The Journal of School Nursing2022, Vol. 38(6) 519–525© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211001833journals.sagepub.com/home/jsn
Abstract
The purpose of this study was to evaluate the feasibility of a school nurse–led mindfulness program in a public school. Elementary students in an urban public school system are exposed to many stressors including poverty, family disturbances, and mental health conflicts. Previous research suggests that mindfulness interventions given by teachers promote prosocial behavior and stress reduction; however, there are no studies that have determined whether the school nurse could lead the program. A pre- to posttest design was employed using school-aged children enrolled in the fourth grade who were administered a mindfulness program. The participants were assessed for emotional states before and after the intervention. A total of 12 students completed the intervention. Students found the mindfulness program to be helpful, and the school nurse may be able to successfully complete the intervention. With appropriate planning, school nurses may be able to successfully implement the mindfulness curriculum in an urban public school.
Keywordsschool-aged children, mindfulness, school nursing
Elementary students experiencing impoverished living conditions in underresourced urban schools are exposed to many stressors at home and in the schools. These include poverty, family disturbances, peer conflicts, and physical and mental health conflicts. Added to this is the increasing pressure of the school board to improve academic performance with limited resources. Adverse childhood experiences (ACE) and prolonged exposure to stressors can have a profound effect on these children (Larkin et al., 2012). School nurses are in a unique position to assist in utilizing interventions to promote improved stress resilience. Previous research has been conducted within the school system by teachers and other professionals with extensive mindfulness training (Black, 2014; Felver et al., 2014; Off, 2018). Mindfulness training was defined as a technique to promote mindful awareness acquired through the intentional focus on the present moment in time without judgment about past or future negative experiences (Kabat-Zinn, 2003). This training was thought to improve student attention, resiliency, proper social behavior, and improved self-regulation. However, there is little to no research as how the role of the school nurse can seek to lead these initiatives in the public school system. The purpose of this study was to assess whether the school nurse can practically implement a mindfulness program in the public school system as evidenced by student participation, teacher satisfaction, and sustained delivery of the intervention over an 8-week period.
Youth who grow up in impoverished urban areas are faced with daily challenges that impact their overall health. Exposure to chronic poverty can greatly impact the health and well-being of children and families. According to Collins et al. (2010), families who live in urban poverty have an increased risk of experiencing traumatic events. Due to the increased risk of exposure to trauma, children living in urban areas are more susceptible to physical and mental health disorders.
Although every child’s experience is different, common stressors experienced by children and families living in urban environments include disrupted family systems, unsafe neighborhoods, community violence, personal victimization, poverty, and racial discrimination (Wade et al., 2014). Children who experience these stressors are more likely to experience symptoms of mental health disorders, including major depression, and posttraumatic stress disorder. Living in poverty further limits children from accessing the necessary resources for management of their mental health symptoms. This creates an endless cycle of trauma, stress, and unchecked mental health symptoms within families and the community (van der Kolk, 2014).
With the increase of stressors seen within elementary schools, administrators are looking to assist the children outside of the education system. Mindfulness training is seen as beneficial in dealing with the abundance of information and increasing socioeconomic stressors by developing the ability to better deal with stress and be able to focus (Napoli et al., 2005). One important role includes children being able to regulate their reaction with mindfulness by becoming more aware of their feelings and thoughts (Parker et al., 2014). Potential significant benefits for both teachers and students, as shown by early results of mindfulness studies in adults, suggest that sustained mindfulness practice can promote flexibility and enhance attentional and emotional self-regulation (Meiklejohn, 2012). Programs that create a nondisruptive classroom by training students in skills that promote prosocial behavior may alleviate teacher burden and benefit student learning (Black, 2014). Traumatic experiences that occur outside the school may be affected with mindfulness by offsetting some psychiatric comorbidities (Ortiz & Sibinga, 2017). With return to schools after the COVID-19 pandemic, the ability to manage increased stressors become paramount.
