In general the prevalence of perceived stress is high among students and especially in healthcare students compared with the general population (1–3). In Switzerland, healthcare students are affected by mental and psychological stress, disorders and illnesses (4). 18% of students reported experiencing long-term health conditions, with mental health disorders constituting the second most prevalent health issue (26%), following chronic illnesses (1, 4–6).In the long run, stress and a lack of preparation for dealing with workloads lead to burnout and career endings, which in turn fuels the existing shortage of skilled workers in the healthcare sector (7–11).

The reasons for stress among students are various but comparable around the world. University students—particularly those in healthcare programs—are exposed to a range of social, economic, and academic stressors, including academic pressure, clinical workload, financial constraints, loneliness, and the demanding nature of their studies, as reflected in the complexity of courses, examinations, and assignments.(1, 6, 12, 13). Thus, various authors postulate that the factors and predictors of stress, depression, anxiety and loneliness should be regularly assessed and appropriate interventions should be developed (12–14), a call also supported by both academic and student associations (15, 16).

Despite the efforts of universities to support the promotion of mental health and the alleviation of stress, currently programmes structurally embedded into the curricula of universities are lacking (1, 15, 17, 18).

Mindfulness-based interventions (MBIs) have been identified as a potentially highly effective approach for the reduction of stress and the enhancement of student well-being (19). Moreover, the combination of MBIs with self-leadership has demonstrated considerable potential in the promotion of well-being and the management of anxiety, stress and depression (19).

The lack of (mindfulness) programmes for students embedded in university curricula can likely be attributed to the already highly loaded curricula and/or the relatively long duration of existing interventions. To address these hindering factors, a concise five-week mindfulness-based self-leadership training (MBSL-Training) was developed in collaboration with healthcare students. The objective of the present study was to evaluate the implementation of the MBSL-Training, focusing on both implementation strategies (barriers and enablers) and implementation outcomes (appropriateness, acceptability, feasibility, fidelity, outcome expectancies).

The research questions were:

Theoretical background

The Logic Model for Implementation Optimisation (LMIO) (Fig. 2) is a tool that has been developed for the purpose of planning, understanding and evaluating the implementation process of interventions (31–33). It is a refinement of the ILM (Fig. 1) that incorporates the implementation perspective. The LMIO demonstrates clear links between the resources used, the implementation strategies, mechanisms and outcomes, that the MBSL-Training aims to achieve. During the formative evaluation study, a contextual analysis was conducted using the Consolidated Framework for Implementation Research (CFIR) (34) to identify the determinants that would facilitate the embedding of the MBSL Training into the university curriculum. This study therefore focused, on the one hand, on the implementation strategy, specifically examining the barriers and facilitators to implementation. Implementation strategies refer to the supports, system changes, and interventions designed to enhance the adoption of evidence-based interventions (EBIs) into routine care (33). On the other hand, the study also assessed five key implementation outcomes (acceptability, appropriateness, feasibility, fidelity, and outcome expectations as a service outcome), as these are crucial for the implementation of the 5-week MBSL-Training in university curricula and for the benefit of students, as explained below.

Acceptance is defined as the extent to which participants are willing to engage with the intervention. It includes participants' perceptions of the intervention's relevance, ease of use, and overall satisfaction. High levels of acceptance are essential for the success of any intervention, as they influence participant retention and engagement. Acceptance can affect the overall effectiveness of the intervention and its potential for broader implementation (35) Understanding the factors that contribute to acceptance can help refine the intervention and enhance its effectiveness (36).

Appropriateness refers to the perceived relevance and suitability of the intervention for the target population. It assesses whether the intervention is seen as fitting, applicable, and beneficial in the specific context. It is important that the intervention is seen as appropriate by both participants and stakeholders to ensure its successful implementation. Appropriateness can influence the willingness of participants to engage with the intervention and the likelihood of its adoption in other settings (37). Different methods can help identify any potential issues and ensure that the intervention meets the needs of the students (38).

Feasibility concerns the practicality of implementing the intervention within the given context. It involves assessing the extent to which the intervention can be successfully used or carried out within the intended setting. Assessing feasibility involves examining logistical considerations, resource availability, and potential barriers. Ensuring that the intervention is feasible is critical for its successful implementation and sustainability (39, 40).

