Mindfulness at Universities : An Increasingly Present Reality

Learning to adapt and adjust to the constant changes and hurdles presented by university life poses a great challenge for students. University students are often critically exposed to a significant increase in academic workloads, enhanced by the great strain exerted on them by examinations, qualifications and grades. Not only can all of this have a negative impact on the students’ academic performance, but also on their mental health and well-being; furthermore, research shows how during critical stress periods university students tend to include risk-taking behaviours as part of their lifestyle. For these reasons, different mindfulness programmes are being developed in order to enhance students’ adaptability to the academic context and thus reduce the high prevalence of mental health problems. Some of these programmes are standardised protocols offered as extra-curricular activities; however, some universities are designing and implementing their own programmes, using available scientific knowledge and adapting it to the academic context. Mindfulness programmes may be a suitable resource for the promotion of a healthy learning environment, by boosting students’ academic achievement together with their emotional and social development. Nevertheless, most of the programmes implemented to date within the university context are still to be validated and integrated into everyday academic life. The protocol created at the University of Zaragoza is currently at this validation stage and aims to contribute to the advancement of scientific knowledge in the field. DOI: 10.29011/2575-7032/100049


The Current Situation Affecting Young University Students
During their years at university, young people enjoy greater freedom and autonomy in the lifestyles they lead.However, university education is a period filled with challenges, in which students face many changes and new responsibilities [1].Among these challenges are increased academic workloads, examinations, the importance of final grades, adaptation to new environments, changes in timetables and diet, and concerns about their economic prospects and employment outlook [1][2][3].
For these reasons, starting university life can involve changes that many young people consider to be both exciting and stressful.Academic stress reaches its highest levels when students enter university, more specifically during the first years of a course and in examination periods [4][5][6].It is quite reasonable to suppose that stress can affect academic performance by interfering in adaptive behaviours such as dedication to study and class attendance, causing difficulties in attention and concentration during examinations and affecting other types of cognitive processes [7,8].
Different studies also reveal that at times of greatest stress (e.g.examination periods), the lifestyles of students can be modified with the inclusion into their regular habits of risk-taking behaviours, including excessive tobacco and alcohol consumption Volume 2018; Issue 01 Educ Res Appl, an open access journal ISSN: 2575-7032 and tranquilliser use, among others [9].On the other hand, the need to remain alert and awake in order to devote time otherwise spent sleeping to intensive study may lead to the excessive consumption caffeine and the use of other stimulants [10].These activities entail risks to their health and may lead to the appearance of addictions and long-term health disorders [1].
As a result, the psychological well-being of university students has become of increasing concern throughout the world in recent years [11].Mental health problems are common in this population.In addition to stress, there is an alarming prevalence of anxiety and depression, affecting between 25% and 50% of university students, which is one of the main reasons for consultations at the psychological services offered by the university system in Spain [12][13][14].Feelings of loneliness, suicidal ideation, and difficulties with family and social relationships are also habitual [15].
Besides the psychological and social impact of these problems, academic performance suffers and rates of abandonment of university studies increase, representing a problem for both students and institutions [15].Moreover, these students are at risk from suffering from burnout at present or in their future [16] with the consequent negative impact on professional practice [17].The study of burnout has been made possible through the use of instruments than enable evaluation of the level of exhaustion owing to academic demands, showing that the responsibilities and pressure posed by university life also 'burn out' and can cause stress [18,19].
All of this demonstrates the need of take suitable preventive measures in order to improve the psychological well-being of students, given that only a small percentage of them are treated by university health services [11].Coping strategies have been shown to help students to better manage their anxiety and academic stress, and to develop skills and positive attitudes in order to optimally relate to the demands of their environment [20,21].Universities should therefore be encouraged to set up preventive programmes that deal with stress in students and reduce the resulting anxiety and depression [14].Finally, it may be useful to offer new stressreduction programmes, utilising specific techniques that can be practised during examination periods or a times of greatest vulnerability [10].

