The Role of Rhythmic Breathing in Stress Reduction for Clinical Nurses

Submitted by Rajitha Bommakanti, Monique Bouvier, Melinda Higgins, Mary Gullatte

Tags: burnout nurse workload stress Stress among Nurses wellbeing yoga

The Role of Rhythmic Breathing in Stress Reduction for Clinical Nurses

Background

Clinical nurses play a vital role in health care delivery. However, numerous studies indicate that this job is extremely stressful (Ibrahim, Komariah, & Herliani, 2022; Balaji & Varne, 2017; Solomon, 2021). The nursing shortage, especially since the pandemic has added an additional level of stress on nurses as they are working short staffed, sometimes longer hours, and less days off between shifts (Lee & Jang, 2020; Falatah, 2021; Duva, Jordan, & Grabbe, 2022).

Nurses serve as patients’ advocates and continually make decisions related to patients’ safety and care in the clinical setting. The ongoing inadequate staffing and overloaded patient care assignments are added burden for nurses (Simpson, Lyndon, & Ruhl, 2016). This unresolved stress can build up overtime, and the symptoms escalate and intensify compromising clarity, focus, and leading to burnout. In a study conducted by Denizsever, Ates, & Seren (2021), workplace stress has a direct effect on nurses’ decision making. If left unchecked, this may result in increased safety concerns for patients.

Pranayama is a component of yoga, the word derives from Yuj in the Sanskrit language, meaning to unite (Tiwar & Negi, 2019). If a person is united within, it means the practitioner can experience the synergy of the mind, body, and soul. Yoga is a holistic approach to life, where a whole person is considered, rather than focusing on one aspect of physical body (Sophia & Selvinsamuel, 2021). It’s a synergistic approach of emotional and physical health. Practice of yoga is about prevention and optimizing health and well-being. The American Nurses Association (ANA) defines holistic care as the integration of body, mind, emotion, spirit, sexual, cultural, social, energetic, and environmental (Harrington, 2015). Practice of Astanga yoga aligns with ANA definition of holistic care.

The father of yoga, Pathanjali revealed yoga sutras the 8 limbs of yoga phrases (Char, 2021). Astanga yoga is the integration of eight limbs of yoga, which are comprised of ethical principles of living a meaningful and purposeful life; that promotes mental clarity, inner peace, has the calming effect on mind and controls the will power (Iyengar, Menuhin, 1994). Pranayama or breathing exercises is the second step of yoga and is one of the yoga sutras, which focus on conscious prolongation of inhalation, breath retention, and exhalation. Pranayama is an important step in yoga which is an ancient Indian science lifestyle (Iyengar, Menuhin, 1994). Prana means life force energy and Yama means control (Iyengar, Menuhin, 1994). The researchers believe that this practice may be useful to clinical nurses to relieve the stress that occurs during delivery of patient care. The well-being of nurses providing patient care is integral to the care that is delivered to patients. Literature review by Topp, Ostergaar, Sondergaar, & Beck (2015) has demonstrated that WHO-5 scale can be used as an outcome measure that has high validity as a screening tool.

Ibrahim, Komariah, & Herliani, (2022), conducted a study to evaluate the effects of mindfulness, breathing, and meditation on the psychological well-being of nurses working with COVID-19 patients. They used the Warwick-Edinburgh Mental Well-being scale (WEMWBS) Indonesian version; the results indicated that there was a significant difference between pre and post intervention scores of the interventional (25 nurses) and the control groups (25 nurses). The researchers concluded that a combination of mindfulness, breath work, and meditation facilitated calmness, which lowered the stress levels of the nurses.

Balaji & Varne (2017), investigated the effects of yogasana, meditation, and pranayama for 3 months and measured cortisol levels and stress among nursing staff. The study results revealed that there were substantial improvements on International Stress Management Association Questionnaire test scores and plasma cortisol levels after the intervention. These investigators concluded that meditation, yogasana, and pranayama can significantly reduce stress among nurses. Another study from 2021 evaluated the effects of anuloma and viloma pranayama on stress among nurses. The results suggested that after the intervention of the two pranayamas the nurses’ stress levels were reduced based on the ENSS scoring (Solomon, 2021).