There have been numerous studies, including randomized controlled trials, which have investigated the effects of a mindfulness-based program on the social and emotional development of school-aged, middle school, and high school students (Felver et al., 2014; Kuyken et al., 2013; Parker et al., 2014; Schonert-Reichl et al., 2015; Sibinga et al., 2016; van de Weijer-Bergsma et al., 2014). There was a great deal of difference in the type of mindfulness program given to the students with all being instructed by either the classroom teacher or a trained professional who was also the main investigator in the study. Outcomes were reported as positive, although not all studies achieved results with statistically significant differences (Felver et al., 2014; van de Weijer-Bergsma et al., 2014). Studies achieving statistically significant results were mainly found in outcomes such as acceptability of the students toward the outcomes, lower stress and depressive symptoms, as well as improved executive functioning (Kuyken et al., 2013; Parker et al., 2014). Perhaps the most consistent theme in prior studies is that only one study was conducted with a predominantly urban minority population (Sibinga et al., 2016). The results of the randomized controlled trial in a predominantly urban minority population found that fifth to eighth graders exposed to a mindfulness curriculum, as opposed to the control group, had significantly lower levels of somatization, depression, negative affect, and posttraumatic symptoms. Janz et al. (2019) developed a wait list–controlled trial of a mindfulness program called Calmspace and delivered it to children in preparatory/Kindergarten through second grade in Australia. The study was delivered by teachers after intense training and showed an increase in executive functioning and attention. Zoogman et al. (2015) completed a meta-analysis that examined 20 studies and found mindfulness intervention to be helpful and had not been shown to cause iatrogenic harm. Also, the study found that youth may learn mindfulness more quickly compared with adults and require fewer sessions and less practice. Also, when teaching youth as opposed to adults, issues of instructor expertise maybe less predictive of the results (Zoogman et al., 2015).
The MindUp™ program combines social emotional learning and mindful practice for school-aged children (The Hawn Foundation, 2011). Lessons combine key components such as the core practice of “deep belly breathing and attentive listening.” Each lesson has additional information based on developmental age. Focus begins with subjective sensebased experience such as movement to cognitive experiences such as taking other’s perspective. Schonert-Reichl et al. (2015) evaluated the MindUp program for students in Grades 4 and 5 in a public school district in Western Canada. Students were randomly assigned to either the MindUP program in addition to a social and emotional learning program or the regular social responsibility program. The addition of the mindfulness program resulted in children with improved cognitive control and greater empathy, decreases in peer-rated aggression, and increase in peer acceptance. A quasi-experimental study in Portugal compared third- and fourth-grade students who received MindUP with students in the control group. Results of the intervention group included an increase in positive affect and a dimension of self-compassion with a decrease in negative affect and suppression compared to the control group (Sampaio de Carvalho et al., 2016). Another study with kindergarten children noted positive changes in children’s behaviors including a significant increase in resiliency and decrease in internalizing behaviors after participation in MindUp program (Off, 2018).
The purpose of this study was to test the feasibility of implementing these same types of programs with urban youth in a similar age-group with the use of the school nurse as the interventionist.
This was a feasibility study to determine whether a schooldriven intervention of mindfulness can be practically completed in an 8-week period. The study employed a pre- to posttest quasi-experimental design to determine potential outcomes and acceptability of the program.
There were 24 school-aged children between the ages of 10 and 11 years who were enrolled in the fourth grade of a public school and were accessible to the principal investigator. Excluded children include those for whom English is a second language or those in a special education setting or students with intellectual disabilities.
The setting was an urban public grade school that was a part of a community partnership with the affiliated hospital, which employs the school nurse. The intervention occurred in the student’s classroom. The school nurse came to the classroom to provide the intervention. The teacher was present during the intervention. Those students who had not consented spent the allotted time in the library.
Demographic information. Parents were asked to fill out a basic demographic form along with the signed written consent form. This data sheet included age, gender, race, grade, diagnoses such as ADHD, and family composition.