International Programmes
The introduction of mindfulness into the university setting is beginning to become a reality.Mindfulness is being brought into the academic world through the experience of teaching staff who seek to share their learning experiences, and the supporting scientific evidence has led to the permeation of mindfulness from the field of research to the field of education.Consequently, a trend is beginning to emerge of promoting well-being in university classrooms through mindfulness.However, it is clear that this situation poses an important question: how can mindfulness be brought into the context of education?While it is evident that the classic mindfulness programmes (Mindfulness Based Stress Reduction, MBSR; Mindfulness Based Cognitive Therapy, MBCT) must be adapted to suit younger students at lower levels of education, this is not the case with university students, because the application of programmes designed for an adult population is apparently feasible.If we add to this the fact that the effectiveness of those stress-reduction programmes and the increase in psychological well-being they bring have been scientifically contrasted on many occasions, and that they are programmed with a clearly established structure, it is clear to see how most of the universities that offer mindfulness programmes do so on an extra-curricular basis and in the form of the above-mentioned programmes.
Nevertheless, a number of different authors have chosen to adapt them to the academic context of a university, or to create alternative programmes by modifying the contents, duration and structure of sessions, among others (Table 1).Bansode, Newell and Martindale (2016) [22], at the University of Edinburgh, designed a method for introducing mindfulness and compassion into their educational community.They began to offer weekly mindfulness sessions in 2008, which raised increasing interest from students and teaching staff.They subsequently began to give a basic, eight-week course to train teaching staff, and later opened the course to all members of the educational community.They followed different approaches, such as the Edinburgh Award in Mindfulness and the creation of Mindfulness Ambassadors, students who promote the initiatives of the programme to fellow students.
The University of Edinburgh mindfulness training programme consists of eight two-hour weekly sessions together with a one-day retreat.The programme is based on the fundamental principles of Mindfulness and Compassion, and combines the practice of mindfulness and group discussion of the experience with the exploration of different topics, such as full awareness, the balance between personal and academic/work situation, and the application of practices in the fields of work and communication (Table 2).Other authors [23]chose a partly face-to-face approach as a way to adapt mindfulness programmes to the university context.They designed their course with a duration of three weeks, alternating face-to-face sessions (two two-hour sessions) and setting homework, consisting of practices, texts to offer reflection on the contents introduced in the sessions, and reminder emails on the importance of performing practices at home (Table 3)   3

Post-session 1 texts
Texts: reflect on actions consist with values; Reflect on important value and a goal for the day.

Post-session 1 emails
Reminders to work on session 1 goal and to practise reflecting on the values you admire in others (day 2 email) [comment in clean text stating day 1 is incorrect] or on values engaged in that day (day 4 email).

Post-session 1 mindfulness resources
Introduction and definition of mindfulness, mindful breathing exercises, instructions to practise mindful breathing.
Session 2: Dealing with barriers Review of session 1. Identifying internal barriers, problems with control strategies, defining and practising willingness, setting a willingness goal for the week, summary of session.
Post-session 2 texts Prompts to practise willingness.

Post-session 2 emails
Reminders to work on session 2 goal and to practise acceptance technique, ways of practising acceptance and commitment skills.

