The COVID-19 pandemic exacerbated already prominent feelings of burnout and stress among nursing students in the United States. Nursing students experienced high levels of perceived stress elicited by numerous interpersonal, intrapersonal, and community factors [1]. Nursing students’ stress contributes to less academic engagement [2], and over 55% of nursing students report increased stress and worsened health after entering nursing school [3]. During the COVID-19 pandemic, economic strain, academic workload, and isolation from peers accelerated nursing students’ stress and well-being [4]. Students cite limited clinical experiential learning and adjustment to web-based learning as prominent barriers influencing their intention to join the nursing workforce [4]. McKee-Lopez et al [5] found that adverse childhood experiences also contribute to mental health status among the nursing population, with nursing students experiencing a higher prevalence of adverse childhood events. Adverse childhood events have been associated with higher rates of burnout and depression among undergraduate nursing students [5]. Urban et al [6] found that nursing undergraduate students reported significantly higher stress levels than their nonnursing major peers. Moreover, COVID-19 can be seen as an adverse experience faced by all new incoming nursing students. A total of 60% of nurses younger than 35 reported an emotional, traumatic, or stressful event related to COVID-19 [7]. Nursing students are a critical component of the future nursing workforce. Currently, 55% of the nursing workforce experiences symptoms of burnout [8], contributing to an alarming acceleration of nurse turnover and shortages nationally. Stress does, in fact, predict nurses’ job satisfaction and turnover intention [9]. In total, 25% of nurses left the profession in 2022 compared with 20% in 2020, and the average hospital turned over 95% of its nursing staff in the past 5 years [10].

Personal resilience, or the capacity to adjust positively to adversity to limit negative impacts, has been correlated with reduced burnout [6]. As the United States faces a critical shortage of nurses confounded by high rates of burnout and stress, nursing schools must develop interventions and strategies to reduce burnout and promote resilience among nursing students. Stress reduction interventions could promote improved stress management and mitigate burnout among students [2,3,11], which can support nursing student retention, on-time graduation, and resilience when students transition to the nursing workforce.

The health care profession’s burnout crisis prompted the National Academy of Sciences to convene a committee and create a report that promotes the collective urgency to address burnout and resilience among health professionals, including nurses and students. Their vision includes a thriving health care workforce that provides high-quality care to patients in an environment that fosters their well-being [8]. The research study and project presented in this paper align with five of the seven priorities outlined by the academy: (1) create and sustain positive work and learning environments and culture; (2) invest in measurement, assessment strategies, and research; (3) support mental health and reduce stigma; (6) institutionalize well-being as a long-term value; and (7) recruit and retain a diverse and inclusive health workforce. There is a lack of substantive research that applies longitudinal analysis, large sample sizes, or randomization to support effective interventions that reduce burnout and promote resilience among nursing students [12], which this study aims to address.

WellNurse (Wellness in Nursing Education to Promote Resilience and Reduce Burnout) is a longitudinal research study implemented at a public nursing school in the northeastern United States to reduce burnout and increase resilience among nursing students. This multidimensional study examines the effect of various interventions on burnout, resilience, perceived stress, and academic performance. This paper aims to describe the comprehensive and holistic interventions and measures provided to nursing students at a public university in the northeast offering BSN and MSN education.

The project’s overarching purpose is to reduce burnout and increase resilience among nursing students at a public university in the northeast. Several objectives were implemented to achieve this aim, including (1) providing access to evidence-based mindfulness-based stress reduction (MBSR) to nursing students, faculty, and staff within a 3-year time frame; (2) providing evidence-based physical fitness, nutritional, and peer mentor training and support to all nursing students, faculty, and staff; (3) establishing a resilience and stress management curriculum to sustain program activities after the grant period with a credit-bearing course; and (4) creating an environment and culture that embraces resilience, wellness, diversity, equity, and inclusion. The study design protocol is registered at Open Science Framework [13].

Matriculated graduate and undergraduate nursing students, faculty, and staff older than 18 years who complete a web-based consent are eligible to participate in the study. The initial phase of the study occurred from March to May 2022, and recruitment is ongoing as new students and faculty will enter the program through December 2024.

The recruitment strategy involves the WellNurse research team visiting various in-person and remote nursing classes and hosting meetings with administrative staff and faculty. The team also posts recruitment messages on the school’s social media pages. Participants are offered a free Fitbit and enrollment in various interventions described below and can choose whether or not they consent to the evaluation aspect of the project. Some academic courses provide course credit, extra credit, or clinical hours to students who agree to participate. Faculty and staff are provided work time to participate in the interventions.

