745436

research-article2017
JHNXXX10.1177/0898010117745436Journal of Holistic NursingTechnique to Reduce Stress in Nursing Students / Kramer

jhn
Education

Energetic Modalities as a Self-Care Technique

to Reduce Stress in Nursing Students Journal of Holistic Nursing
American Holistic Nurses Association
Volume XX Number X
XXXX 201X 1­–8
Deborah Kramer, EdD, RN, CPNP, FNP © The Author(s) 2017
College of Mount Saint Vincent 10.1177/0898010117745436
journals.sagepub.com/home/jhn

This article describes the outcomes of nursing students taking a course in complementary and alterna-
tive therapies focusing on energetic modalities that were used as a means of self-care. Students kept
journal logs and did a formal presentation for the class. Nursing students reported decreased stress and
improved concentration, academic performance, productivity, and problem-solving while experiencing
a greater appreciation of their clinical experiences. Using Therapeutic Touch and other subtle energy
interactions, the students also cited improved interpersonal relationships, increased feelings of calm-
ness, a higher degree of self-awareness and self-care, reduced physical pain, increased energy, and
greater appreciation of the world around them. The theoretical framework was Margret Neuman’s
theory of health as expanding consciousness. While this is an elective nursing course, the nursing stu-
dents were primarily juniors and seniors already taking clinical courses. A research study with a wide
sample of student participants, especially freshmen, and using quantitative as well as qualitative meas-
ures would be beneficial to determine if such a course should be part of the standard nursing curricu-
lum to not only expand nurses’ understanding of complementary and alternative therapies but also to
help students with their own self-care and influence their practice as clinicians.

Keywords: students; stress management/relaxation; alternative and complementary therapies; health