In a study conducted by Sharma (2020), the effects of pranayama on stress management among student nurses from two different hospitals were evaluated. The researchers divided the subjects into 3 groups. Group 1 subjects practiced fast pranayama, group 2 practiced slow pranayama, and group 3 was the controlled subjects. This study has explored how fast and slow pranayama practice effects the mitigation of stress on student nurses. The study results demonstrated that both types of pranayama practice are equally effective in stress reduction. When compared fast and slow pranayama practice significant benefit was seen in slow pranayama practice. The findings from the perceived stress scale indicated that the participants reported moderate stress for the pre intervention scores, and mild stress for the post intervention scores. The results suggested that pranayama is effective tool for stress reduction/management among student staff nurses.

Literature reports clinical nurses face stress in performing their daily delivery of patient care, which in turn disrupts their mental state and can have negative effects on their decision-making. Subsequently, this may lead to negative effects on patient care.

Theoretical Model

The theoretical underpinning of Polyvagal Theory (PVT) and the evidence from previous research guided the researchers to answer if pranayama/RB influences nurse’s stress level and well-being. PVT created and developed by Dr. Stephen Porges describes the physiological/psychological states of human behavior as well as the challenges related to wellness and mental health (Porges, 2017). The theory proposes that specific intentional behaviors such as breath, vocalizations, and posture that are the ancient yogic rituals can trigger a physiological state mediated by vagal pathways that foster health and optimize wellbeing (Porges, 2017). The theory emphasizes that to optimize wellbeing and reap positive benefits one must practice self-regulation the ability to manage emotional state and physiological responses to stressors (Porges, 2017). Porges (2017) theory proposes many methods of self-regulation based on activation of the vagus nerve toning. Some of the methods include slow diaphragmatic breathing, gentle touch, chanting, prayers, meditation, and dance (Porges, 2017).

Yogic practices have been explored for centuries by philosophers, religious leaders, and writers, and more recently by scientist, and there are many different understandings of what it means. Sullivan et al., (2018), has shared the frameworks for understanding the convergence of PVT and yoga therapy link physiological, psychological, and behavioral attribute for self-regulation and resilience. Self-regulation and resilience is the ability to be in homeostasis and be able to bounce back and adapt to stressful situations (Sullivan et al., 2018). PVT emphasis the importance of vagal toning to regulate nervous system for optimal social and psychological performance. In PVT one of the recommended vagal toning practices is breath work to influence the neural pathways (Porges, 2017). In yoga therapy pranayama or rhythmic breathing is one of the effective ways to stimulate vagal toning and elicit relaxation response (Tiwar & Negi, 2019).

Based on the evidence the researchers intended to study Pranayama /RB techniques that promote progressive relaxation, and its effects on stress and wellbeing. Breath regulation provides vital energy that is the prana, the life force energy. Study by Heck et. al. (2017). highlighted conscious breathing could promote top-down emotional regulation with limbic system (as shown in Figure 1).

The aim of this study was to explore the effects of daily practice using a combination of fast and slow pranayama/RB provided support on acute care clinical nurses helps lower overall stress and improves overall well-being.

Method & Design

A descriptive cross sectional pilot study was performed at an academic medical hospital in the southeast United States after receiving Emory University Institutional Review Board approval, to promote compliance with all regulatory and ethical obligations involved in human subjects’ research. All methods followed the ethical standards. An official letter was written to the hospital Nursing Officer.

