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Artigo 2
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Original Article
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physical postures (asanas), breathing (pranayama), The yoga instructor was a 500‑Hour Registered Yoga
meditation, and relaxation.[9] Research related to the Teacher with 14 years’ experience, who holds a 200‑hour
use of yoga in students and health‑care professionals Registered Yoga Teacher Kundalini certification.
is limited but promising; however, among studies that Kundalini yoga involves pranayam (breathwork),
explore the use of yoga to reduce stress in health‑care kriyas (sets of yoga postures), mudras, eye‑focus, body
providers, most have had small samples, which may locks, and meditation.[14] For student convenience, the
limit their generalizability.[10‑13] yoga intervention was scheduled at the end of the school
day (3 pm) and lasted approximately one hour. The class
The current study is important because finding ways to consisted of postures (asanas), breath‑work (pranayama),
reduce stress in nursing students and promote healthy and meditation. Participants were encouraged to modify
behaviors could improve overall health, as well as work the positions to match their skill level and reduce the
and school performance, and may help students develop risk of injury. Although varying degrees of physical
coping skills that can be used in many life situations. challenge were offered for positions, yoga postures
Therefore, the purpose of this study was to explore the were consistent throughout the intervention. Variety
effects of a yoga intervention on stress, self‑compassion, was also offered in both the breathing techniques and
and quality of life (QOL) in undergraduate nursing meditation options. By the end of the first 6 weeks,
students. Integrating yoga in nursing curricula may participants were introduced to three different breathing
enable educators to take advantage of a low‑cost techniques (Alternating Nostril Breathing, Three Part
intervention to help students cope with academic, life, Breath, and Bee Breath) and three different meditation
and work stressors. techniques (Progressive Relaxation, Kirtan Kriya, and
Tattva Balance and Beyond).
Methods
Instruments
This study used a two‑group, quasi‑experimental, Measures included participant demographic
repeated measures longitudinal design. Data were characteristics, the Perceived Stress Scale‑14 (PSS),
collected at three time points over a 12‑week period (at the Self‑Compassion Scale (SCS), the World Health
baseline, week 6, and week 12). Organization QOL‑BREF scale (WHOQOL‑BREF),
and two investigator‑developed questions related to
Participants and setting participation in the intervention, participation in yoga
A convenience sample of second semester upper division not related to the study (“other yoga”), and reasons for
students in a large university undergraduate nursing not attending the yoga intervention (intervention group).
program in the U. S. participated in the study. This group Demographic information included age, gender, and
of students was targeted because the second semester of ethnicity.
the junior year is typically the most stressful for students
in the program. Participation was voluntary; however, The PSS was used to assess the degree to which students
students were offered two extra credit points for every perceived their lives as stressful. Stress is defined in
survey they completed. These points were divided the PSS as “the degree to which respondents find their
among the three courses they were enrolled in (Adult 1, lives unpredictable, uncontrollable, and overloading”.[15]
Families, and Pharmacology). Students were also offered Fourteen items address a person’s stress within the last
an alternate opportunity for extra credit at each time point month, using a Likert‑type scale ranging from 0 (never)
if they did not want to participate in the study. No extra to 4 (very often), with higher total scores indicating
credit could be used to earn a passing grade in a course. higher levels of stress. The PSS has been used in diverse
populations and has demonstrated good reliability with
After approval by the university Institutional Review a Cronbach’s alpha of between 0.74 and 0.86 in general
Board (IRB), students were informed about the study and student populations.[15]
through an E‑mail announcement in the beginning of
the semester and invited to participate. Survey responses The SCS is a 26‑item measure of self‑compassion in
were kept confidential, and no personally‑identifiable six subscales: Self‑kindness, self‑judgment, common
information was recorded or used in data collection, humanity, isolation, mindfulness, and over‑identification.