Post-session 2 mindfulness resources
Mindfulness of internal experience, labelling mindfulness exercise, resources for practising other exercises.Intensive and partly face-to-face programmes, which aim to adapt to the time restraints of students, contrast with extensive programmes that are included within a curriculum as a singlesemester or full-year course.This is the case of the programme implemented in Taiwan by Ching et al. (2015)[24] consisting of 18 weekly 50-minute sessions.The course content was structured along the following lines: (1) course orientation, basics of body scan, mindful eating; (2) advanced body scan, 3-minute breathing meditation, training attention and awareness through mindful breathing, basics of diary on mindfulness practice; (3) walking meditation (live in the moment), breathing techniques, the classical basis of the mindfulness meditation course; (4) [25]as an elective.It is explained as a programme promoting self-reflection, without falling into self-judgement, about own behaviours, attitudes and sources of motivation that favour or hinder leading a healthy lifestyle.The programme achieves this aim together with empathy through the mindfulness of our choices and strategies for behavioural change.Given that the programme is embedded into the medical curriculum, an integrated approach was sought that would combine direct experience with lectures on existing scientific evidence together with cases presented on a weekly basis in order to give insight into the clinical application of the content.Finally, a feature of the programme is the systematic approach to assessment.Although the degree of personal involvement is optional, knowledge of core content and skills dealt with are assessed by means of the following mechanisms: the personal practice diary is evaluated for its educational value (feedback, constructive criticism); the students' ability to understand and apply the basic content is subject to summative assessment (final examination) to ensure a basic level of skill and understanding; the written examination is complemented by other evaluative tasks (role play of a situation in which a student -doctor -must guide a patient on the ways of introducing changes to their behaviour; debate on mindfulness-based stress reduction strategies or oral presentation on the relationship between stress and health, among other options).The part corresponding to mindfulness is realised in the stress-release programme, tutorials which combine short, daily meditation practices (two five-minute 'full stops' per day, together with the as many 15-30-minute breaks as necessary depending on the students' motivation and requirements) with reflection and class discussion on key elements of mindfulness.Class discussion driven by different questions that induce debate on the basic concepts of mindfulness.Examples include: Are there inherently stressful events or are they stressful because of the way we perceive them?Is stress generated by thoughts, feelings and different events, or is generated by the way we relate to them and out attitudes towards them?What is the effect of being more in the present moment through the connection with our feelings instead of worrying about the past or the future?These and other questions (some explored as homework) allow reflection on the eight key elements of the programme: perception, letting go and acceptance, presence of mind, limitations, listening, self-discipline, emotions and expansion of personal interest [26].

Spanish Programmes
Mindfulness is gradually being introduced into different universities in Spain through an offering of courses, training and seminars, self-study and lectures, among others.Nonetheless, relatively little thought has been given to the development of programmes specific to the university setting.Table 4 shows some of the programme designs that have been created in Spain.Demarzo et al. (2017) [27]designed an offering consisting of two mindfulness programmes (general and intensive) with a duration of eight and four weeks, respectively.The two-hour sessions of the general programme include work on the following content: raisin meditation exercise, introduction -What is mindfulness?(session 1), mindful breathing, dealing with thoughts and emotions during practice (session 2), body scan, primary pain and secondary suffering (session 3), walking meditation (session 4), mindful body movements, seated meditation (session 5), sequence of seated meditation, body scan, walking meditation and mindful body movements (session 6, silent session), kind attention (session 7), practice of values, review of previous practices, how to incorporate mindfulness into daily life, programme closure (session 8).

Authors
The shorter version keeps the first three sessions unchanged, but the fourth and last session incorporates walking meditation together with the closing contents -review of previous practices, how to incorporate mindfulness into daily life and the programme closure.
Other designs have sought to introduce mindfulness gradually, in the form of micro-sessions held at the beginning of a class.This is the case of the programme developed by [28], which consists of playing short recordings (5-10 minutes in length) of mindful breathing, body scan and another type of guided meditation (mountain meditation exercise).The duration of the programme is seven weeks, with two sessions per week.
In between the two-hour sessions and the micro-sessions seen in the previous example, there are programmes with a lower duration of face-to-face sessions, complemented by personal homework.Some of these programmes highlight work on certain elements, such as anxiety [29] or emotional exhaustion, burnout and academic engagement [30].The latter programme features the use of metaphors as a learning resource.

Other Resources Used
Complementary to the offering of the mostly standard protocol mindfulness programmes (MBSR), different universities around the world, less so in Spain, have begun to introduce elements for the purpose of facilitating the implementation of mindfulness in the university community.These attempts range from the introduction of 'full stops', formal mindfulness practices of up to 30 minutes' duration during the lunch break (Monash University) to the inclusion of mindfulness in the academic curriculum (Stanford University), by way of the creation of mobile and online platforms (Harvard University) and summer schools (University of Oxford), among other initiatives.Special mention should be made of initiatives of the Harvard University, where its offering of resources -sustained through the creation of Calm College, with different online resources for the practice of mindfulness -is combined with the incorporation of students who play a leading role in the creation of a more mindful and aware community.For instance, through the formation of meditation groups open to the entire educational community that are led by experienced students who meet for daily practice.These initiatives are promoted on a spatial level through the creation of meditation rooms on campus.More particularly, different campus faculties conduct specific actions, as is the case of the law school, where the HLS Mindfulness Society offers resources and 15minute daily meditation to students and teachers.
Similarly, other universities offer the mindfulness practice as a part of broader health improvement programmes (Stanford University's Wellness on Wheels, the University of Buckingham's Positive Health University, Monash University's ESSENCE Lifestyle programmes).These types of initiatives commonly include facilitators and counsellors whose purpose is to promote integration of mindfulness into students' daily lives.
A number of universities have introduced mindfulness in as a combination of theory and practice, with the aim of uniting the firstperson experience of mindfulness practice with an understanding of its mechanisms of action and the science that supports it.This is the

