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The MINDBODYSTRONG Intervention for New Nurse Residents: 6‐Month

Effects on Mental Health Outcomes, Healthy Lifestyle Behaviors, and Job
Satisfaction

Article in Worldviews on Evidence-Based Nursing · November 2019

DOI: 10.1111/wvn.12411

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 Special Issue

The MINDBODYSTRONG Intervention for

New Nurse Residents: 6-Month Effects on
Mental Health Outcomes, Healthy Lifestyle
Behaviors, and Job Satisfaction
Marlene Sampson, PhD, RN ● Bernadette Mazurek Melnyk, PhD, RN
● Jacqueline Hoying, PhD, RN

Key words ABSTRACT

newly licensed Background: In 2017, the National Academy of Medicine convened its Action Collaborative for
registered nurses, Clinician Well-being and Resilience in an effort to stem the epidemic levels of burnout, depres-
new nurses, mental sion, and suicide among healthcare clinicians. Nurses report higher rates of substance abuse,
health, healthy depression, and suicide than the national average. Newly licensed registered nurses (NLRNs)
lifestyle behaviors, report high levels of burnout and stress. Suboptimal health in nurses is linked to medical errors.
job satisfaction, Few studies address the mental health and lifestyle behaviors of NLRNs or provide evidence-
anxiety, depression, based solutions to improve these outcomes.
stress, evidence- Aims: This study evaluated the 6-month effects of the MINDBODYSTRONG for Healthcare
based interventions Professionals program on the mental health, healthy lifestyle behaviors, and job satisfaction of
NLRNs participating in a nurse residency program.
Methods: A two-group randomized controlled trial was conducted with 89 NLRNs at a large,
Midwestern academic medical center. The intervention group received eight 30– to 35-min
weekly sessions as part of the MINDBODYSTRONG program, a cognitive behavioral skill-build-
ing program incorporating strategies to improve mental and physical health. The control group
acted as the attention control group receiving eight weekly 30– to 35-min debriefing sessions
as part of the normal nurse residency program.
Results: Data were collected at baseline, immediately postintervention, 3 months postintervention,
and 6 months postintervention. The intervention group scored better on mental health outcomes,
healthy lifestyle behaviors, and job satisfaction at 6 months postintervention than the control group.
Significant improvements were found for depressive symptoms and job satisfaction; there were
moderate to large positive effects for the MINDBODYSTRONG program on all variables.
Linking Evidence to Action: The MINDBODYSTRONG program sustained its positive effects
across time and has excellent potential as an evidence-based intervention for improving the
mental health, healthy lifestyle behaviors, and job satisfaction in NLRNs.

BACKGROUND physical and mental health (Melnyk et al., 2018). Depression

Healthcare professionals across the nation report high lev- and poor health in nurses are linked to medical errors
els of burnout, depression, and suboptimal health affecting (Chesak et al., 2015; Melnyk et al., 2018), which under-
patient safety and healthcare quality (Dyrbye et al., 2017; scores the need to address poor health in nurses since med-
Jordan, Khubchandani, & Wiblishauser, 2016; Jordan, ical errors are now the third leading cause of death in the
Nowrouzi-Kia, Gohar, & Nowrouzi, 2015). Nurses have United States (Makary, 2016).
higher rates of substance abuse (Ivey, 2015), are twice as Newly licensed registered nurses (NLRNs) report high
likely to suffer from depression (Batalla et al., 2019; Letvak, levels of stress and stress-related illnesses (Arrowsmith,
Ruhm, & McCoy, 2012; Melnyk et al., 2018), and commit Lau-Walker, Norman, & Maben, 2016; Frogeli, Rudman,
suicide at higher rates (Alderson, Parent-Rocheleau, & Ljotsson, & Gustavsson, 2018; Lovgren, Gustavsson, Melin,
Mishara, 2015; Hall, Johnson, Watt, Tsipa, & O’Connor, & Rudman, 2014). As many as 66% of NLRNs report severe
2016; Melnyk et al., 2018; Rizzo, 2018) than the national levels of burnout in their first years of practice (Laschinger
average. In addition, over 50% of nurses report suboptimal & Fida, 2014). Since NLRNs make up more than 10% of