Fidelity refers to the degree to which an intervention is delivered as intended by the programme developers. It encompasses adherence to the intervention protocol, the quality of delivery, and the extent to which participants engage with the intervention. High fidelity is crucial for ensuring that the intervention's effects can be attributed to the program itself rather than variations in its implementation. It helps in maintaining the internal validity of the study and ensures that the outcomes are a direct result of the intervention. Previous research has highlighted the importance of fidelity in behavioral interventions, emphasizing that deviations can significantly impact outcomes (41, 42).

Outcome expectancy refers to the participants’ beliefs about the potential benefits of the intervention. It includes their expectations regarding the positive outcomes they might achieve through participation. Positive outcome expectancy can enhance motivation and engagement, leading to better outcomes. Understanding participants' expectations can provide insights into how the intervention is perceived and its potential impact (43, 44).

Methods

Study area and context

The study was performed at the OST – Eastern Switzerland University of Applied Sciences in St. Gallen. The OST is an autonomous public institution, which combines over 170 years of educational and research tradition and has been established in its new form since 2019.

Currently the OST runs undergraduate and graduate programmes at six departments with a total student population of 3800. This study was conducted at the institute of physiotherapy, which is a part of the health department with undergraduate physiotherapy students in their 6th semester (out of 8). The training was embedded in their timetable for easy access and was not compulsory.

Study design

As shown in Fig. 3 we used a convergent mixed methods design with two measurement timepoints for the primary outcomes at five and 12 weeks. The data were collected from April to June 2024.

Legend: Acceptability of Intervention Measure (AIM); Intervention Appropriateness Measure (IAM); Feasibility of Intervention Measure (FIM); Workshop Appraisal Scale (WASC)

Study participants and their recruitments procedures

The 5-week MBSL-Training was embedded in the curriculum of undergraduate physiotherapy students in their 6th semester, in the form of an elective course. A total of 44 students enrolled and met the inclusion criteria, which was a signed informed consent. The exclusion criteria were no signed informed consent.

The MBSL-Training

The MBSL-Training was conducted on site over a period of five weeks. For two hours per week, students received input on the topics of mindfulness, self-leadership, stress and mental well-being. To maintain fidelity, standardized training materials and protocols have been used. Instructors are trained and experienced in the subject and were following a specific script during mindfulness and self-leadership exercises to maintain consistency. However, the focus was on the practical application of mindfulness and self-leadership skills. The students received these exercises on homework cards with the task of practising them until the next training session. The homework cards described the aim of the exercise and instructions on how to do it. The subsequent training session began with a reflection on what had been learned and clarified questions about it, before further inputs and exercises were carried out with the students. By the end of the fifth training session, the students had a large repertoire of mindfulness and self-leadership exercises and used them to create an individual MBSL-Training programme that was suitable for them. They were to do this as often as possible over the next seven weeks. To make it easier to stick with it, the students selected a training buddy from their class. These buddy teams discussed together when, what, and how they wanted to practice. In addition, they were reminded once a week to do it via their learning platform.

Measures

In addition to demographic data, four validated self-report instruments were used to assess the primary outcomes. Acceptability was assessed using the Acceptability of Intervention Measure (AIM) capturing participants’ perceptions of how agreeable or satisfactory they found the MBSL-Training. Appropriateness was measured with the Intervention Appropriateness Measure (IAM) which evaluates the perceived fit, relevance, and compatibility of the training within the academic and healthcare student context. Feasibility was assessed using the Feasibility of Intervention Measure (FIM), reflecting the extent to which the training could be successfully implemented in a university setting (37, 45). Outcome expectancy, conceptualized as a service outcome, was measured with the related sub-scale of the Workshop appraisal scale (WASC) (46) and relates to participants’ beliefs regarding usefulness and anticipated benefits of the MBSL-Training. Fidelity was evaluated through self-reported frequency of engagement in the MBSL-Training during the five-week intervention period, providing insight into adherence to the MBSL-Training protocol.

The AIM, IAM and FIM instruments were used in German (47) and consisted of a total of 12 questions (4 per instrument), rated on a Likert scale from 1 (strongly disagree) to 5 (strongly agree). Higher averages on these instruments indicate a higher degree of agreement with the respective implementation outcomes. The related sub-scale of the German WASC (46) containing questions on outcome expectancy consisted of a total of 3 questions, which were evaluated on a Likert scale ranging from 1 (no, not at all ) to 7 (yes, very much). Thus, the greater the mean of the individual questions, the higher the outcome expectancy was rated.