Scientific Evidence of Mindfulness in the University Setting
Mindfulness-based interventions have aroused great interest in recent years in the education setting, including universities.As described in the preceding section, a number of universities offer students different mindfulness initiatives and programmes.Nonetheless, evidence on the effectiveness of these types of interventions on university students is scarce.Most of it consists of randomised studies with small sample sizes, lack of follow-up, and poor methodological quality [31].One of the first studies was conducted by [32], which compared the effects of mindfulness meditation over the space of one month with those of relaxation and a control group that did not receive treatment.The data obtained suggested that, in comparison with the control group, brief training in mindfulness meditation and relaxation reduced anxiety and improved positive states of mind.However, meditation seemed to have a specific effect of reducing distracting thoughts and behaviours.
Another study worthy of mention is that by [33], which consisted of a controlled trial with a sample of 288 psychology and medicine students at the University of Oslo and the University of Tromsø.The results showed how the medicine and psychology students experienced significant improvement in psychological distress, subjective well-being and mindfulness after taking part in the MBSR programme.There are also two studies conducted with nursing students [34,35].These studies showed how mindfulness could be effective for reducing measurements of depression, anxiety and stress, and increasing attention.It therefore appears that mindfulness-based interventions may be particularly useful in helping nursing students to manage stress and depression, especially when commencing clinical practice.
In Spain, Demarzo et al. (2017) [27] conducted a study to assess the effectiveness of an 8-week mindfulness-based intervention and an abbreviated version with a 4-week duration for improving the well-being of a non-clinical population.Specifically, this study was conducted with university students, and assessed different variables of well-being and mindfulness, positive and negative effect, self-compassion, resilience, anxiety and depressive symptoms.The intervention groups showed significant improvements in comparison with the control group, with similar effect sizes.These results suggest that the effectiveness of abbreviated mindfulness programmes can be similar to that of a standard programme, which makes it potentially more accessible to a larger number of populations, including the university community.
A recent study conducted by [36]at the University of Cambridge produced promising results, suggesting that mindfulness would be more effective than other preventive interventions.This study was conducted with a sample of 616 students, finding that those who had received mindfulness training were a third less likely to experience significant stress levels, and producing increased resilience to stress.The same students also gave better results in perceived well-being during examinations.
There is currently a limited body of literature in relation to meta-analyses performed on studies that only evaluate the effectiveness of mindfulness programmes.Nevertheless, there are in fact meta-analyses that evaluate the effectiveness of general prevention programmes, among which these interventions are included.A meta-analysis performed in 2013, incorporating studies with programmes based on cognitive, behavioural and mindfulness approaches [14] showed these interventions to be effective for reducing levels of anxiety and depression, which are also associated with low cortisol levels.The meta-analysis conducted by [15] confirmed the empirical grounding for the effectiveness of prevention programmes (including mindfulness programmes) for students in tertiary education at risk of later mental health problems.Finally, a systematic review from 2017, which was conducted with university students studying healthrelated degree courses (psychology, medicine, nursing, etc.) showed how mindfulness was able to reduce tension, anxiety and depression, and improve states of mind, self-efficacy and empathy in those students [17]