analysis, or reporting. Randomization was not employed Self‑compassion is theoretically defined as “being open
in the study. It was deemed inappropriate to compel to and moved by one’s own suffering, experiencing
students who were not amenable to yoga to participate feelings of caring and kindness toward oneself, taking
in the intervention, as this would increase the potential an understanding, nonjudgmental attitude toward
for attrition. Students self‑selected into the intervention one’s inadequacies and failures, and recognizing that
by attending a yoga class held each Monday afternoon one’s own experience is part of the common human
during the 12‑week study period. experience”.[16] Respondents used a Likert‑type scale,
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ranging from 1 (almost never) to 5 (almost always) to “intervention and other yoga” group (n = 23) participated
indicate their agreement with instrument items, with in the intervention but also engaged in yoga practice
higher scores indicating more of an attribute. Items in outside the intervention. The “other yoga only”
the self‑judgement, isolation, and over‑identification group (n = 9) participated only in yoga practice outside
subscales were reverse scored, and there is no overall the intervention, with no participation in the intervention.
score calculated for the SCS; rather, individual subscale The “no yoga” group (n = 26) neither participated in the
mean scores are reported, in accordance with Neff’s[17] intervention nor practiced yoga outside the intervention.
recommendations. This instrument has shown strong Group demographics are presented in Table 1.
reliability (Cronbach’s α 0.75–0.92) with use in a number
of populations, including health‑care professionals.[18] Participants in all groups had similar characteristics and
were roughly equivalent: predominantly female, aged
The WHOQOL‑BREF is a 26‑item survey that evaluates 19–21, and Caucasian. There were 75 participants in the
quality of life (QOL) in four subscales: Physical health, first yoga intervention session, but attendance declined
psychological, social relationships, and environment. in subsequent sessions to 38 participants, constituting a
Overall QOL and satisfaction with health are also 50% attrition rate.
evaluated in the WHOQOL‑BREF via single items.
The WHO,[19] para 2 defines QOL as “an individual’s Perceived Stress
perception of their position in life in the context of Perceived stress at baseline was moderately high for
the culture and value systems in which they live and all groups with mean total scores ranging from 38.80
in relation to their goals, expectations, standards, and to 42.33.
concerns”. A Likert‑type scale ranging from 1 (very
poor) to 5 (very good) is used for all items, with higher There were no statistically significant differences in
scores indicating better QOL. This survey has been used perceived stress between groups at any time point.
in diverse populations and has good reliability with
Cronbach’s α of 0.68–0.82.[20,21] There were statistically significant within‑group
differences in the “intervention only” group: their mean
Investigator‑developed questions about the yoga perceived stress scores increased from 38.80 to 43.27
intervention were: (1) “How many times did you attend by the end of the study (P = 0.024). The “intervention
the yoga intervention?” (2) “How many times did you and other yoga” group had the lowest stress scores at
practice yoga at home or attend a different yoga class?” week 6 (41.87) and week 12 (41.48), but these were not
and free‑text intervention group responses to (3) “If you statistically significant. Cronbach’s alpha for the PSS in
did not attend the yoga intervention, please tell us why”. this study was 0.81. Mean scores for perceived stress are
presented in Table 2.
Data analysis
Participant characteristics were analyzed using Self‑compassion
descriptive statistics (frequencies) and instrument Self‑compassion was measured in six subscales:
responses were reported as mean scores. Mixed‑model self‑kindness, self‑judgment, common humanity,
analysis of variance was used to examine within‑ and isolation, mindfulness, and over‑identification.
between‑group differences over time, with acceptable
P = 0.05 (95% confidence interval). Intellectus Statistics™ In the self‑kindness subscale, the main effect between
software was used to analyze the data. groups was significant (F3, 69 = 3.86, P = 0.013). At
baseline and at week 12, those who participated in
Results the intervention and also practiced other yoga had
significantly higher self‑kindness scores than those in
Seventy‑three participants completed the surveys at all other groups. Indeed, the “intervention and other yoga”
three time points and were included in analysis, with 38 group had the highest mean self‑kindness scores at any
students participating in the intervention group and 35 time point.
in the control group. Based on responses to questions
regarding participation in the yoga intervention and For all self‑compassion subscales, there were no
in other yoga practice, and in order to account for statistically significant within‑group differences noted.