and wellness coaching; stress and coping

Introduction about their academic and clinical regimens and the

high levels of stress they feel (Ross et al., 2005;
Several studies have found that nursing students Stark, Hoekstra, Hazel, & Barton, 2012). A survey of
frequently experience stress, and at higher levels 409 nursing education program deans and heads of
than medical students, social workers, and phar- affiliated sites revealed high levels of problematic
macy students (Cristobal, Martinez Navia-Osorio, & behaviors in class, including inattention, absence,
Vacas Diaz, 2010). Approximately one third of nurs- and lateness (Jones, Echevarria, Sun, & Ryan, 2016;
ing students experienced stress severe enough to Lashley & De Meneses, 2001).
induce anxiety or depression (Kurebayashi, do Prado, High levels of stress affect student performance
& da Silva, 2012; Pryjmachuk & Richards, 2007). and should be the subject of concern for nursing
Like medical students, nursing students have to educators. This stress is caused by academic, finan-
absorb a large amount of information at the begin- cial, work-related, and interpersonal circumstances
ning of their studies (Fares, Al Tabosh, Saadeddin, (Cristobal et al., 2010). Poor stress management in
El Mouhayyar, & Aridi, 2016; Hamaideh & Hamdan-
Mansour, 2014; Heinen, Bullinger, & Kocalevent,
2017; Hojat, Erdmann, & Gonnella, 2013; Kraemer, Author’s Note: Please address correspondence to Deborah
Kramer, College of Mount Saint Vincent, 6301 Riverdale
Luberto, O’Bryan, Mysinger, & Cotton, 2016). Avenue, Riverdale, NY 10471, USA; e-mail: Deborah.kramer@
Nursing faculty report hearing their students talk mountsaintvincent.edu.
2  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
nursing students affects their ability to provide
“comprehensive nursing care” for patients (Kang,
Choi, & Ryu, 2009). Stress also negatively affects
communication, interpersonal effectiveness, and
empathy (Beddoe & Murphy, 2004; Birden et al.,
2014; Garrosa, Moreno-Jimenez, Liang, Liang, &
González, 2008).
A number of efforts have been made over the
past few years to reduce stress in nursing students
and health care professionals using mindfulness-
based techniques. These techniques have a positive
impact on learning while improving physical, emo-
tional, behavioral, and spiritual levels (Dehghan-
Nayeri & Adib-Hajbaghery, 2011; Fortney & Taylor,
2010; Galbraith & Brown, 2011; Garland, Rouleau,
Campbell, Samuels, & Carlson, 2015; Guillaumie,
Boiral, & Champagne, 2017; Michalsen et al., 2016;
Morley & Williams, 2015; Schure, Christopher, &
Christopher, 2008). They have also been shown to
reduce symptoms of stress and increase quality of
life (Arias, Steinberg, Banga, & Trestman, 2006;
Hassed, 2004; O’Leary, O’Neill, & Dockray, 2016;
Pipe et al., 2009; Williams et al., 2005).
Mindfulness meditation in particular has been
reported to reduce mood problems and psychologi-
cal distress and increase empathy and conscious
awareness (Barnes, Hattan, Black, & Schuman-
Olivier, 2017; Guillaumie et al., 2017; Kelly, 2017;
McConville, McAleer, & Hahne, 2017; Moscaritolo,
2009; O’Driscoll, Byrne, McGillicuddy, Lambert, &
Sahm, 2017; Spadaro & Hunker, 2016; Yasdani,
Razael, & Pahlavanzadeh, 2010). In an 8-week
mindfulness stress reduction course to cope with
personal and professional stress and foster empathy,
baccalaureate nursing students used guided audio
meditation tapes at home and completed journal
assignments. This intervention reduced students’
stress and anxiety (p >.05). There were also benefits
in attitude, time pressure, and dimensions of empathy
(Schwind et al., 2017). Integrated stress reduction
techniques that address interpersonal, emotional,
and spiritual needs as well as mental and physical
ailments are increasingly reported to be effective
ways to reduce stress symptoms (Anheyer et al.,
2017; Lee, Kim, Kim, Joo, & Lee, 2017; Michalsen
et al., 2016; Morley & Williams, 2015; Nasser &
Przeworski, 2017).
Also in the past several years, the use of comple-
mentary and alternative medicine (CAM) has become
widespread in the United States, often alongside
conventional therapies, in pursuit of health and well-
being. According to the 2012 National Health
Interview Survey (NHIS), 33.2% of adults reported
using CAM in the previous 12 months. More than
$30 billion was spent by 59 million adults on out-of-
pocket payments for these alternative therapies,
amounting to 9.2% of the total out-of-pocket expen-
ditures on health care for 2012 (National Center for
Complementary and Integrative Health, 2016).
Despite growing evidence of its effectiveness and
increased acceptance by the medical profession,
CAM, while increasingly being offered to nursing
students as an elective course (Kreitzer et al., 2008),
is still not been taught routinely in nursing schools
(Burger & Lockhart, 2017; Guillaumie et al., 2017;
Stark et al., 2012). These courses can serve not only
to teach CAM techniques for clinical use by health
care professionals but also to teach self-care tech-
niques for reducing stress in nursing students.
Course Description
This article describes the outcomes of nursing
students taking a course in CAM titled “Healing
with Energy” that focused on energetic modalities
that were used as a means of self-care. It was not a
research study. The course had a cap of 12 students
initially that was expanded to 20 students due to
high demand. This article is based on 2 years of stu-
dents taking the course, and the students verbally
gave permission to share their outcomes.
One way to introduce stress reduction to nursing
school students is through a course on using ener-
getic healing techniques with patients. The students
