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Learn more: PMC Disclaimer | PMC Copyright Notice Nurs Educ Perspect . 2025 Jun 5;47(3):174–176. doi: 10.1097/01.NEP.0000000000001422 Search in PMC Search in PubMed View in NLM Catalog Add to search Impact of a Brief Biofeedback Intervention on Nursing Students’ Worry and Resilience Rachel Fadden Rachel Fadden 1 The authors are faculty, Department of Nursing, Miami University, Hamilton, Ohio. 3 Rachel Fadden, DNP, MSW, RN, LSW, is assistant clinical lecturer. Find articles by Rachel Fadden 1, 3 , Ashlyn M Johnson Ashlyn M Johnson 1 The authors are faculty, Department of Nursing, Miami University, Hamilton, Ohio. 2 Ashlyn M. Johnson, DNP, APRN-CNP, FNP-BC, PMHNP-BC, CNE, is assistant professor. Find articles by Ashlyn M Johnson 1, 2, ✉ , Victoria D Jurevic Victoria D Jurevic 1 The authors are faculty, Department of Nursing, Miami University, Hamilton, Ohio. 4 Victoria D. Jurevic, DNP, RN, CNE, PCCN-K, is assistant professor. Find articles by Victoria D Jurevic 1, 4 Author information Article notes Copyright and License information 1 The authors are faculty, Department of Nursing, Miami University, Hamilton, Ohio. 2 Ashlyn M. Johnson, DNP, APRN-CNP, FNP-BC, PMHNP-BC, CNE, is assistant professor. 3 Rachel Fadden, DNP, MSW, RN, LSW, is assistant clinical lecturer. 4 Victoria D. Jurevic, DNP, RN, CNE, PCCN-K, is assistant professor. ✉ For more information, contact Dr. Johnson at [email protected] . ✉ Corresponding author. Issue date 2026 May-Jun. Copyright © 2025 The Authors. Published by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. PMC Copyright notice PMCID: PMC13086109 PMID: 40470905 Abstract The aim of this pilot study was to evaluate the impact of a brief biofeedback intervention on nursing students’ resilience and worry. The efficacy of this intervention was evaluated using a pretest-posttest design to compare students’ scores on the Brief Resilience Scale and Student Worry Questionnaire from pre- to post-intervention. There were significant improvements in students’ overall worry and general worry from prior to after the intervention. These results suggest that a brief biofeedback intervention may positively impact nursing students’ worry and resilience. Additional research using an experimental design and increased number of biofeedback sessions is encouraged. Keywords: Biofeedback, College Populations, Nursing Students, Resilience, Worry Nursing students exhibit notably higher levels of stress, anxiety, sleep disruptions, and stress-related health issues compared to the broader student population ( Bartlett et al., 2016 ). In 2020, the American Association of Colleges of Nursing (AACN) called for nursing academia to transition from crisis prevention to resilience training and the teaching of healthy self-care behaviors. Nursing students need support for resilience training; this need is so important that the AACN (2021 ) included a competency for demonstrating healthy self-care behaviors that promote wellness and resilience in the current publication of the Essentials. Resilience training can include a variety of methods, such as the development of emotional insight ( AACN, 2021 ), as well as deep breathing and relaxation techniques, including the use of heart rate variability biofeedback (HRVB; Goessl et al., 2017 ). BACKGROUND Heart rate variability (HRV), a measure of the amount of time between heart beats, can be indicative of mental health problems ( HeartMath Institute, 2023 ) such as depression and generalized anxiety, characterized by excessive worry that is difficult to control ( American Psychiatric Association [APA], 2013 ). HRVB is a scientifically validated method that integrates HRV with techniques designed to improve emotional regulation, cognitive performance, and overall well-being. The HeartMath® biofeedback system emphasizes the concept of coherence, a state in which the heart, mind, and emotions are aligned and function harmoniously. Biofeedback interventions have been widely applied across diverse populations, including students, health care professionals, and individuals with chronic conditions such as hypertension and anxiety ( Oakes, 2022 ). HRVB allows users to visualize the heart’s changing rate in real time ( HeartMath, 2023 ). Studies have demonstrated that HRVB can effectively reduce stress, anxiety, and depression, while also improving resilience ( Oakes, 2022 ). Maintaining parasympathetic activity dominance during restful periods may play a crucial role in achieving high HRV and could be essential for building resilience against stress and mental health disorders ( An et al., 2020 ). This research may be significant for nursing students, who face high levels of stress and anxiety that can impact their academic success and long-term professional development. The project builds on existing research by evaluating the impact of a brief HRVB intervention in reducing worry and enhancing resilience in nursing students. Worry is a predominant symptom of anxiety ( APA, 2013 ), and HRV is associated with resilience as it indicates