Holistic and comprehensive interventions are under investigation that align with 4 of the National Academy of Health’s priorities areas: Priority 1: create and sustain positive work and learning environments and culture, priority 3: support mental health and reduce stigma, priority 6: institutionalize well-being as a long-term value, and priority 7: recruit retain a diverse and inclusive health workforce [8].

Faculty integrate selected WellNurse interventions into their classes by offering extra credit or providing assignments attached to interventions. Additionally, faculty use class time to implement short periods of mindfulness either through guided meditations, outdoor walks, or open discussion about how students might embrace mindfulness and self-care during a rigorous schedule.

A graduate student was hired to promote WellNurse activities and interact with students on social media. These posts highlight brief research findings about resilience, stress, and well-being among nurses and students. They also guide students through time management, test-taking strategies, community-building activities, and more.

MBSR is an 8-week experiential program including 2.5-hour weekly class sessions and a 1-day silent retreat. MBSR engages participants in simple evidence-based mindfulness practices, including meditation, mindful walking and movement, cognitive reframing, and communication strategies. Pioneered in 1979 by Dr Jon Kabat-Zinn at the University of Massachusetts Medical Center, MBSR includes didactic and experiential training that teaches participants to cultivate self-awareness by redirecting attention away from past or future concerns and focusing instead on the present moment. With regular practice, participants learn to change habitual stress reactivity patterns and instead more flexibly respond to stress with adaptive coping. As a result, participants learn to avoid internalizing stress in reactive patterns of negative emotion [35] and, thus, reduce distress and prevent negative health and mental health outcomes.

WellNurse partnered with the University of California San Diego School of Medicine Center on Mindfulness and Brown University Mindfulness Center to provide remote, 8-week MBSR courses via Zoom and intensive week-long, in-person MBSR courses. MBSR was offered as an elective course to count toward the students’ elective requirements for Nursing. Additionally, faculty and staff were provided work time to participate in the program. Selected WellNurse project personnel including faculty, staff, and graduate students completed a multiyear teacher training certification process through the University of California San Diego and Brown University Mindfulness Center to develop a group of certified MBSR teachers to support long-term project sustainability.

This monthly workshop is innovative in combining gamified learning, cooking self-efficacy, mindful eating, and nutrition education for prelicensed nursing students. The course outline consists of (1) mindful eating concepts, (2) nutrition education, (3) participants designing their own healthful and accessible recipe, (4) participants mindfully eating and voting on their favorite meal, and (5) discussion and application to clinical practice. Participants are also encouraged to do 2 “homework” assignments per week, each emphasizing healthy eating or mindfulness behaviors. Participants also receive ingredients for recreating their healthful recipe at home and a “dorm-friendly” recipe book developed by a registered dietitian nutritionist. All students, staff, and faculty are encouraged to join, but students in designated courses receive credit for attendance.

Participants are eligible to receive a free Fitbit Versa 2. Fitness trainers provide weekly 5K training in the fall and spring semesters to prepare participants for a 5K walk or run. Additionally, the campus recreation center offers nursing-specific fitness courses such as yoga and full-body workouts to promote a fitness community. Faculty integrated fitness step challenges using the FitBit devices as part of class assignments.

The University of Maine institutional review board reviewed and approved the WellNurse research project procedures (02-05-2-2022).

The project was funded on January 1, 2022. Data collection started in March 2022. A total of 267 participants have been recruited. Results will be published after each semester starting in December 2023.

The primary study variables will be analyzed 4 times per year to track population outcomes and changes. Regression analysis will be conducted to examine the relationship of students’ on-time progression, stress, resilience, and burnout with physical and emotional health variables and on-time progression. Subanalysis will be conducted for unique groups such as first and fourth year students, faculty and staff, and graduate students, as well as students from historically underrepresented populations such as first-generation college students and racial and ethnic minorities. Additionally, program retention, on-time graduation, and faculty and staff retention will be tracked over time. The cost of implementing MBSR, massage therapy, MasterChef, and fitness events will be tracked to determine cost per student. Additionally, feasibility will be measured using qualitative focus group interviews with students who complete specific interventions along with attrition in rates for completing specific interventions such as MBSR and MasterChef.

Quantitative evaluation of MBSR outcomes will be conducted by comparing MBSR participants with matched control participants at selected intervals with regard to key study variables (eg, stress, burnout, and mindfulness skills). Participants enrolled in MBSR are assessed immediately before their first MBSR session and immediately after completing the final MBSR session. Matched controls are identified for each MBSR participant by randomly selecting nonenrolled individuals from the WellNurse participant pool on the basis of identical gender identity, birth year, and role (faculty, staff, and student). Controls are assessed at the same intervals as MBSR participants.