practice the techniques on themselves during the
course and thus gain self-care experiences as well.
Such a course is based on the Einsteinian model of
quantum physics that describes human beings as
networks of complex energy fields (Gerber, 1996).
These subtle energy fields interface with physical
systems in the body and are affected by our emo-
tions, spiritual balance, and environment. Traditional
medicine—the Newtonian model—in contrast, views
the body as an intricate machine down even to the
cellular structure (Gerber, 2001). It is theorized that
the biofield is the mechanism through which ener-
getic modalities operates. Energetic modalities
include biofield therapies such as Reiki, Therapeutic
Touch, external qi healing, and other subtle energy
interactions, as well as homeopathy, acupuncture,
 Technique to Reduce Stress in Nursing Students / Kramer   3
magnet therapy, and bio-electromagnetic therapy
(Rubik & Jabs, 2017). Techniques used in the course
include (1) meditation, (2) specific energetic tech-
niques developed by Donna Eden (such as three
thumbs, crown pull, triple warmer, zip-up, cross
crawl, and Wayne Cook posture), and (3) hands-on
touching techniques developed by Sharon Weiselfish-
Giammatteo (see Table 2 for definitions of the
energy techniques used in a CAM course).
A course on using energy was offered in the
spring semester as an elective to nursing students in
their sophomore, junior, or senior years at a univer-
sity in a major metropolitan area. The course had a
cap of 20 students and 15 enrolled. It was led by a
nurse practitioner with expertise in craniosacral
therapy, integrative manual therapy, applied kinesi-
ology, meditation, osteopathic manipulation, as well
as multiple manual and energetic diagnostic and
therapeutic interventions. The course used Margret
Newman’s theory of health as expanding conscious-
ness as its theoretical framework. Newman based
her theory on Martha Rogers’s theory of unitary
human beings, which suggests that man and envi-
ronment are inseparable and that our human and
environmental fields affect each other in every way
at our level of consciousness (Rogers, 1990). All
that occurs is part of our human process, which is
ever changing (Newman, 2008). This includes
physiochemical and growth processes, conscious-
ness, and cognitive processes. When the environ-
mental field changes, so does the human field,
according to Rogers’s theory (Rogers, 1990). This
theory was discussed in the course and manifested
in the student outcomes as they reported being
more aware of themselves and an increased connec-
tion with their surroundings, that is, “expanding
consciousness.”
The course is designed so that students learn to
understand the scientific basis for energetic healing
modalities and explore the various techniques of
energetic healing that enhance the energetic field’s
flow, balance, and harmony. Students also develop an
understanding of consciousness, intention, presence,
and awareness as well as self-care and self-awareness.
And they learn to demonstrate behaviors that pro-
mote personal and professional growth and under-
stand modalities for addressing mind–body problems
through self-healing. The course also fosters students’
thinking about clinical healing using the Einsteinian
as well as the traditional Newtonian models.
Table 1.  Energetic Modalities Course Topics
The healing experience and the energy field
Subtle energy fields and consciousness
Historical background of energy fields
Energy centers and energy flow
Thought and intention
Illness and energy fields
Energetic healing modalities
Self-healing
Topics covered in the energetic healing course
encompass different aspects of the process, includ-
ing theoretical and historical paradigms and applica-
tion of actual techniques. Practicing on themselves
what they are learning in the course, students
explore following their breath, quieting their thought,
techniques that are hands on, and other forms of
energy healing (see Table 1 for detailed course top-
ics and Table 2 for energetic healing modalities
taught). The course uses lectures, discussion, dem-
onstrations, and hands-on practice. The content and
readings are informed by evidence-based practices,
research studies, and theoretical writings on spiritu-
ality, consciousness, the mind–body connection, and
healing. Students are responsible for documenting
and describing their daily practice of the techniques
taught in class by writing daily journal logs that
include observations of any changes they experience
in awareness, consciousness, or presence.
Students were also required to give an oral pres-
entation describing how their use of energetic heal-
ing modalities affects their personal self-care
practices and nursing practice. (Students not yet in
clinical work based their presentations on their
interactions with others in the college.) They were
expected to use three articles to support their under-
standing of one energetic technique and describe
how using the technique had affected their personal
and professional practice. The first portion of the
presentation is based on the student’s observations
and thoughts, and the second part is a discussion
from the literature on implications of using the cho-
sen energetic modality with clinical practice or in
general self-care/interactive practices.
The students engage in a “mindful dialogue,” a
technique in which they become quiet and follow
their breath wherever it may take them (Krug,
Kramer, Bukatman, Gordon, & Mermelstein, 2013).
As the course progresses, the students become profi-
cient in focusing on just their breath and eliminating
4  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX

Table 2.  Energy Practices

Technique Description

Mindful dialogue breathing technique
Meditation
Chakras
Donna Eden’s energetic techniques
William Tiller’s energy fields
Sharon Weiselfish-Giammatteo’s integrative
manual therapy processing of energy
A dialogue one has with his or her inner self—when a person becomes quiet
and follows his or her breath
Act of stilling the mind and closing off all active outside thoughts that induces
an ability for deeper consciousness
The energy centers in the body through which energy flows (Eden & Feinstein,
2008)
A series of specific techniques developed by Donna Eden to promote the flow
of physical, emotional, and spiritual energies in the body (Eden & Feinstein,
2008)
Subtle energies that explain the field interactions and electromagnetic flow that
regulate all beings and the environment (Tiller, Kohane, & Dibble, 2000)
Energetic processing centers of the body that facilitate connections and healing
when touched (Weiselfish-Giammatteo, 2002)

distracting thoughts. They become nonjudgmental
observers of their breath. During class discussions,
the students think about how to describe compas-
sion, what is mind energy and how to use it, and how
mind energy can lead to a new awareness during
their everyday experiences.
Themes From the Journals
All completed journals as part of the course
requirement. Journals were used so that the stu-
dents could observe and self-reflect on changes they
are observing when using these techniques to care
for themselves. Although the students gave permis-
sion to share their journal entries, I did not feel
comfortable quoting directly from the journals.
Review of the students’ journal logs and noting
commonly used words revealed several themes that
were then tabulated. Students reported feeling less
stressed and calmer in both their academic and per-
sonal lives as well as in clinical situations. The tech-
niques they were learning enabled them to keep
their minds from wandering, to stay focused, and to
concentrate on the task at hand. In addition, stu-
dents reported greater appreciation for the clinical
experiences they were gaining and how much they
were learning from their patients. The various ener-
getic techniques allowed the students to take more
time for themselves. And the self-caring practices
enabled them to achieve a positive mood that sus-
tained them throughout the day.
The journals also revealed improvements in the
students’ concentration, their productivity at school
and at work, and in their ability to solve problems.
Another finding reported by the nursing students
was that they were able to use energetic techniques
to reduce physical pain such as cramps and head-
aches. It also improved their appreciation for the
world around them. Students discussed their new
ability to take themselves out of a stressful situation
and into a place where stress is blocked out for a
short time, enabling them to regain control of their
emotions. The techniques especially helped the stu-
dents appreciate their clinical experience. Another
student talked about appreciating being in the
moment with her patients and how much she learned
from them by doing this. Students talked about
being calm, relaxed, and focused with the CAM
techniques and remarked on the help it gave their
studies. They used the exercises then they felt
stressed or could not focus and feel immediately
refreshed. The techniques enabled students to study
for longer periods of time, especially using the three
thumps and breathing techniques (see Table 3 for
themes and summaries of journals).
Discussion
The students studied concepts of energetic
modalities and practiced what they were learning.
Energetic modalities are based on the biofield model
that posits a broader concept of field interactions
and flow of information in relation to the environ-
ment. Energetic modalities include biofield thera-
pies such as Reiki, Therapeutic Touch, and other
subtle energy interactions, as well as homeopathy,
acupuncture, magnet therapy, and bio-electromag-
netic therapy (Rubik & Jabs, 2017).
 Technique to Reduce Stress in Nursing Students / Kramer   5