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© 2019 Sigma Theta Tau International
 Special Issue
the nursing workforce (Blevins, 2016), identifying evi- immediately following and at 3 months following comple-
dence-based strategies to improve their physical and mental tion of the MINDBODYSTRONG intervention (Sampson et
health well-being is imperative. al., 2019).
Recognizing the serious impact of burnout on clini-
cians, the National Academy of Medicine (NAM) con- Sample and Setting
vened the Action Collaborative on Clinician Well-being Participants were NLRNs hired between July 1, 2018, and
and Resilience in 2017. The aim of the collaborative is to September 30, 2018, at a large Midwestern academic medi-
develop evidence-based solutions to reduce burnout, de- cal center. One hundred and twelve NLRNs were invited to
pression, and suicide in healthcare clinicians (NAM, 2016). participate in the original study, of which 89 completed the
baseline and immediate postintervention assessments. The
follow-up data collection was completed with these nurses
PURPOSE at 6 months postintervention.
The purpose of this study was to evaluate the more long-
term effects of a cognitive behavioral skill-building program Ethical Considerations
entitled MINDBODYSTRONG for Healthcare Professionals The study was approved by the organization’s institutional
on perceived stress, anxiety, depressive symptoms, job review board (#2017B0255).
satisfaction, and healthy lifestyle behaviors in NLRNs par- NLRNs were new employees and may have felt obli-
ticipating in a nurse residency program that aligns with gated to participate in this study. In addition, the prin-
NAM’s call to action. A prior published study that evalu- cipal investigator (PI) was the director of the residency
ated the immediate postintervention and 3-month short- program, which could have resulted in additional pres-
term effects of the MINDBODYSTRONG program with 89 sure to participate in the study. However, because com-
NLRNs found positive effects on these outcomes (Sampson, pletion of the residency program and of regular surveys
Melnyk, & Hoying, 2019). was a standard requirement for all NLRNs in the organi-
zation, the participants were not treated any differently
than any new grad hired into the system. In addition, the
PI was blinded to the consent process, and all potential
THEORETICAL FRAMEWORK
participants were provided a letter emphasizing that par-
The theoretical framework for this study is cognitive be-
ticipation or nonparticipation in the study would not im-
havioral theory (CBT; Beck, 1979; Beck, 2005). The seminal
pact employment or successful completion of the nurse
work by Beck on CBT asserts that an individual’s cognitions
residency program.
play a pivotal role in emotional and behavioral responses to
stressful life events. These responses influence how indi-
The MINDBODYSTRONG Intervention Program
viduals control automatic negative thoughts that contribute
The MINDBODYSTRONG program is adapted from the
to anxiety and depression. CBT is effective in the treatment
cognitive behavioral skill-building intervention Creating
of disorders such as posttraumatic stress disorder, anxiety,
Opportunities for Personal Empowerment (COPE) program
addiction, and depression (Beck, 1979).
developed by Bernadette Melnyk. COPE has been shown
Based on this construct, it was asserted that delivery of
to decrease depressive symptoms, anxiety, and stress while
the MINDBODYSTRONG program would improve NLRNs’
improving healthy lifestyle behaviors in children, adoles-
cognitive beliefs about their ability to manage stress, re-
cents, and college-age youth in various studies (Buffington,
sulting in decreased anxiety and depressive symptoms that
Melnyk, Morales, Lords, & Zupan, 2016; Hart-Abney, Lusk,
would sustain over time due to learned cognitive behav-
Hovermale, & Melnyk, 2019; Hoying, Melnyk, & Arcoleo,
ioral skills. It also was hypothesized that provision of the
2016; Melnyk, Kelly, & Lusk, 2014; Melnyk et al., 2016).
MINDBODYSTRONG program would positively influence
The MINDBODYSTRONG program consists of eight weekly
and sustain the NLRNs’ healthy lifestyle choices and sense
sessions (Table 1) that focus on three areas: caring for the
of well-being, which, in turn, would increase their job
mind, caring for the body, and skills building. Participants
satisfaction.
learn CBT concepts, establish weekly goals, and complete
skill-building activities.

METHODS The Attention Control Intervention Program

Study Design As an alternative to the MINDBODYSTRONG program, the
This study was a 6-month follow-up study to a prospective, control group received eight 30– to 35-min weekly de-
blinded, cluster randomized controlled trial (RTC) pilot briefing sessions. These facilitator-led sessions consisted of
study that tested the effects of the MINDBODYSTRONG discussions surrounding challenging events experienced
program on stress, anxiety, depressive symptoms, job sat- during the past week. Participants received support and
isfaction, and healthy lifestyle behaviors among NLRNs guidance from the group facilitator and cohort peers.