The instruments and demographic data of interest were all programmed on the Unipark survey platform ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IiOwwKyY","properties":{"formattedCitation":"(49)","plainCitation":"(49)","noteIndex":0},"citationItems":[{"id":6,"uris":["http://zotero.org/groups/5915990/items/E8NK76M3"],"itemData":{"id":6,"type":"software","title":"IBM Corp. (2022). IBM SPSS Statistics for Windows, Version 29.0.1.0. Armonk, NY: IBM Corp"}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (49)(Tivian) and made available to participants in digital form via a link. To ensure the provision of consistent and reliable answers, a control question was included in two places.

To examine the implementation strategy (enabler and barriers), qualitative data was collected in the form of a structured essay. The essay comprised four questions. The first question concerned the selection of exercises from the MBSL-Training, and the rationale behind this selection. The second question addressed the barriers and enablers for integration of the MBSL-Training in daily life. Furthermore, respondents were invited to propose modifications to the MBSL-Training programme, and to articulate whether prospective students can derive benefit from such a training and, if so, why. The completion of these essays was mandatory for students enrolled in the elective course (with an option to opt out), while the measurement at timepoint one was optional for them.

Demographic characteristics of the study participants

The sample comprised 44 participants. Of these, 37 (84%) were female and 7 (16%) male, with an average age of 24 years (range 21–36). Eight (18%) of 44 were not working alongside their studies, while 23 (52%) were in paid employment and 13 (30%) work irregularly on an hourly wage basis. On average, students work 5 hours per week while studying (Range: 0-20h).

All 44 participants provided informed consent to participate in the study. Nine participants provided incorrect answers to the control questions while four participants only filled in demographic data in the initial measurement. Thirty-one participants completed the measurements at timepoint one. To address the research question 'How do students evaluate the implementation outcomes (acceptance, appropriateness, feasibility, fidelity and outcome expectancy) of the MBSL-Training’, the data from the 31-subject sample was analysed.

As demonstrated in Table 1, participants reported favourable perceptions of the MBSL-Training across all assessed implementation outcomes. As previously outlined, acceptability, appropriateness and feasibility were evaluated using a 5-point Likert scale, with a theoretical midpoint of 3.00. The MBSL-Training received high ratings for acceptability (M = 3.89, SD = 0.70, 95% CI [3.63, 4.14]) and was perceived as appropriate (M = 4.09, SD = 0.64, 95% CI [3.85, 4.32]). The intervention was also considered feasible by the majority of participants, although responses showed some variability (M = 4.08, SD = 0.57, 95% CI [3.87, 4.29]).

In response to the question regarding the number of training sessions attended (with a possible range of 1 to 5), the mean value reported was 4.13 (M = 4.13, SD = 0.92, 95% CI [3.79, 4.47]) (Table 1).

The present study aimed to evaluate the implementation of the 5-week MBSL-Training. The study was guided by two primary research questions: (1) How do students evaluate the acceptance, appropriateness, feasibility, fidelity, and outcome expectancy of the MBSL-Training? and (2) What are the barriers and enablers of the implementation of the MBSL-training in the daily life from the students’ perspective?

The quantitative data indicate a generally positive evaluation of the 5-week MBSL-Training across key implementation outcomes, with consistently high ratings across multiple domains and a favourable outcome expectancy. The findings suggest that the 5-week MBSL-Training is both feasible and acceptable to the students, and that it is appropriate from their perspective. This is further evidenced by the high level of participation in training, which reflects a strong commitment to the intervention among the participants. Outcome expectancy data showed that participants believe that the training will help them in their further studies to better manage stress and increase their mental well-being. They came to the same conclusion regarding the future transition to professional life. However, the variability in individual expectations, as reflected in the broad confidence intervals, suggests that personal factors such as experiences and familiarity with similar training programmes may influence these perceptions. This aligns with the qualitative data, where students expressed satisfaction with the training and its perceived benefits. These findings are in line with previous research. Medlicott et al. (50) reported that university students demonstrated high levels of acceptability and adherence to an extracurricular mindfulness-based intervention (MBI) that included participant incentives. The study observed moderate improvements in well-being and reductions in mental health difficulties among participants. Similarly, other studies have demonstrated that MBIs can lead to enhanced well-being and reduced stress among tertiary students (51–53).