Table 3.  Themes From the Journals

Theme Student Reflection

Reduction of stress/being more calm
Improving appreciation of clinical
experiences
Greater degree of self-awareness/
realization of stress/taking time for
oneself/self-care/acceptance of what was coming.
is coming
Improves productivity/enables working Students wrote that the exercises helped them face the day and get a good deal of work
through and solving problems
Facilitates academic improvement
Enhances concentration
Reduces physical pain and increases Students also remarked on how the breathing helped reduce physical ailments such as
energy
Improves appreciation for world
around them
Students wrote about being calmer despite all the stress around them and reduced anxiety
just by doing the breathing techniques they were taught.
Students wrote about being more in control of their minds, less wondering when focus was
needed, and being able to remain calm in stressful situations.
Students appreciated being in the moment when caring for their patients and it made their
clinical patient experience more satisfying.
Students described being able to focus on their breathing before entering the patient’s
room, how it helped calm their anxiety and place them more in the moment, and reduce
anxieties that formerly weighed on them.
Students wrote in their journals about enjoying long walks and appreciating nature while
they breathed deeply and felt the air go through them and become ready for whatever
Students commented on how the exercise helped them get in the mood for the day and
work, how their bodies felt lighter the whole day.
done.
Students commented how their daily life was improved, how the breathing enabled them to
clear their minds, listen to themselves without judgment, observe their breath, and clear
their thoughts.
This process, they said, made them more aware of their surroundings and to be more
present.
Students found that phrases from the training would come to them repeatedly and this
would help them to meditate and to accomplish tasks. These phrases included “focus on
the now,” “be present,” “focus only on your breath,” “accept things for how they are,” and
“reality.”
Students wrote how the training and practice helped them keep their mind free and to
retain more information.
Students also saw improvement using the techniques in studying and test-taking.
Students found the three thumps and breathing to be very effective together in fighting
fatigue and avoiding distraction while working.
Students commented that they were able to accomplish more work more quickly because
their mind was not always drifting.
getting cramps during exercise or back pain. For one student, this fixed a lifelong
problem of pain during exercise.
Students wrote they were depending on the exercises to give them energy.
Students wrote that they were more observant when outside about natural elements in the
landscape, perhaps due to their concentration on being present and being appreciative—
for example, how a tree stands in the grass.
A student wrote that as they walked, they took in their surroundings and began to notice
things not observed before.

While this is an elective nursing course, the stu-
dents in the course were primarily juniors and sen-
iors already taking clinical courses. The course led to
a reduction in levels of stress by nursing students as
revealed through their journals as well as academic
improvements as reported by the students, more
self-awareness and greater ability to concentrate and
work through problems. Other benefits seem to be
reduced physical pain and increased appreciation for
their clinical work and the world around them.
The fact that students practiced these tech-
niques in the classroom setting together may have
contributed to these positive outcomes and their
ability to do the techniques on their own. Violet
Malenski and Vidette Todaro-Franceschi tried to
explore co-meditation as a means to reduce stress in
a nursing school setting. Although they had diffi-
culty recruiting students, they found potential for
decreased anxiety and charted reductions in systolic
blood pressure, heart rate, and respirations after
6  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
only one experience with co-meditation (Malinski &
Todaro-Franceschi, 2011). In their study, partici-
pants synchronized their breathing in dual pairs and
learned to totally focus on each other. This shared
intimacy led to a unique caring relationship among
the dyad. In a current study of staff in a pediatric
oncology unit receiving mindfulness training to
reduce burnout, staff journals suggest that doing a
mindfulness technique together when faced with a
particular stressful situation helped the participants
refocus and deal more calmly with the situation
(Moody et al., 2013).
The fact that more health insurance companies
are reimbursing their subscribers for CAM services
according to the 2012 National Health Interview
Survey (60% of those who used chiropractic care,
25% of those using acupuncture, and 15% of those
using massage; National Center for Complementary
and Integrative Health, 2016), indicates a growing
acceptance of CAM as a valid modality in self-care.
Subscribers are also more willing to pay out of
pocket for CAM services (National Center for
Complementary and Integrative Health, 2016).
Conclusion
This article reports only on results from a course;
it was not a study. A formal study is recommended
with a wide sample of student participants, including
first-year students at the beginning of their nursing
studies, who can make these energetic healing tech-
niques part of their daily practice and have it inter-
nalized by the time they reach their clinical courses.
Starting to work with patients, students have indi-
cated, is a particularly stressful time in their educa-
tion (Kang et al., 2009). The study would use
quantitative as well as qualitative measures and be
beneficial to determine if a complementary and alter-
native therapy healing course should be part of the
standard nursing curriculum to enhance students’
academic and clinical experience. The hope is that
such a course would not only expand nurses’ under-
standing and awareness of complementary and alter-
native interventions, but help students with their
own self-care and impact their practice as clinicians.
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Deborah Kramer, EdD, RN, CPNP, FNP, is a nurse practi­
tioner with over 30 years of experience integrating alterna­tive
therapies into her practice. She is the director of the under­
graduate nursing program and Associate Professor of Nursing at
the College of Mount Saint Vincent. She founded and managed
a center for education and alternative therapy and currently
practices and does international research on the outcomes of
alternative therapies.