Worldviews on Evidence-Based Nursing, 2020; 17:1, 16–23. 17

© 2019 Sigma Theta Tau International
The MINDBODYSTRONG Intervention for New Nurse Residents: 6-Month Effects

Table 1. MINDBODYSTRONG Curriculum Content

Content

Session Caring for the mind Caring for the body Skills building

1 Thinking, feeling, and behaving Nutrition: health and energy Positive self-talk
The ABCs of CBT mindfulness
2 Self-esteem and positive self-talk Physical activity Self-esteem and positive
Thankfulness self-talk
Managing change
3 Stress Healthy eating on the go Managing stress
Healthy coping
Abdominal breathing
4 Problem-solving Strength training Strategies to overcome
Setting goals barriers
Steps to problem-solving
5 Sleep Wellness wonder foods Sleep diary
6 Dealing with emotions in healthy Flexibility training Dealing with emotions
ways Flexibility
Using guided imagery
Coping strategies
Effective communication
7 Coping with stressful situations Self-determined nutrition and Coping with stressful situations
physical activity goals
8 Pulling it all together—review Establish long-term goals

Measures considered moderate depressive symptoms, scores between

Perceived stress. The Perceived Stress Scale (PSS) assesses 15 and 19 were considered moderately severe depressive
thoughts and feelings about stress during the past month symptoms, and scores ≥ 20 were considered severe depressive
(Cohen, Kamarck, & Mermelstein, 1983). Using a 5-point symptoms. This tool has been used in multiple studies and has
Likert scale that ranges from 0 (never) to 4 (very often), a strong Cronbach’s alpha of .92 at the cutoff of 3.
participants reported how they felt on each of the 10 items.
Scores on the items are totaled with a range between 0 and Job satisfaction. Job satisfaction was measured using the Job
40, with higher scores reflecting higher stress. The PSS has Satisfaction Scale (Price & Mueller, 1986). This seven-item scale
established validity with good reliability with multiple queries responses such as “I find real enjoyment in my job” and
populations (Cronbach’s alpha = .84). was measured on a 5-point Likert scale ranging from 1 (strongly
disagree) to 5 (strongly agree). Cronbach’s alpha for this scale
Anxiety. The Generalized Anxiety Disorder Scale (GAD-7; ranges between .72 and .95.
Lowe et al., 2008) was used to measure anxiety. The GAD-
7 measures feelings and actions associated with anxiety Healthy lifestyle behaviors. The Healthy Lifestyle Behaviors
within the prior 2-week period. Responses were based on a Scale was developed by Melnyk, Hrabe, and Szalacha (2013).
4-point Likert scale ranging from 0 (not at all) to 3 (nearly The 16-item scale asked for responses on statements such as “I
every day). Scores between 5 and 9 were considered mild make healthy food choices” and “I set goals I can accomplish.”
anxiety, scores between 10 and 14 were considered moderate It was scored on a 5-point Likert scale ranging from 1 (strongly
anxiety, and scores ≥ 15 were considered severe anxiety. The disagree) to 5 (strongly agree). Cronbach’s alpha is reported
GAD-7 is a widely used tool with Cronbach’s alpha of .86. at and above .73.

Depressive symptoms. The nine-item Personal Health Statistical Analysis

Questionnaire-9 (PHQ-9) was used to measure depressive Data were analyzed using IBM SPSS Statistics (Version
symptoms over the previous 2-week period (Kroenke, Spitzer, 23; IBM Corp., Armonk, NY, USA). Data were visually
& Williams, 2003). Scores were based on a 4-point Likert examined for accuracy of coding. Seventy-three (82%)
scale ranging from 0 (not at all) to 3 (nearly every day). participants completed the 6-month postintervention as-
Scores between 0 and 4 were considered minimal depressive sessment. The overall attrition rate for the 6-month time
symptoms, scores between 5 and 9 were considered mild point was 17% (19% for the control group and 17% for
depressive symptoms, scores between 10 and 14 were the intervention group). It is important to note that while

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© 2019 Sigma Theta Tau International
 Special Issue
17% of participants did not complete the 6-month survey, Table 2. Means and Standard Deviations
they remained employed in the organization, and attri-
tion was not due to organizational turnover. No missing M SD N
data were noted. Data from a descriptive analysis were Stress
obtained to compare means, standard deviation, skew-
Control group 13.44 5.658 34
ness, and kurtosis. Continuous data were examined for
outliers and normality using histograms and frequency Intervention group 13.18 6.303 39
tables. The assumptions of normality and equal variance Anxiety
were confirmed. Control group 5.59 4.272 34
Intervention group 4.49 4.599 39