Hospital based acute care clinical nurses were voluntarily recruited to participate in this study, and they were told that they had the right not to participate and can voluntarily drop off from the study at any time. The participant was consented verbally, and after assuring the confidentiality of responses, an appointment was scheduled to collect baseline data and train them in the use of three different RB exercises. The Ujjayi Pranayama or ocean breathing practice which makes an ocean sound with inhalation and exhalation, by constricting the epiglottis muscles. This type of slow breathing focuses on flushing toxins out of all lobes of the lung takes approximately 8 minutes to complete (Satyananda, 2006; Char, 2021). The Bastrika Pranyama or bellows breath is a fast practice in which the participants inhale with diaphragmatic breath in and then forcefully expel all the air from the lungs during exhalation. This type of pranayama improves oxygenation and vitality leading to calming of the mind and creating energy for the body. This practice takes approximately three minutes to complete (Satyananda, 2006; Char, 2021). The last practice, Surya Bhedana Pranayma or right nostril breathing, is focused breathing through only right nostril, while left nostril is closed. This slow breathing practice increases pranic energy and takes about three minutes to complete. Pranic energy has an effect on a person's strength, vitality, and energy. It enhances the nervous system, especially sympathetic nervous system, giving a boost of energy (Satyananda, 2006; Char, 2021).

Statistical Analysis

All data was collected and stored on a protected secure REDCAP server from October 3, 2023 – December 5, 2023, with follow-up data collected through January 18, 2024. The participants were asked to complete two surveys and a demographic questionnaire prior to teaching them the RB exercise techniques. Prior to analysis, all data was reviewed for completeness and all measurements were scored according to published instructions; a modified version of the Secondary Traumatic Stress Scale-5 {STSS} (Bride, 2013) and World Health Organization-5 Well-being index {WHO-5} (Bech, 2004) surveys. Paired t-tests were performed with a 5% level of significance (p<.05) to test for changes from baseline to 1mo and from baseline to 2mo. For significant tests (p<.05) for the changes from baseline, Cohen’s d effect sizes were also calculated. All analyses were conducted using SPSS v.27.

The responses for the two instruments were Likert-styled designed using five-point variations. After completion of the baseline surveys, education on the RB techniques was provided to the participants by a trained individual. After the participants demonstrated that they were competent in the art of RB practice techniques, they were instructed to practice the techniques daily for the next two months. The daily RB practice compliance included two RB practice sessions in the morning (Ujjayi breathing and Bastrika breathing) and one mid-day RB practice session (right nostril breathing).

After month one and month two of RB daily practices, the participants were electronically sent the two surveys to complete. At the end of the study, the participating nurses were offered an elective credit for their institutions’ advancement plan.

Results

Of the 39 nurses who started the survey, only 20 nurses completed the consent process and baseline questionnaires. The analyses were conducted with the 19 remaining nurses all from a single community hospital. Of the 19 nurses who consented and completed baseline, 10 also completed the 1mo follow-up questionnaires and a slightly different set of 10 nurses completed both baseline and the 2mo questionnaires, with only 8 nurses completing all 3 time points.

The majority of the 19 nurses were older than 35 years (57.8%) and had a BSN (84.2%). There was a slight majority of nurses with 10 years or less experience (57.9%) and most had only been on their unit 0-5 years (63.2%). All the nurses worked day shift.

For the STSS-5 scores, there was a slight decrease in the scores from baseline to 1mo and 2mo (Table 2) for the total scores as well as the avoidance and intrusion sub-scores, but these changes were minimal and not statistically significant from baseline. However, for the 10 nurses who completed both baseline and either the 1mo or the 2mo follow-up for the WHO-5, they showed significant increases in their well-being from baseline, with an average improvement of +/- 12.40 +/- 11.54 points at 1mo (p=.008) and 7.60 +/- 8.10 at 2mo (p=.016) (Table 2, Figure 2). These improvements represent a large effect size for improved well-being scores at both follow-up time points (Cohen’s d=1.075 at 1mo, d=0.938 at 2mo, where d=0.2 is considered “small”, d=0.5 is considered “moderate” and d=0.8 is considered “large”).