The Positive and Negative Affect Schedule (PANAS). The PANAS-Short Form (PANAS-SF) was used to assess the children’s emotions pre- and postmindfulness training. Students’ positive and negative emotions were measured consisting of 10 positive and 10 negative words to be rated to indicate the extent an emotion has been felt over the last week, a scale from 1 (very slightly or not at all) to 5 (extremely). The PANAS-SF is a valid and reliable instrument (Thompson, 2007). The test–retest coefficient of reliability was reported at .84; convergent and criterion-related reliability and cross-cultural validity have also been established. Merz et al. (2013) found it was reliable and valid for use among African Americans in a sample aged 18–78 years.
Children’s Self-Descriptive Questionnaire (SDQ). The SDQ was utilized to look at internalizing factors (eight questions) and externalizing factors (six questions). Interest/self-confidence in the area of math and all school subjects included seven and six related questions, respectively. Finally, peer relationships consisted of a total of six questions. These questions asked “how true is this about you” with ranking of not at all (1) to very true (4). A pre- and postquestionnaire was completed with the students. The reported reliability testing of the SDQ resulted in an a coefficient between .72 and .88 (Pollack et al., 2005).
Program Evaluation Questionnaire. The investigator created a Program Evaluation Questionnaire that was given to each student when completed. The classroom teacher and the school nurse also completed a Program Evaluation Questionnaire upon completion of the intervention. Both quantitative and qualitative questions were asked. Children completed the paper-pencil Program Evaluation Questionnaire individually and returned to the school nurse immediately after completing the intervention.
Approval was granted by the school research committee prior to implementation. Letters of approval were obtained by the principal of the school involved. Institutional review board approval was sought from Washington University. The study was approved and given expedited status. Parents were asked to sign a consent for the mindfulness program and children were asked to sign an assent. Consents were obtained by sending home information with the student and a follow-up phone call. The investigator also attended a school event in an attempt to obtain more consents. Children in fourth grade were assented by the school nurse prior to the intervention.
The mindfulness program was taught by the school nurse at the school in the student’s classroom. The school nurse was given the manual for the Mind UP™ curriculum for Grades 3–5 prior to the start of school and had time to review the content. During the planning session with the school principal and classroom teacher, a time limit of 8 weeks was decided upon based on their school schedule. This was due to time needed for the students to review for upcoming state examinations. The school nurse followed the lesson plans from the MindUp curriculum. The MindUp curriculum has four units and a total of 15 lessons (Table 1). Two lessons, mindful smelling and mindful tasting, were not offered as there was concern for possible allergic reaction. The intervention by the school nurse would consist of 10–12 lessons depending on the ability to cover the content based on the amount of time. The school nurse also requested notebooks for each student in order to complete journal writing to reflect on what they learned in each lesson as recommending in the curriculum. The classroom teacher was provided with the MindUp book and encouraged to practice the exercises throughout the school day, especially the core practice.
The PANAS-SF and SDQ were administered to the students 1 week prior to the sessions. Program evaluations occurred immediately following the completion of the program. A demographic data sheet was completed to describe sample characteristics. The student, school nurse, and teacher program evaluations were given the last day of the intervention. After completion of the program, the children were given a certificate of completion and a $10 gift card.
Univariate summary statistics (mean, SD, count, percentage) were created for demographic variables and instrument scores. Participant data were not linked between demographic nor pre- and postintervention data collection. Despite the lack of independence, a series of nonparametric Wilcoxon–Mann–Whitney tests were used to assess the distribution preintervention compared to the distribution postintervention. Alpha was preset at 5% for all testing of significance. All analyses were performed using IBM SPSS Statistics for Windows Version 24.0.
There were 12 participants from the same classroom whose parents signed a consent and who completed the study, with varied completeness, pre- and postintervention. All 12 participants completed the postevaluation questions, whereas eight of the participants’ parents completed the demographic section. Demographic summary statistics are reported in Table 2. The majority of the participants were female (62.5%), 75% of parents were married and 100% of the participants were of African American race.