University of Zaragoza Mindfulness and Compassion Programme
This programme, designed by some of the authors of the present article, is structured around two central elements, mindfulness and compassion.Its main objective is to improve the well-being of university students, favouring the management of stress and enabling them to cope with difficult situations through self-compassion.
The programme consists of 90-minute group sessions, held once a week over a space of 6 weeks, and is offered as an extra-curricular activity.There were two main reasons for this time frame, which is shorter than that of standard programmes (8 sessions, each with a 2-hour duration): the first being the existence of studies that suggest the effectiveness of abbreviated mindfulness programmes may be similar to that of standard programmes[27], and the second being the intention of overcoming one of the most common barriers that hinder university students from seeking assistance, 'not having time for treatment' (reported in a survey by 46.7% of students) ([37].This shorter time frame is meant to address the limited time available to this group.
The sessions combine theory with practice.With regard to the theory component, the key concepts of mindfulness and self-compassion are set out over the length of the programme, in addition to others related to time management, stress, anxiety and the balance between personal life and academic/work life.It should be stressed, however, that no lectures are given; rather, reflection and debate arise from a series of questions posed to students.The practical component of the programme consists of formal and informal practices of mindfulness and self-compassion performed by students under the guidance of specialist instructors.Appendix 1 provides a summary of the structure and contents of the programme by session.Furthermore, importance is given to homework set for the students between sessions.The tasks performed are recorded in a practice journal that students are asked to keep, and they are provided with a notebook for this purpose.Some of these tasks consist of guided practices using audio recordings; others require journal entries; while others focus on the incorporation of mindfulness in different moments of the students' daily lives.The final session stresses the importance of continuing do perform these tasks after the programme is finished in order to maintain the effects achieved over time.
The effectiveness of this programme was assessed by a randomised controlled study on a population of university students enrolled in a psychology degree course, with promising preliminary results, due to be published in 2018.The sample is currently being expanded to include students in health and social science courses and other degree courses.
Finally, we present the idea that the inclusion of this programme in the university cannot be an isolated case; rather, it should be seen as a first step to the creation of a more mindful and more present university.We advocate the formation of regular practice groups, comprising those students who have completed the 6-week programme.We also consider mindfulness training that is open to other members of the educational community (members of the university's governing body and senate, technical staff, etc.), and not merely limited to students.

Conclusions
Students commencing university studies encounter a period of challenges in which they must adjust to the demands of a new academic environment and to the changes inherent to their new lifestyle.These changes often affect the personal well-being of students and cause alterations to their emotional state, interpersonal relationships, and physical and mental health.Recent studies have drawn attention to consequent increased levels of stress, anxiety and depression, evidencing a common set of problems in the lives of university students [13,14].All of this underscores the need for educational institutions to implement suitable preventive measures and programmes that enable students to cope with the changes between the secondary and tertiary systems, and to improve their mental health [11].
Mindfulness is seen as an option in this context, owing to the supporting scientific evidence and its potential for adaptation to the academic setting, and is now being introduced into university communities in Spain and internationally.While there is widespread use of standard protocols designed for adult populations, different programmes can be found that seek to adapt mindfulness to the university context and population [22,23].
Given this situation, the educational and research community is faced by the challenges of working to validate mindfulness programmes designed for implementation in universities, and to nurture the process of introducing mindfulness into universities, so that the experiences do not end once the intervention associated with research studies finalises, in order to enable mindfulness to be integrated into daily university life.Consequently, the programme we have described aims to introduce mindfulness, not as a didactic resource, but as one of the pillars of university identity and a base on which to construct programmes for the promotion of well-being.
Defining values, clarifying personal values, reflecting on values, defining SMART and values-based goals, setting a values-based goal for the week, summary of session.
case of the Mind-Body Medicine Program integrated into the curriculum of the Georgetown University School of Medicine, and the Supervised Pathway Training in Mindfulness-based Cognitive Therapy (MBCT)/Mindfulness-based Stress Reduction (MBSR) for students of psychology at the University of Exeter.Likewise, mention should be made of elective subjects for university students in the clinical field (Mindfulness for Physicians, Compassion Cultivation for Physicians, and Mindfulness:An Awareness-Based Stress Reduction Program in Medicine are examples of elective courses offered at Stanford University).

Table 1 :
International mindfulness programmes designed for work with university students.

Table 2 :
The University of Edinburgh mindfulness training programme.

Table 4 :
Spanish mindfulness programmes designed for work with university students.

Table 5 :
Main initiatives currently developed for introducing mindfulness into the university setting.Source: own design.