Statistical analysis will test whether MBSR participants differ significantly from controls with regard to postintervention levels of each outcome variable, controlling for preintervention levels. ANOVA models will be used to conduct initial comparisons. With time, larger samples, and thus more statistical power and more complex models (eg, multilevel modeling), can be tested to evaluate the potential impact of instructor, delivery modality (in-person vs remote), duration (1 week vs 8 weeks), and dose (number of sessions attended), as well as individual participant characteristics (eg, gender identity and role). Ongoing assessments for all WellNurse participants will allow for longer term follow-up of MBSR and control participants with regard to distal outcomes of interest (eg, academic retention). We expect significant differences between MBSR and control participants; immediate postintervention effects may be strongest, with somewhat weaker longitudinal effects observed over time. Analyses will also be able to test whether those participants who engage in ongoing mindfulness practice after formal MBSR training may experience improved outcomes as compared with those individuals who discontinue regular practice.

MasterChef will be evaluated initially for feasibility through a qualitative focus group design along with an expert content analysis. After modifications to the program based on feasibility analysis, the intervention will be evaluated using a matched-based cohort design with the non-MasterChef control group selected through match-based design according to gender, ethnicity, and year in college, with a focus on gender, ethnicity, and year in college. Descriptive and frequency statistics were used to analyze the sample’s baseline and demographic data. A 2-way repeated-measures analysis will be used to assess significant changes in baseline and postintervention outcomes within the experimental group, and as a comparison to the control. Participants will complete the aforementioned nutrition measures before the week-long Fall 2023 program delivery, directly after the program, and again at the end of the semester. A control will be recruited through a matched-based design. A 2-way repeated-measures ANOVA will be used to identify significant changes between baseline data, postintervention data, and follow-up data between the intervention and control group. The program will also be implemented in the format of monthly workshops. A multivariate ANOVA will be used to compare health outcomes between curriculum formats. Multiple linear regressions will be used to identify predictors of diet quality using the combined fall and spring samples. Significance levels will be set at P<.05.

Data logs generated from Fitbit devices will be collected from the Fitabase platform [36], a partner to Fitbit, and preprocessing including merging the data of all participants in the study and purging the data set from empty cells or invalid data was made on the raw data. The privacy-respected data set, besides participants ID and event date, involves information on 3 major categories, sleep, activity, and wearing time, with each category covering more information in their respective parameters for a duration of fall and spring academic semesters. The sleep category provides information ranging from sleep minutes in rapid eye movement, deep, light, and total asleep minutes to sleep efficiency. The activity category is reporting time and distances traveled in very active, moderately active, lightly active, and sedentary modes, alongside calories, basal metabolic rate, and approximated heart rate levels. Analysis of the data set is done using the Python language [37] and the Scikit-learn [38], Pandas [39], Numpy [40], Matplotlib [41], and Seaborn [42] packages by applying the multiple linear regression method and also generating a heatmap of the parameters.

MasterChef will be evaluated initially for feasibility through a qualitative focus group design along with an expert content analysis. After modifications to the program based on feasibility analysis, the intervention will be evaluated using a matched-based cohort design with the non-MasterChef control group selected based on gender, ethnicity, and year in college matched-based design, with a focus on gender, ethnicity, and year in college. Descriptive and frequency statistics were used to analyze the sample’s baseline and demographic data. A 2-way repeated-measures analysis will be used to assess significant changes in baseline and postintervention outcomes within the experimental group and as a comparison with the control. Participants will complete the aforementioned nutrition measures before the week-long Fall 2023 program delivery, directly after the program, and again at the end of the semester. A control will be recruited through a matched-based design. A 2-way repeated-measures ANOVA will be used to identify significant changes between baseline data, postintervention data, and follow-up data between the intervention and control group. The program will also be implemented in the format of monthly workshops. A multivariate ANOVA will be used to compare health outcomes between curriculum formats. Multiple linear regressions will be used to identify predictors of diet quality using the combined fall and spring samples. Significance levels will be set at P<.05.

Stress and burnout among nurses and students is not a new phenomenon. However, the COVID-19 pandemic has exacerbated the challenge and demonstrated the urgency in mitigating stress to improve well-being and resilience and reduce burnout. As the United States faces a looming nursing shortage and burnout crisis, more research that includes large sample sizes and longitudinal studies is needed to determine and implement resilience-building and stress reduction interventions within nursing programs [12]. Interventions that demonstrate effectiveness at improving student retention, reducing the risk of burnout, and improving resilience and well-being will be infused into a course, which will be embedded as part of the standard nursing curriculum.

WellNurse aims to examine multiple resilience-building and stress-reducing strategies while creating a culture that promotes student, faculty, and staff well-being in concert with academic and clinical preparedness and job satisfaction. Dissemination of findings will be released as they are available with an anticipated release date of initial findings in 2024.

Data sharing is not applicable to this article as no data sets were generated or analyzed during this study.