Summary statistics of the study instrument subscales PANAS-SF and SDQ by study period are reported in Table 3. Using the Wilcoxon–Mann–Whitney tests as a proxy, not direct, assessment of group differences in distribution between pre- and postintervention, no statistically significant group differences were detected although, despite the limited sample, the PANAS-SF positive affect was approaching statistical significance (p = .051). Summary statistics of the postevaluation questions from the postintervention study period are reported in Supplemental Table.
The school nurse was able to complete 12 lessons in the allotted time frame provided by the school administrator. All but one of the students stated they liked the lessons and felt it helped them. Some of the student quotes included “it helped me calm other students down when they get mad at things”; “I did not like it, I loved it”; “It helped me so I think it will help my big brother too.” The school nurse also reported that the program was helpful in caring for students and assisting with their emotional regulation but felt the time allotted was not long enough. The teacher also felt the lessons were helpful but costly from a time standpoint and felt it would be better served as an extracurricular activity before or after school rather than taking time away from the classroom instruction.
The current study was unique, in that it is the first study to utilize the school nurse as the interventionist in a mindfulness curriculum. Due to the small sample size, statistical significance was difficult to achieve. The purpose of the current study was to determine whether a school nurse in an urban public school could practically implement a mindfulness program. Unlike previous studies with school-aged children, the school nurse rather than the teacher or an outside professional completed the intervention (Felver et al., 2014; Kuyken et al., 2013; Parker et al., 2014; Schonert-Reichl et al., 2015; Sibinga et al., 2016; van de Weijer-Bergsma et al., 2014). The school nurse was in a unique position for they have a relationship with the students based on concern for their health and well-being. Teachers are an integral component to the practice of mindfulness in the classroom but may not have the time required to first learn and then to teach the program.
The students were able to complete the lessons as taught by the school nurse. A more condensed time frame was used due to upcoming statewide testing in the classes. Also, mindful tasting and mindful smelling were not included due to possibility of allergies. Due to the student’s active interest and participation, two more lessons were added at the end of the intervention.
Mindfulness could be provided during before or after school care, so instructional time is not utilized. Completion of the full 15 lessons would be more feasible if done outside of school instructional time as it would not interfere with allotted teaching times. The school nurse could also train the teachers and staff in the core principles of the program in order to utilize the strategies in all areas of the school day. In the future, all the nurses in the school district could implement the program, as it has been shown to be feasible to do so in one school. Mindful minutes could become part of the school’s daily announcements over the school wide speaker system.
Attending to students’ social–emotional health has been an increasingly important component of educating children, especially in high-risk environments (Black, 2014). The school nurse continued to utilize components of the mindfulness program in her clinic with participants and found this to be useful. For example, the school nurse has incorporated the breathing technique along with proper spacer technique when giving albuterol with spacers.
The MindUp curriculum is publicly available in an inexpensive book from Scholastic Books®, which increases the likelihood of the program being acceptable. A future study to determine the effect of mindfulness activities directed by the school nurse in the school clinic could be useful.
The current study, however, had several limitations including a small sample size. In order to generalize about the effectiveness of this program for other urban public school, a large randomized controlled trial with the school nurse as the interventionist is needed. There are also many logistics to instituting a mindfulness program in order to allow adequate time to teach the lessons while balancing the other important education requirements. Also, to be effective, the portions of the mindfulness program, such as the core practice of pause, listen, and breath, need to be included in the daily schedule by the teacher, which is difficult to mandate. Each teacher may have different ways to manage the classroom. Utilizing a 1-min core practice to center students between transitions is an example of embedding the practice in the daily classroom culture.
School nurses are in a unique position to facilitate a mindfulness program in elementary schools. This study shows that it was feasible for a school nurse to lead mindfulness education in the school. Children were receptive to this program and were easily engaged by the school nurse. The classroom teacher had concern about the time allotted to teach this program taking away from other important instruction. The school principal was key to the program successfully being instituted, as well as having a prior relationship with the school district as a part of a community partnership with the affiliated hospital that employs the school nurse.
