt changes on anxiety levels, not unlike those that suddenly occur in practice. Role and the unknown have been reported factors influencing student anxiety with simulation (
      • Labrague L.
      • McEnroe-Petitte D.
      • Bowling A.
      • Nwafor C.
      • Tsaras K.
      High-fidelity simulation and nursing students’ anxiety and self-confidence: A systematic review.
      ). As is common practice in the setting, roles are assigned at the end of the prebriefing. In this study, participant role in simulation, whether in the intervention or control group, did not impact post-sim anxiety scores. This is an interesting finding worthy of further investigation. A retrospective review of final course grades found no significant differences between the groups, suggesting similar academic abilities.

      Implications for Practice

      Data from this study suggests mindfulness activities in prebriefing are viewed as valuable to students but should be interpreted with caution. Results of this non-randomized study are too limiting to be generalizable, however, data suggests this is an area where further research would be important. This study explored the influence of mindfulness in prebriefing to reduce anxiety associated with simulation. What is not known is how mindfulness activities influence anxiety and the outcome of performance and clinical judgment. The impact of the unknown and other sudden changes, which regularly occur in practice, are worthy of exploration given this study's findings.
      The use of brief mindfulness exercises need not be time-consuming and can be easily adapted to other areas of stressful clinical practice and in educational settings, such as before an exam or before a potentially high-risk skill. Ultimately, mindfulness exercises should be studied as a potential part of the theoretical framework for prebriefing practice in simulation as well, possibly becoming an essential part of best practice.

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