the possible influence of practicing yoga outside of However, the “intervention and other yoga” group had
the intervention, participants were divided into four the highest subscale scores at baseline and week 12,
groups for analysis: “intervention only,” “intervention indicating that they had the most self‑compassion overall
and other yoga,” “other yoga only,” and “no yoga.” for all groups. In the “positive” subscales (self‑kindness,
The “intervention only” group (n = 15) participated common humanity, and mindfulness), the “intervention
only in the intervention at all three time points. The and other yoga” group also reported consistently higher
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mean scores across all time periods, and the “other yoga
only” group had the lowest mean scores for the (negative) World Health Organization quality of life
“over‑identification” subscale at any time point. subscales
For the WHOQOL subscales, highest mean scores
Cronbach’s alpha coefficient for the SCS in this study was for physical health, psychological health, social
0.94, with subscale reliability ranging from 0.76 to 0.88. relationships, and environment were noted in either the
Self‑compassion means scores are presented in Table 3. “Intervention only” or “intervention and other yoga”
group at any time point.
Overall quality of life and satisfaction with health
There were no statistically significant differences between
Overall QOL mean scores were moderately high at
groups at any time point on physical health, psychological
baseline for all groups (4.12–4.52). However, scores
health, social relationships, or environment.
declined over time for all groups except for the “other
yoga only” group, which remained the same at week 12. Physical health scores either remained the same or
trended downward in all groups, with decreases in
Overall, QOL was highest in the “intervention and other
physical health being statistically significant only in
yoga” (4.26) group at all‑time points, but there were no the “intervention and other yoga” group from baseline
statistically significant differences between or within to week 6 (P = 0.006) and from baseline to week 12
groups over time for Overall QOL. Table 4 presents (P = 0.015).
“Overall QOL” mean scores.
Social relationship mean scores increased between
Satisfactions with health mean scores at baseline were baseline and weeks 6 and 12 for the “Other yoga only”
moderate (3.46–4.00). The “other yoga only” group group, and environment mean scores increased from
had the highest mean satisfaction with health scores at baseline to week 12 for the “intervention only” group,
all time points and the “intervention and other yoga” although these findings were not statistically significant.
group had the lowest mean scores by the end of the
study (3.17). There were no statistically significant There were no noteworthy or statistically significant
between or within‑group differences at any time point, findings for the psychological health subscale
as indicated in Table 5. over time, for any group. Cronbach’s alpha for the
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Table 3: Self‑compassion mean scores Reasons for not attending the yoga intervention
Group Mean (SD) Those who attended the first yoga intervention but did
Baseline Week 6 Week 12 not participate in subsequent sessions were asked to
Self‑kindness provide the reasons why they stopped participating.
Intervention only 2.67 (0.95) 2.92 (1.00) 2.67 (0.83) The most common reasons for not continuing to attend
Intervention and Other Yoga 3.44 (0.62)* 3.30 (0.73) 3.37 (0.80) the yoga intervention included being too busy, stress
Other Yoga only 2.51 (0.86)* 2.62 (0.60) 2.43 (0.98)* related to school, having to study, needing to go home,
No Yoga 2.88 (0.88) 2.88 (0.89) 2.81 (0.81)
work conflicts, needing to obtain clinical assignments,
Self‑judgment
preferring other types of exercise and yoga, and not
Intervention only 2.87 (0.90) 2.88 (1.06) 2.88 (0.77)
liking yoga or experiencing a lack of comfort or energy
Intervention and Other Yoga 3.23 (0.90) 3.15 (0.86) 3.10 (0.93)
with the intervention.
Other Yoga Only 2.53 (0.90) 2.71 (0.83) 2.73 (1.05)
No Yoga 2.83 (0.99) 2.66 (0.70) 2.82 (0.89)
Common humanity
Discussion
Intervention only 2.75 (0.86) 2.93 (0.84) 3.05 (0.55)
This study aimed to deliver an intervention that
Intervention and Other Yoga 3.58 (0.62) 3.35 (0.58) 3.27 (0.80)
would lower stress and provide coping skills for
Other Yoga Only 3.08 (0.99) 3.25 (0.77) 2.83 (0.94)
No Yoga 3.07 (0.80) 3.08 (0.71) 2.90 (0.83)
nursing students. However, results show that there
Isolation were statistically significant increases in perceived
Intervention only 2.92 (0.86) 2.98 (0.97) 3.13 (0.80) stress over time (P = 0.024), and physical health (QOL)
Intervention and Other Yoga 3.17 (0.87) 2.99 (0.79) 3.15 (1.02) scores decreased significantly from baseline to week
Other Yoga Only 3.14 (1.15) 3.25 (0.74) 2.97 (0.89) 6 (P = 0.006) and from baseline to week 12 (P = 0.015).