RESULTS Depressive symptoms

Results from the initial study (Sampson et al., 2019) revealed Control group 5.65 5.026 34
no significance between group mean differences at base- Intervention group 3.31 4.047 39
line. However, results from a repeated measures ANOVA Job satisfaction
showed significant differences in stress (F[1, 87] = 5.459,
Control group 19.53 4.208 34
p = .022, ɳ2p = .059), anxiety (F[1, 86] = 17.469, p = <.001,
ɳ2p = .167), depressive symptoms (F[1, 87] = 15.63, Intervention group 21.23 1.842 39
p = <.001, ɳ2p = .152), and healthy lifestyle behaviors (F[1, Healthy lifestyle behaviors
87] = 2.54, p = .015, ɳ2p = .029) following the interven- Control group 56.91 6.117 34
tion. There was not a significant between-group differ-
Intervention group 59.28 4.751 39
ence for job satisfaction in the original study; however, a
moderate to large effect size was noted for all time points
(Sampson et al., 2019).
At the 6-month time point (Table 2; Figures ‒5), the with NLRNs who received MINDBODYSTRONG, report-
control group’s mean scores were higher than the in- ing better mental health outcomes on the study’s measures.
tervention group for all mental health variables. Mean The intervention group consistently fell within the normal
scores collected at baseline and 3 months postinterven- range on mental health outcomes, while the control group
tion from the initial study (Sampson et al., 2019) were remained in the mildly elevated range on the GAD-7 and
included for reference in each figure. Independent sam- PHQ-9 scales. While there is a paucity of data available re-
ple t-tests were conducted for the variables stress, anx- lated to anxiety and depressive symptoms in NLRNs, stress
iety, depressive symptoms, healthy lifestyle behaviors, has been explored extensively. Literature shows an increase
and job satisfaction at 6 months postintervention. There in stress between the beginning of the residency program
were significant differences in depressive symptoms (t[1, and the 6-month time period (Edwards, Hawker, Carrier,
71] = 2.20, p = .031, CI 0.221–4.46) and job satisfaction & Rees, 2015; Goode, Lynn, McElroy, Bednash, & Murray,
(t[1, 71] = 2.29, p = .025, CI −3.18–0.22). Cohen’s d was 2013). A similar pattern was noted for participants of this
calculated to determine effect size from 3 months postin- study; however, while stress levels increased slightly for the
tervention to 6 months postintervention. Large effect intervention group from 3 to 6 months postintervention,
sizes were found for stress (d = 4.99), anxiety (d = 2.37), anxiety and depressive symptoms remained in the normal
depressive symptoms (d = 2.55), and job satisfaction range. A future intervention trial might consider a 3-month
(d = 1.05). A small effect size (d = 0.2) was found for intervention booster to further bolster the positive effects
healthy lifestyle beliefs. of the MINDBODYSTRONG program on stress over time.
Job satisfaction scores were identical for both groups
at 3 months postintervention. At the 6-month postinter-
DISCUSSION vention time point, nurse residents had been employed
The MINDBODYSTRONG program provides a compre- in the organization for approximately 9 months. The lit-
hensive approach for improving the mental health, job erature shows a decline in job satisfaction for new nurses
satisfaction, and healthy lifestyle behaviors of NLRNs. The between months 6 and 12 in their first year (Cline, La
intervention group scored significantly better in all men- Frentz, Fellman, Summers, & Brassil, 2017; Edwards et al.,
tal health variables at 3 months postintervention (Sampson 2015; Goode et al., 2013). However, in this study, the inter-
et al., 2019). At 6 months postintervention, there was vention group scored significantly better than the control
a significant difference for depressive symptoms, with group, and a large effect size was noted. An increase in
MINDBODYSTRONG participants reporting less depres- job satisfaction for the intervention group supports that the
sive symptoms, which were in the normal range. However, MINDBODYSTRONG program had a positive effect on this
large effect sizes were noted for all mental health variables outcome.

Worldviews on Evidence-Based Nursing, 2020; 17:1, 16–23. 19

© 2019 Sigma Theta Tau International
The MINDBODYSTRONG Intervention for New Nurse Residents: 6-Month Effects

Perceived stress
25

20

15

10

0
Immediate Post- 3 months Post- 6 months Post-
Baseline
intervention intervention intervention
Control Group 20.05 13.05 15.07 13.44
Intervention Group 20.13 12.72 10.66 13.18
Control Group Intervention Group

Figure 1. Mean changes over time for perceived stress.