Furthermore, the high ratings across implementation outcomes may be attributed to the strong leadership and consistent support demonstrated by the director of the bachelor's programme in physiotherapy. His proactive engagement played an essential role in facilitating the integration of the MBSL training. Within the context of university-based implementation, the presence of a committed individual who offers vision, establishes structural support, and holds influence over curricular decisions appears to be a critical factor for success. This observation aligns with previous findings by Hudson et al. (54), who emphasised the importance of leadership and institutional backing in the effective implementation and adoption of curricular innovations.

The qualitative data highlight a range of barriers that students encounter when attempting to integrate the MBSL-Training into their daily lives. These include difficulties with time management, everyday stress, forgetting to practice, mental health challenges, lack of established routines, and limited self-discipline. Such barriers reflect the practical constraints students face in maintaining consistent engagement with the training amidst demanding schedules. Conversely, several facilitators were identified, including the use of reminders, intrinsic motivation, the development of personal routines, the perceived effectiveness of the exercises, and the flexibility of the training format. These enablers suggest that implementation is supported when participants experience tangible benefits and can adapt the training to their individual needs. Notably, the identified barriers—particularly those related to time and stress—may help explain that acceptance was slightly lower rated by the participants. At the same time, enablers such as motivation and reminders likely contributed to the high fidelity and positive outcome expectancy reported. These findings are consistent with previous research. Nardi et al. (53) identified similar barriers for an 8-week MBI in college students, including difficulties with time management and everyday stressors such as commuting and balancing academic and work responsibilities. Similarly, Sarfraz et al. (55) reported that reminders and flexibility served as important facilitators for the successful implementation of MBIs. In addition, other studies have highlighted the role of participant motivation and the perception of personal benefits as key factors supporting implementation of MBIs in daily life (56, 57).

A key strength of this study is its mixed-methods design, which provided a comprehensive perspective and enabled a more nuanced understanding of the research questions. This approach also contributed to the iterative development of the MBSL training. Nonetheless, several limitations should be acknowledged. First, the relatively small quantitative sample size and the homogeneity of the sample—limited to students from a single field of study at one university—may restrict the generalisability of the findings, particularly to broader populations or other academic contexts. While a small sample size primarily affects the reliability and validity of the results, sample homogeneity significantly limits the extent to which results can be applied to other groups or settings. Second, data were collected immediately following the 5-week intervention, preventing assessment of potential long-term effects. Thus, the study could not address the effectiveness of the training regarding the intervention goals of reducing stress and enhancing mental well-being. To address these limitations, the forthcoming main study will adopt a randomised controlled trial design with an active control group. It will incorporate four quantitative measurement points and one qualitative data collection point to allow for a more robust evaluation of both short- and long-term outcomes.

The integration of quantitative and qualitative data offers a comprehensive understanding of the implementation and outcome expectancy of the five-week MBSL-Training among health students. The findings suggest that the MBSL-Training is an acceptable, appropriate and feasible intervention to support students’ mental health. Moreover, the results underscore the relevance and value of embedding stress-reduction and well-being interventions within the university curriculum.

The comparison of quantitative and qualitative data underscores the overall positive reception of the MBSL-Training and its potential to support students in managing stress and enhancing mental well-being. At the same time, the findings highlight the need to address practical barriers that may hinder implementation and limit the training’s effectiveness. Targeted strategies—such as improving time management, fostering routine-building, offering consistent reminders, and enhancing intrinsic motivation—may help mitigate these barriers and reinforce identified enablers, thereby optimising the impact of the programme. Introducing the training earlier in the academic curriculum and supplementing it with additional support mechanisms may further strengthen its effectiveness. Following the above introduced intervention logic model, future research should focus on rigorously evaluating the efficacy of the MBSL-Training, while also incorporating the identified barriers and enablers to inform the development of a more tailored and individualised approach. Such efforts hold promise for improving students’ capacity to manage stress and promote sustainable mental well-being within academic settings.