Other opportunities exist within the school day to practice mindfulness. The school nurse is an important advocate for children’s health and mindfulness.
We wish to thank Jessica McCullough, school nurse, who administered the program in the school. We are also grateful to the student participants, their parents, and teacher and administrators in the school district for their participation in this project.
Lisa Henry contributed to conception or design; contributed to acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Colleen W. Smithson contributed to conception or design; drafted the manuscript and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Lisa Marie Steurer contributed to conception or design; contributed to acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Patrick Ercole contributed to acquisition, analysis, or interpretation; drafted the manuscript; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. This work was supported in part by a grant from the St. Louis Children’s Hospital Foundation.
Lisa M. Steurer, PhD, RN, CPNP-PC https://orcid.org/0000-0002-7212-9861
Supplemental Material for this article is available online.
Black, D. S. (2014). Mindfulness training and classroom behavior among lower-income and ethnic minority elementary school children. Journal of Child and Family Studies, 23(7), 1242–1246. https://doi.org/10.1007/s10826-013-9784-4
Collins, K., Connors, K., Davis, S., Donohue, A., Gardner, S., Goldblatt, E., Hayword, A., Kiser, L., Strieder, F., & Thompson, E. (2010). Understanding the impact of trauma and urban poverty on family systems: Risks, resilience, and interventions. Family Informed Trauma Treatment Center. http://nctsn.org/nccts/nav.do?pid=ctr_rsch_prod_arorhttp://fittcenter.umaryland.edu/WhitePaper.aspx
Felver, J. C., Frank, J. L., & McEachern, A. D. (2014). Effectiveness, acceptability, and feasibility of the soles of the feet mindfulness-based intervention with elementary school students. Mindfulness, 5, 589–597. https://doi.org/10.1007/s12671-013-0238-2
The Hawn Foundation. (2011). The MindUp curriculum grades 3–5. Scholastic Books.
Janz, P., Dawe, S., & Wyllie, M. (2019). Mindfulness-based program embedded within the existing curriculum improves executive functioning and behavior in young children: A waitlist controlled trial. Frontiers in Psychology, 10, 1–17. https://doi.org/10.3389/fpsyg.2019.02052
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156. https://doi.org/10.1093/clipsy.bpg016
Kuyken, W., Weare, K., Ukoumunne, O. C., Vicary, R., Motton, N., Burnett, R., Cullen, C., Hennelly, S., & Huppert, F. (2013). Effectiveness of the mindfulness in schools programme: Nonrandomised controlled feasibility study. British Journal of Psychiatry, 203, 126–131. https://doi.org/10.1192/bjp.bp.113.126649
Larkin, H., Shields, J. J., & Anda, R. F. (2012). The health and social consequences of adverse childhood experiences (ACE) across the lifespan: An introduction to prevention and intervention in the community. Journal of Prevention & Intervention in the Community 48(4), 263–270. https://doi.org/10.1080/10852352.2012.707439
Meiklejohn, J. H. (2012). Executive summary. Integrating mindfulness training to K-12 education: Fostering the resilience of students and teachers. Mindfulness, 3(4), 291–307. https://doi.org/10.1007/s12671-012-0094-5
Merz, E. L., Malcarne, V. L., Roesch, S. C., Ko, C. M., Emerson, M., Roma, V. G., & Robins Sadler, G. (2013). Psychometric properties of positive and negative affect schedule (PANAS) original and short forms in an African American community sample. Journal of Affective Disorders, 151, 942–949. https://doi.org/10.1016/j.jad.2013.08.011
Napoli, M., Krech, P. R., & Holley, L. C. (2005). Mindfulness training for elementary school students: The attention academy. Journal of Applied School Psychology, 21(1), 99–125. https://doi.org/10.1300/j370v21n01_05
Off, N. (2018). Exploring a mindfulness-informed social emotional learning program in kindergarten classrooms: The moderating role of participant characteristics on behavioural outcomes [Electronic thesis, The University of Western Ontario].
