Running head: BIOFEEDBACK INTERVENTIONS FOR NURSING STUDENTS 1

Biofeedback Intervention for Stress and Anxiety among

Nursing Students: A Critique

Demetria Booker, Patricia Donegan, Amanda Fite, Kelly Gunn, Natalie Noday, & Mirna Rascon

Walsh University
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The Problem

The proposed problem is “anxiety and stress in nursing students leads to more difficulty

in successfully completing clinical training”. Stress and anxiety among nursing students is a

common problem; these students have additional vulnerability to stress as well as a higher level

of stress when compared to non-nursing students. Managing stress and anxiety triggers via a

biofeedback mechanism will allow nursing students to be more successful in their clinical

training, and this in turn will lead to more productive and contributing members of the nursing

profession. Additionally, finding a solution to the management of stress and anxiety among

nursing students has clinical applicability because this has a longitudinal and long-lasting impact

on the development of future nurses.

Theoretical Framework/Conceptual Framework

The conceptual framework for this study began with the idea that nursing students

experience stress and anxiety throughout their programs; specifically, second-year nursing

students encountered additional stress during their first clinical training experience. The research

techniques proposed followed the map outlined by the conceptual framework. Sixty individuals

that fit the criteria were randomly assigned to the non-intervention (control) group or the

intervention (biofeedback) group. The control group would continue with their clinicals without

training in biofeedback mechanisms, and the biofeedback group would be trained in the use of a

biofeedback device and technique. This study utilized a heart rate variability measurement

device called an emWave PSR. The device helped the biofeedback group recognize their

involuntary heart rate variability and become aware of moments of stress and anxiety. With the

feedback obtained from the emWave PSR, the students were able to utilize techniques to
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decrease their response to the stressor. The researchers believed this would increase the students’

performance and future contribution to the profession of nursing.

Research Hypothesis

The hypothesis is that if nursing students can better manage their stress and anxiety, they

will be more successful in their clinical training (Ratanasiripong, Ratanasiripong, & Kathalae,

2012). According to Hulley et al. (2007), a good research question can be assessed by utilizing

the FINER criteria. This assesses if a research question is feasible, interesting, novel, ethical and

relevant. The feasibility of this study has positives and negatives. One negative is that the size of

this study could have been larger. One positive included the size of the device, as the emWave

PSR was manageable for the students during their clinical experience. The price for emWave

devices ranged from $100 to $300, which depending on the number of subjects chosen, would be

manageable under the right budget.

This study has the potential to positively impact the future of nursing, which makes it

relevant and of great interest to a large population from throughout the entirety of the profession.

Participants in the study were all volunteers and comprised of adult students at the college. Each

subject has their institutional review board’s approval to participate.

The predication that nursing students will thrive and become contributing members of the

profession with the use of stress and anxiety management has an agreeable outcome. The

biofeedback and control groups began with similar pre-scale scores on their Perceived Stress

Scale and State Anxiety Scale. After the five-week study, the control group showed an increase

in their Perceived Stress Scale. Regarding anxiety, the biofeedback group had a significant

decrease on their State Anxiety Scale while the control group recorded a moderate increase.
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Review of Literature

This randomized controlled study reports a logical investigation of the impact of the

emWave PSR and its’ effectiveness on reducing stress and anxiety. The intervention that was

utilized was comprehensive in nature by developing an extensive five-week training program for

nursing students to assist in the problem of stress and anxiety management, by becoming

competent with using the device’s equipment. The purpose was implemented to specifically

examine the impact this early mechanism had on the levels of stress and anxiety of second-year

baccalaureate nursing students as they began their first clinical experience at a public school in

Thailand. There were several issues noted in the study that contribute to the emotional challenges

students face throughout their course of education and clinical training. This training program

was specific and in-depth, creating a positive connection with the students and their stress and

anxiety levels. Furthermore, the results demonstrate that this intervention tool, “not only kept the

nursing students’ stress levels from increasing, but also significantly reduced their levels of

anxiety” (Ratanasiripong et al., 2012, p. 3). Therefore, as the theory stems from the foundation of

the research problem, it is evident to correlate the relationship to the research purpose, as it was

carried and reflected upon throughout the entire study. Two scales were utilized to assess the

participants’ levels of stress and anxiety, one being a State Scale that represents FLAGSHIP

research. The literature also includes research that was dated back to 1983. Although the study

was originally performed in 2012, there is research from twenty-nine years ago incorporated in

the findings of the literature, along with research from the latest year of 2011. Based on the

review, a case for conducting this study can be made to contribute to the psychological

perspective of the nursing profession, by easing stress and anxiety levels in students prior to

entering the field. There have been multiple studies over the past decade performed to help aid in
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the management of this educational journey and this study supports the trial of the new

generation of portable biofeedback equipment. This tool is also cost-effective and time sensitive,

which can help implement new teaching ideas for nurse educators and clinical instructors within

reasonable guidelines.