No Yoga 3.02 (1.06) 2.87 (0.99) 2.92 (1.07) These results indicate that nursing students experienced
Mindfulness stress, continued to perceive their lives as stressful
Intervention only 3.25 (0.97) 3.37 (0.89) 3.27 (0.83) regardless of yoga practice, and that stress increased
Intervention and Other Yoga 3.64 (0.60) 3.53 (0.63) 3.56 (0.62) while physical QOL and satisfaction with health
Other Yoga Only 3.03 (0.69) 3.08 (0.40) 2.92 (0.64) decreased over the course of the study. This is contrary
No Yoga 3.23 (0.77) 3.11 (0.75) 3.09 (0.82) to numerous other studies which have shown that
Over‑Identification yoga‑based and mindfulness interventions can decrease
Intervention Only 2.93 (1.00) 3.00 (0.83) 3.20 (0.79) stress in college‑age students and nursing/health
Intervention and Other Yoga 3.00 (0.93) 2.98 (0.84) 3.21 (0.81) profession students.[10,22‑25]
Other Yoga Only 2.67 (0.73) 2.69 (0.76) 2.81 (0.95)
No Yoga 2.83 (1.10) 2.82 (0.95) 2.88 (0.94) It is possible that scheduling the intervention at the end
*Indicates significant between‑group differences (P<0.03). Bold indicates the
highest mean score at each time point. SD=Standard deviation
of a class day was too overwhelming for students who
had been on campus all day. Many students expressed
Table 4: Overall quality of life that personal and academic obligations prevented them
Group Mean (SD)
from attending the yoga sessions, and ironically, while
Baseline Week 6 Week 12
the yoga intervention was designed to reduce stress,
Intervention only 4.47 (0.92) 4.20 (0.77) 4.20 (0.77) students cited increased stress related to academic
Intervention and other yoga 4.52 (0.51) 4.30 (0.47) 4.26 (0.69) expectations as a reason for not continuing to attend
Other yoga only 4.12 (0.64) 3.88 (0.83) 4.12 (0.99) the yoga sessions.
No yoga 4.24 (0.60) 4.16 (0.62) 4.08 (0.70)
SD=Standard deviation It is also possible that students attended the yoga sessions
with the expectation that the intervention would provide
Table 5: Satisfaction with health mean scores a more physically challenging experience, or those not
Group Mean (SD) familiar with yoga before the intervention may have
Baseline Week 6 Week 12 anticipated that the intervention would provide a “quick
Intervention only 3.60 (1.35) 3.53 (1.06) 3.67 (1.05) fix” for stress. The class was slow‑paced and primarily
Intervention and Other Yoga 3.70 (0.93) 3.70 (0.93) 3.17 (1.11) integrated breathing techniques and meditation, which
Other Yoga Only 4.00 (0.71) 3.78 (0.97) 3.89 (1.27) may have contributed to the intervention not meeting
No Yoga 3.46 (1.03) 3.50 (0.99) 3.42 (1.17) student expectations, as students identified discomfort
SD=Standard deviation or lack of energy following intervention participation.
The literature shows that students often engage in
WHOQOL‑BREF scale as a whole was 0.87, indicating physical activity or exercise to reduce or manage stress
good reliability. Cronbach’s alpha coefficients for and many students related having opted for their
subscales were 0.73 (physical), 0.74 (psychological), and regular exercise routine instead of participating in the
0.65 (social) [Table 6]. yoga intervention.[6,7] In light of the possibility that these
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Important findings from this study were that students Conflicts of interest
who practiced the most yoga (those who participated in There are no conflicts of interest.
the intervention and practiced “other yoga”) reported
less stress, better QOL, and greater self‑compassion References
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