the ability to recover from physical and psychological stressors ( Lalanza et al., 2023 ). Therefore, worry and resilience were selected as dependent variables due to their significant impact on student well-being, with HRVB expected to enhance resilience and alleviate worry. We asked the following research question: For students enrolled in bachelor of science in nursing (BSN) programs, how does participation in a brief HRVB intervention affect resilience and student worry scores? We hypothesized that HRVB using HeartMath technology would be associated with improved resilience and decreased worry in nursing students. METHODS AND DESIGN A small-scale pilot study was conducted to test the efficacy of a brief, three-session, biofeedback intervention using the HeartMath quick coherence technique to improve resilience and decrease worry in BSN students. HRV is a marker of resilience as it indicates one’s ability to recover from physical and psychological stressors ( Lalanza et al., 2023 ). During an HRVB session, a sensor is attached to the earlobe and is then connected to the HeartMath computer program, allowing the user to visualize the relationship between HRV and controlled breathing. The user is guided to breathe slowly, five to seven breaths per minute, during a 10-minute session. The quick coherence technique is intended to help shift into a coherent state by increasing parasympathetic activity. A quasi-experimental, pretest-posttest design was utilized to test efficacy. Impact of the intervention was assessed via the Brief Resilience Scale (BRS) and the Student Worry Questionnaire (SWQ). This research was approved by the university institutional review board. There were no anticipated risks related to participation in this study. Students provided informed consent and were free to withdraw from participation at any time. Sample/Setting Junior-level BSN students at a regional campus in the Midwestern United States were invited to participate in pilot testing of an HRVB intervention using the quick coherence technique. This research was not associated with any course, and students were not incentivized in any way. The intervention was aimed at improving resilience and decreasing worry during the spring semester of the 2022 to 2023 academic year. Forty-eight students were eligible to participate. Of these, 14 students agreed to participate and 11 completed the posttest; however, due to improper reporting of the self-selected anonymous code, only 10 students’ pre-post tests could be matched and analyzed. Participants’ ages ranged from 20 to 44 years. The sample included students who identified as female (80%), and the majority were employed, unmarried, and without children. A student demographic survey included questions on participant age, gender, employment, children, and marital status. Measurement Resilience was measured using the six-item BRS, which was developed as a self-report scale to measure the ability to bounce back and recover from stress. The BRS has been tested in multiple samples including students, cardiac patients, and patients with chronic pain. It was determined to be valid and reliable with good internal consistency (Cronbach’s alphas ranged from .80 to .91) and test-retest reliability (intraclass correlation = .69, one month in one sample; .62, three months in another sample) ( Smith et al., 2008 ). Participants were asked to rate each of the six items on a Likert-type scale, ranging from strongly disagree to strongly agree; three negatively worded items were reverse scored. The average BRS score is interpreted as 1.00 to 2.99, 3.00 to 4.30, and 4.31 to 5.00 representing low resilience, normal resilience, and high resilience, respectively ( Smith et al., 2008 ). Student worry was measured using the 12-item SWQ, which was developed as a self-report measure to assess the frequency and intensity of student worry across domains related to students’ lives. It has three subscales: general worry (Items 1–6), nonsocial worry (Items 7–9), and social worry (Items 10–12) ( Davey et al., 2022 ). Testing showed the six-item general worry subscale to have good construct validity and internal reliability, with Chronbach’s alpha = .86. However, Chronbach’s alphas were low at .54 and .53 for the nonsocial worry items and social worry items, respectively ( Davey et al., 2022 ). Participants were asked to rate each of the 12 items on a four-point scale ranging from 1 = never true to 4 = always true . Overall and average scores were calculated for each subscale. Procedure Participants met individually with the primary investigator once weekly for three weeks for HRVB sessions utilizing HeartMath technology. Students were asked to complete pretesting, which included a demographic survey, the BRS, and the SWQ at baseline. The HeartMath program instructed participants through the three phases of the quick coherence technique: heart focus, heart breathing, and heart feeling. These techniques, used with continued practice, are designed to improve baseline HRV. The week following the third and final session, participants