Distraction-focused interventions on examination stress in nursing students: Effects on psychological stress and biomarker levels. A randomized controlled trial

Background: Nursing students all over the world experience high levels of stress with negative impacts on their health, emotional state and performance. Aim: This study aimed to investigate the effects of distraction-focused interventions on examination stress and anxiety in nursing students. Methods: A randomized controlled, parallel trial design was conducted from January to June 2016. After baseline measurement, 72 participants were randomized to one of the following groups (n = 18 each): (i) animal-assisted therapy; (ii) music therapy; (iii) mandala painting; (iv) control group. Outcomes of all groups in terms of stress-reduction were compared by measuring self-reported perceived stress (STAI-State and visual analogue stress scale) and salivary biomarker levels (Cortisol and Immunoglobulin A). Results: Fifty-seven complete data sets (n = 12-16 for each group) were analysed. All distraction-focused interventions showed stress and anxiety reduction in everyday school situations. By contrast, on days with examinations, stress reductions did not reach statistical significance in regard to self-reported psychological stress. At the same time, interventions resulted in significantly decreased levels of stress biomarkers (P <.001). Conclusions: Our preliminary findings suggest positive but situation-dependent effects of distraction-focused interventions in academic settings. Further research should investigate the complex relationship between physiological and psychological stress parameters.