Protection of Human Rights

The study was designed to minimize risks of negative emotions and maximize benefits of

positive ones by having participants learn how to modify physiological activity to improve

psychological health, performance, and self-esteem in the clinical practice setting. The

participants were instructed to utilize the portable device for five weeks and to then record their

practice time with the device. The evidence supporting these participants’ rights have been

maintained by the correspondence to the priori power analysis by G* Power computer program.

An independent ethics review was then obtained by the college’s institutional review board, and

the students were recruited to participate in the study via a volunteer basis. Informed consent was

signed as a legal document to maintain all rights of the individuals participating.

Research Design

A randomized controlled trial is the research design utilized in this study. There were

intervention and non-intervention groups; both of these groups were enrolled and studied

concurrently. The research question being studied is “Does early biofeedback intervention

programs impact the level of stress and anxiety of second year of baccalaureate nursing students

as they begin their first clinical experience?” The participants were selected based on a priori

power analysis by G* Power computer program, and they were randomly assigned to either the

biofeedback group or the control group. All participants partook in pre and post intervention

surveys that discussed demographics, perceived stress, and a state anxiety scale. The biofeedback
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group received two training sessions led by researchers on how to use the biofeedback device for

the duration of the 5-week study. The biofeedback device provided immediate visual and

auditory feedback to sustain heart rhythm patterns. Contrastingly, the control group did not

receive any training or access to the biofeedback device. This study permits replication because

the same process can be used by independent researchers to arrive at the same results.

Sampling

The targeted population of the study included sixty second-year baccalaureate nursing

students. These participants were volunteer female students were female between the ages of 18

and 21 with a grade point average (GPA) ranging between 2.98 and 3.90. Of this sample group,

the students were broken into either the biofeedback intervention group, or the control group.

Data Collection

Surveys were distributed to all participants to determine stress and anxiety levels prior to

initiating the study. The survey was also distributed and collected following completion of the

study. The students in the biofeedback group received two trainings on how to use the emWave

PSR to assist in stress and anxiety management, and they were instructed to use the device three

times a day for the duration of the study. The purpose of a biofeedback device is to help a person

become aware of their heart rate, skin temperature, brainwave activity, blood pressure,

respirations, and muscle activity. In this study, the emWave PSR was used to teach these students

how to control their heart rate variability through breathing and positive emotions techniques.

Quantitative Analysis

The study was conducted by comparing two groups to determine if a biofeedback device

can help reduce stress and anxiety among second-year nursing students. Furthermore, the study

determines the reliability and validity of the biofeedback device. The link between the analysis
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and the findings is logical and clear because the nursing students in the biofeedback group were

able to maintain the same level of stress over the 5-week study period. Contrastingly, the control

group had a significant increase in their stress over the same time period. Participants in the

biofeedback group had a small increase in perceived stress, but were able to reduce their anxiety.

However, the control group had a significant rise in stress and anxiety. Variables such as age and

GPA showed no significant correlation in regards to anxiety and stress response. The article

presented graphs on page 4 and a table on page 3 that accurately displayed pertinent information.

Threats to Internal and External Validity

There was no significant difference in age and GPA between the biofeedback group and

the control group. “There were also no significant differences in the preintervention Perceived

Stress Scale and the preintervention State Anxiety Scale between the two groups”

(Ratanasiripong et al., 2012, p. 3). Based on findings from other studies, both stress and anxiety

levels are expected to increase for nursing students when they begin their first clinical training if

they do not receive any interventions (Ratanasiripong et al., 2012).

Conclusions and Recommendations

This study was only conducted at one nursing school in one country, and future studies

should consider replicating the study at multiple nursing schools throughout a country. “A

follow-up study on the impact of the biofeedback training on stress, anxiety, and academic

performance of nursing students after one to two years will help nurse educators to better

understand the long-term efficacy of the biofeedback intervention program” (Ratanasiripong et

al., 2012, p. 4). The results of the data analysis tied back to the theoretical framework. It has been

documented that nursing students across the world experience stress and anxiety throughout their

education and training, hence the proposed theory. It is imperative that nurse educators continue
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the effort to help nursing students manage their stress and anxiety during this formative process.

Nursing educators can train students in critical thinking skills and create programs to help

develop their self-esteem and reduce anxiety. Additionally, the more physiologically healthy the

nursing students are, the more likely they are to succeed, graduate, and become productive and

contributing members of the nursing profession (Ratanasiripong et al., 2012). This research study

can be put into practice by using the information gathered to help reduce stress and anxiety in the

field of nursing.
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References

Hulley, S. B., Cumming, S. R., Browner, W. S., Gray, D. S., & Newman, T. B. (2007).

Designing Clinical Research, 3rd ed. Philadelphia, PA: Lippincott, Williams and Wilkins.

Ratanasiripong, P., Ratanasiripong, N., & Kathalae, D. (2012). Biofeedback intervention for

stress and anxiety among nursing students: A randomized controlled trial. International

Scholarly Research Network, 1-5.