were asked to complete the BRS and the SWQ to assess the impact of the HRVB intervention. RESULTS The project team performed the statistical analysis utilizing IBM Statistical Package for the Social Sciences (SPSS, Version 28) from the data of the 10 participants for whom pre-post data could be linked. Data were analyzed via paired-samples t -tests to compare pre and post resilience and student worry scores. Participants’ resilience increased from a mean score of 2.93 on the BRS at pretest to 3.18 at posttest; however, the increase in pretest scores compared to the posttest was not statistically significant (pretest, M = 2.93, SD = 0.97; posttest, M = 3.18, SD = 0.75), t (9) = −2.22, p <.05. Participants’ overall worry decreased significantly from pretest compared to posttest (pretest, M = 2.85, SD = 0.62; posttest, M = 2.53, SD = 0.58); t (9)= 2.61, p = .03. Additionally, general worry was significantly reduced (pretest, M = 3.0340, SD = 0.77973; posttest, M = 2.6990, SD = 0.67051); t (9)= 2.383, p = .041. However, there were no significant differences in social worry or nonsocial worry. DISCUSSION The pilot study showed statistically significant reductions in overall student worry and general worry in nursing students following the intervention; however, decreases in social worry and nonsocial worry were not statistically significant. The improvements in worry in this pilot study are consistent with previously published research that demonstrated substantial reductions in self-reported stress and anxiety associated with HRVB ( Goessl et al., 2017 ). Findings from the current study are also partially consistent with previous research on building resilience in university students. Some increase in resilience was noted among participants, with the mean score increasing from the low resilience category to normal resilience; however, this improvement was not statistically significant. Previous research demonstrated the efficacy of using HeartMath to improve resilience in 10 participants who showed low resilience scores at baseline ( Sha’ari & Amin, 2021 ). The lower dose of the intervention in our study may have impacted the results. LIMITATIONS Limitations of this project include the small sample size, the low dose of the intervention, and the timeframe, which may have impacted internal validity. The small sample would result in low power and may have negatively impacted the statistical significance of results. Furthermore, the sample consisting of regional students on a single campus may limit generalizability to students across other campuses. The low dose of the intervention could also be considered a limitation of this pilot project. HeartMath is recommended to be used over a six- to nine-week period for the best results ( HeartMath Institute, 2023 ); this study tested only three weeks of use. However, previous research ( Sarwari & Wahab, 2018 ) with 20 undergraduate college students explored its use in three 2-minute sessions using the Quick Coherence Technique and demonstrated some positive changes in the degree of heart coherence. The timeframe in the semester during which the pilot study was conducted may have impacted the results. Participants were nearing the end of the semester and faced two exams and a final exam in didactic courses, which may have been a significant stressor for students. However, this time was paired with the potential for the emotional relief of going into summer break. CONCLUSION Implementing techniques to effectively manage stress, worry, and anxiety; improve coherence; and build resilience can positively impact nursing careers, patient outcomes, and health care systems ( Fountouki & Theofanidis, 2022 ). HeartMath is a validated HRVB technology that can enhance HRV, reflecting healthy functional ability and adaptability to inherently stressful or worrisome situations ( HeartMath Institute, 2023 ). Further research is needed to evaluate the use of HRVB in nursing students and the impact on student worry and resilience. Research with an experimental design with a higher dose of intervention may demonstrate improved outcomes. The findings of this pilot study indicate that utilization of HRVB through the quick coherence technique with HeartMath technology has the potential to decrease worry and improve resilience in nursing students. Footnotes The authors have declared no conflict of interest. Contributor Information Rachel Fadden, Email: [email protected]. Ashlyn M. Johnson, Email: [email protected]. Victoria D. Jurevic, Email: [email protected]. REFERENCES American Association of Colleges of Nursing . (2021). The essentials: Core competencies for professional nursing education . https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf [ DOI ] [ PubMed ] American Psychiatric Association . (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author. An E. Nolty A. A. T. Amano S. S. Rizzo A. A. Buckwalter J. G., & Rensberger J. (2020). Heart rate variability as an index of resilience. Military Medicine , 185(3–4), 363-369. 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