Table 1: Demographics (n=19)

		N (%)
Age	20-25	1 (5.3%)
	26-30	3 (15.8%)
	31-35	4 (21.1%)
	36-40	1 (5.3%)
	41-45	3 (15.8%)
	46-50	2 (10.5%)
	51-55	1 (5.3%)
	56-60	1 (5.3%)
	61-65	0 (0%)
	66-70	3 (15.8%)
Shift	Day Shift	19 (100%)
	Night Shift	0 (0%)
Occupation	RN	11 (57.9%)
	unknown	8 (42.1%)
Education	AND	1 (5.3%)
	Diploma	2 (10.5%)
	BSN	16 (84.2%)
Years’ Experience	0-5	5 (26.3%)
	5-10	6 (31.6%)
	10-15	2 (10.5%)
	>15	6 (31.6%)
Years Worked on Unit	0-5	12 (63.2%)
	5-10	4 (21.1%)
	10-15	1 (5.3%)
	>15	2 (10.5%)

Table 2: World Health Organization Well-being Index – 5 (WHO-5) and Secondary Traumatic Stress Scale DSM-V (STSS-5) Descriptive Statistics and Changes from Baseline to 2mo

Measure	Timepoint	n	Mean (SD)	Compare To Baseline	Change Score Mean (SD)	Paired t-test p-value	Effect Size Cohen’s d
STSS-5 Intrusion Subscore	Baseline	19	11.63 (3.96)
	1mo	10	11.40 (2.91)	1mo – baseline	-0.30 (3.71)	.804	-0.081
	2mo	10	11.50 (2.88)	2mo – baseline	-0.90 (2.23)	.235	-0.403
STSS-5 Avoidance Subscore	Baseline	19	4.42 (1.50)
	1mo	10	4.50 (4.65)	1mo – baseline	0.30 (2.06)	.656	0.146
	2mo	10	4.60 (4.43)	2mo – baseline	0.20 (1.87)	.743	0.107
STSS-5 Total Score	Baseline	19	18.16 (5.27)
	1mo	10	17.50 (4.79)	1mo – baseline	-0.50 (4.99)	.759	-0.100
	2mo	10	17.80 (4.05)	2mo – baseline	-0.90 (3.48)	.434	-0.259
WHO-5 Total Score (0-100)	Baseline	19	60.63 (17.55)
	1mo	10	69.60 (12.10)	1mo – baseline	12.40 (11.54)	.008	1.075
	2mo	10	66.40 (11.19)	2mo – baseline	7.60 (8.10)	.016	0.938

Figure 2: Mean WHO-5 scores by Timepoint

Conclusion

Nursing roles are high stress due to the constant evolving needs of providing the best patient care, often with limited resources. The high stress can lead to burnout and a decrease in the nurse's well-being. Recent funding announcements have focused on improving the well-being of our healthcare clinicians.

The results of the surveys indicated the training and daily reminders for rhythmic breathing improved in this small pilot sample, as evidenced by their World Health Organization- 5 Well-being index scores (WHO-5). The stress scale did not see any significant changes due to the small sample. While this was a small pilot study at one community hospital, the results showed that teaching nurses how to practice a simple breathing technique can improve their overall well-being.

This small study demonstrated the impact of educating nurses on these simple techniques that can be practiced daily. Healthcare organizations should make an effort to incorporate these types of simple, but effective, interventions into the onboarding and yearly education to staff. They should arm their clinicians with skills to help mitigate stress and improve their clinician’s well-being.

Future state of this project will be to spread the knowledge of rhythmic breathing to the entire hospital by integrating the teachings into the yearly required education. Different methods of practice, such as daily practice huddles, 10-minute breaks to practice rhythmic breathing techniques, and/or the creation of an app to download will be investigated. Overall, health systems need to invest some time and energy into their staff’s well-being and reduction of stress and these simple RB techniques have the potential to positively affect all the staff.

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Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors did not receive any financial support for the research.