Ortiz, R., & Sibinga, E. M. (2017). The role of mindfulness in reducing the adverse effects of childhood stress and trauma. Children, 4(3), 16. https://doi.org/10.3390/children4030016
Parker, A. E., Kupersmidt, J. B., Mathis, E. T., Scull, T. M., & Simms, C. (2014). The impact of mindfulness education on elementary school students: Evaluation of the master mind program. Advances in School Mental Health Promotion, 7(3), 184–204. https://doi.org/10.1080/1754730x.2014.916497
Pollack, J. M., Atkins-Burnett, S., Najarian, M., & Rock, D. A. (2005). Early childhood longitudinal study, kindergarten class of 1998–99 (ECLS-K), psychometric report for the fifth grade (NCES 2006-036). PsycEXTRA Dataset. https://doi.org/10.1037/e428752005-001
Sampaio de Carvalho, J., Pinto, A. M., & Maroco, J. (2016). Results of a mindfulness-based social-emotional learning program on Portuguese elementary students and teachers: A quasiexperimental study. Mindfulness, 8(2), 337–350. https://doi.org/10.1007/s12671-016-0603-z
Schonert-Reichl, K. A., Oberle, E., Lawlor, M. S., Abbott, D., Thomson, K., Oberlander, T. F., & Diamond, A. (2015). Enhancing cognitive and social-emotional development through a simple-to-administer mindfulness-based school program for elementary school children: A randomized controlled trial. Developmental Psychology, 51(1), 52–66. https://doi.org/10.1037/a0038454
Sibinga, E. M. S., Web, L., Ghararian, S. R., & Ellen, J. M. (2016). School-based mindfulness instruction: An RCT. Pediatrics, 137(1), 1–8. https://doi.org/10.1542/peds.2015-2532
Thompson, E. R. (2007). Development and validation of an internationally reliable short-form of the positive and negative affect schedule (PANAS). Journal of Cross-Cultural Psychology, 38(2), 227–242. https://doi.org/10.1177/0022022106297301
van de Weijer-Bergsman, E., Langenberg, G., Brandsma, R., Oort, F. J., & Bögels, S. M. (2014). The effectiveness of a schoolbased mindfulness training as a program to prevent stress in elementary school children. Mindfulness, 5, 238–248. https://doi.org/10.1007/s12671-012-0171-9
van der Kolk, B. (2014). The body keeps the score: Brain, mind and body in the healing of trauma. Penguin Books.
Wade, R., Shea, J. A., Rubin, D., & Wood, J. (2014). Adverse childhood experiences of low-income urban youth. Pediatrics, 134(1), x13–x13. https://doi.org/10.1542/peds.2013-2475d
Zoogman, S., Goldberg, S. B., Hoyt, W. T., & Miller, L. (2015). Mindfulness interventions with youth: A meta-analysis. Mindfulness, 6, 290–302. https://doi.org/10.1007/s12671-013-0260-4
Lisa Henry, MSN, RN, PNP, AE-C, is a Pediatric Nurse Practitioner at St. Louis Children’s Hospital.
Colleen W. Smithson, MSW, LCSW, is a Social Worker at St. Louis Children’s Hospital.
Lisa M. Steurer, PhD, RN, CPNP-PC, is a Manager at St. Louis Children’s Hospital.
Patrick M. Ercole, PhD, MPH, is a statistician at Sansom Consulting.
1 Healthy Kids Express, St. Louis Children’s Hospital, MO, USA
2 Department of Quality, Safety, and Practice Excellence, St. Louis Children’s Hospital, MO, USA
3 Sansom Consulting, San Antonio, TX, USA
Corresponding Author:Lisa M. Steurer, PhD, RN, CPNP-PC, Department of Quality, Safety, and Practice Excellence, St. Louis Children’s Hospital, One Children’s Place, St. Louis, MO 63110, USA.Email: lisa.steurer@bjc.org