Anxiety
8
7
6
5
4
3
2
1
0
Immediate Post- 3 months Post- 6 months Post-
Baseline
intervention intervention intervention
Control Group 5.98 6.86 7.1 5.59
Intervention Group 4.96 1.85 2.36 4.49

Control Group Intervention Group

Figure 2. Mean changes over time for anxiety (0–4.99 = normal range for anxiety; 5–9 = mild anxiety).

The intervention group scored better than the control due to the small sample size and a nonrandom sample.
group for healthy lifestyle behaviors at both the 3-month and A larger, fully powered, multisite study is needed to
6-month postintervention follow-ups. A small effect size was determine the level of impact the MINDBODYSTRONG
noted for this variable, suggesting that the addition of a booster program has on NLRNs across different settings.
session between these time points might be beneficial. Contamination might also have occurred, as residency
cohorts are nested within the organization, and partici-
pants in the intervention group interacted with those in
STRENGTHS AND LIMITATIONS the control group during working hours. Since the study
A strength of this study is that it measured both the short- was conducted over several months, maturation of study
and more long-term effects of the interventions as part of participants was also a limitation.
an RCT; that is, data that were collected 6 months after Another limitation of this study was attrition of some
participants completed the MINDBODYSTRONG and an at- of the participants, although a 17% attrition rate through
tention control program were used. RCTs are the strong- 6 months postintervention is within the acceptable range
est designs for controlling internal validity, which is the of ≤20% (Dumville, Torgerson, & Hewitt, 2006).
ability to say that it was the intervention that produced
the outcomes, not other extraneous variables (Melnyk &
Morrison-Beedy, 2019). IMPLICATIONS FOR FUTURE RESEARCH
The limitations of this study include the ability to gen- The MINDBODYSTRONG program aligns with NAM’s
eralize the findings to the larger population of NLRNs call for evidence-based solutions to improve clinician

20 Worldviews on Evidence-Based Nursing, 2020; 17:1 16–23.

© 2019 Sigma Theta Tau International
 Special Issue
Depressive symptoms
7

0
Immediate Post- 3 months Post- 6 months Post-
Baseline
intervenon intervenon intervenon
Control Group 4.98 5.45 6.07 5.65
Intervenon Group 4.15 1.64 1.8 3.31

Control Group Intervenon Group

Figure 3. Mean changes over time for depressive symptoms (0–4.99 = normal range for depressive symptoms;
5–9 = mild depressive symptoms).

Healthy lifestyle behaviors

Control Group Intervention Group

63
62
61
60
59
58
57
56
55
54
Immediate Post- 3 months Post- 6 months Post-
Baseline
intervention intervention intervention
Control Group 59.35 58.27 57.34 56.91
Intervention Group 59.38 62.2 61.4 59.28

Figure 4. Mean changes over time for healthy lifestyle behaviors.

Job satisfaction
Control Group Intervention Group

23
22.5
22
21.5
21
20.5
20
19.5
19
18.5
18
Immediate Post- 3 months Post- 6 months Post-
Baseline
intervention intervention intervention
Control Group 19.95 21.86 21.62 19.53
Intervention Group 20.13 22.47 21.91 21.23

Figure 5. Mean changes over time for job satisfaction.

Worldviews on Evidence-Based Nursing, 2020; 17:1, 16–23. 21

© 2019 Sigma Theta Tau International
The MINDBODYSTRONG Intervention for New Nurse Residents: 6-Month Effects

well-being. Results from this study show promise in im- Nursing, Columbus, OH, USA; The Ohio State University,
proving the mental health, job satisfaction, and healthy Columbus, OH, USA; Jacqueline Hoying, Assistant Professor
lifestyle behaviors of new nurses with the manualized, of Clinical Practice, Director, MINDSTRONG Program, The
cognitive behavioral skill-building MINDBODYSTRONG Ohio State University College of Nursing, Columbus, OH,
program. A fully powered RCT is needed to understand the USA
full impact of this program on the mental health, healthy Address correspondence to Marlene Sampson, The Ohio
behaviors, and job satisfaction for an even longer period of State University Wexner Medical Center, 600 Ackerman
time. Future studies should include additional variables such Road, Suite E2017, Columbus, OH 45321, USA; marlene.
as burnout, resilience, absenteeism, and turnover to bet- [email protected]
ter understand how provision of the MINDBODYSTRONG
program influences these outcomes. In addition, booster Accepted 16 October 2019
content should be considered at 3 and 6 months postinter- © 2019 Sigma Theta Tau International
vention. Finally, longitudinal data should be collected at 12,
18, and 24 months postintervention to determine the long-
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