Effect of Four-Season Symphony on Anxiety and Self-Efficacy in Nursing Students during Clinical Rotations

Clinical training is most crucial component of nursing education as it enables students to apply theory to practice. In nursing education, it has been discovered that clinical training is always more challenging than the theoretical portion.1 One of the most significant and challenging stage of nursing education is initial clinical training. Students move from theoretical knowledge to practical application in actual clinical settings during this time. During their first year of nursing school, nursing students must adjust to a number of new situations such as demanding coursework conflicting demands and clinical preparation.2 There is a gap between academic and clinical nursing practice, despite improvements to academic nursing education. A grounded theory study found that students' clinical behaviors reflect "traditional routine-based" practice, which hinders students in transferring their knowledge to real-life settings.3

 

Studies show that15 to 20 % of students report having high levels of anxiety with over 30 % of nursing students reporting particularly high levels. It is well known that such high levels of anxiety have adversely impact on clinical training.4 The study highlights the importance for the mentors to undertake purposeful interventions (prior to the commencement of the nursing students' clinical placements) in order to better prepare potential nursing students' educational and clinical needs.5 Anxiety is more common particularly in the early phases of clinical practice compared to other times.  Nursing students may also struggle with the stress of issues related to an unsupportive environment, largely due to the nursing staff.6 It impedes the educational process of students, their clinical practice, and affects their quality of life that could lead them to drop out of the nursing program.1,7 At the beginning of clinical practice, nursing students experience intense anxiety due to perceived deficits in knowledge and skills, fear of making a mistake that could harm the patient or inducing negative reactions and low self-confidence resulting from lack of experience.8 Students frequently struggle with a lack of confidence about expectations before clinical experiences, which play a crucial role in nursing education. This uncertainty is a significant source of anxiety and can undermine their self-efficacy, as it directly impacts their ability to develop professional skills and establish a solid foundation for their future nursing careers.9 Students often face uncertainty and lack of experience, encountering new and unpredictable situations that can heighten their anxiety and diminish their sense of self-efficacy and competence. Because students do not always fully express that they feel confident about their abilities to carry out and complete their clinical tasks their self-efficacy is not at its best and this needs to be improved.10 A study’s findings highlight the significant anxiety levels among clinical training students. To improve their experiences, it is crucial to address this issue and consider implementing strategies that support students with anxiety, enabling them to perform effectively during their clinical training.11 A phenomenological study conducted in Nepal provides the understanding of the nurses’ thoughts and actions of aesthetics in their nursing practice. The inductive knowledge from the experiences of the nurses informs the nursing discipline and profession to promote aesthetics in nursing.12 Another study showed that music therapy has a significant positive impact on anxiety and pain perception. After intervention, music therapy reduces anxiety (P <. 001 and during the experimental change opioids were used significantly less frequently (P =. 002). As a result, music therapy is effective in lowering anxiety.13 Another study found Creativity-based Positive Psychotherapy intervention in addressing low self-efficacy among individuals with depression. The results supported that the intervention was effective in improving both self-efficacy (p < .05) and reducing depression (p < .05).14 A study was conducted to assess the impact of spirituality training on the moral sensitivity of nursing students. The results showed a statistically significant difference in moral sensitivity scores between the groups (p < 0.0001).15

 

The Four-Season Symphony (FSS) framework addresses the shortcomings of traditional nursing education by incorporating four key dimensions: intellectuality, spirituality, ethics, and esthetics. This holistic approach is designed to foster a more balanced development in nursing students, equipping them with the competencies and necessary skills to manage the demands of clinical practice effectively.16

 

By integrating these dimensions into nursing education, the Four-Season Symphony has the potential to holistic learning environment and create a more supportive that enhances students' well-being and academic success. This study will justify by the need to develop and implement Four Season Symphony (Spiritual and Aesthetic dimensions) for reducing anxiety and improving self-efficacy among nursing students. If the Four-Season Symphony's spiritual and aesthetic dimensions are found to positively impact anxiety and self-efficacy, it could lead to the development of innovative educational strategies that enhance students' emotional resilience and clinical performance. This will ultimately create a more compassionate and supportive healthcare context for students, which may improve learning experiences and patient care delivery. By exploring its spiritual and aesthetic dimensions, this study aims to assess whether integrating these elements into the nursing students' routine could provide additional benefits beyond traditional methods.17 Therefore, it is crucial to investigate the potential benefits of incorporating the FSS: I SEA approach into the clinical training of nursing students, as it may provide a novel means of enhancing their well-being and professional development.  This lack of evidence presents a significant gap in nursing education research.

Study design

The design of this study was quasi-experimental that was one group pre and post which was used to evaluate the effect of Four-Season Symphony on self efficacy and anxiety in nursing students during their clinical rotations.

 

Study Settings

This study was conducted at College of Nursing DHQ Vehari.

 

Sample and Sampling technique

Purposive sampling technique was used in this study. 60 Undergraduates BSN students aged (usually 18 to 30 years) of 2nd and 3rd semester who are in their initial clinical rotation. Participants with severe psychiatric disorders or medical conditions were excluded. The sample size for this study was 60 calculated by using Cochran's formula for finite populations.

 

Data Collection Tools

For the data collection the following tools were used.

TOOL I. Socio-Demographic Questionnaire

The demographic questionnaire was contained information regarding participant age group, gender, marital status, religion, family structure, academic year and semester.

 

TOOL II. Zung Anxiety Self-Assessment Scale

Participants were asked to complete the 20 items to measure anxiety by using Zung Anxiety Self-Assessment Scale which was developed by William W. K. Zung in 1971. This tool was validated by Sylvia Z. Ramirez and James Lukenbill in 2008 with Cronbach alpha coefficients of 0.8.

 

Each item was rated on a four -point scale 1 to 4 with a higher score indicating extreme anxiety (Ramirez & Lukenbill, 2008).

 

1(None or a little of the time) 2(Some of the time) 3(Good part of the time) 4(Most or all of the time)

TOOL III. Schwarzer & Jerusalem General Self-Efficacy Scale

 

Participants were asked to complete the 10 items to measure self efficacy by using General Self-Efficacy which was developed by Ralf Schwarzer & Matthias Jerusalem in 1995. This tool was validated with Cronbach alpha coefficients range between .76 and .90 by the same authors.

 

Each item was rated on a four -point scale 1 to 4 with a higher score indicating more self efficacy (Schwarzer & Jerusalem, 1995).

 

1(Not at all true) 2(Hardly true) 3(Moderately true) 4(Exactly true)

Permission was obtained from the original developer of both tools.

 

Data Collection Procedure

Pre-interventional phase

In this phase, inclusion and exclusion criteria was applied to determine participant’s selection for the study. Once the participants are selected and consent is obtained from all, they were briefed on the aims and objectives of the study. I was collected and recorded pre-phase data and participants were evaluated based on their levels of anxiety and self-efficacy. Additionally, I got permission from the Principal of College of Nursing DHQ Vehari to apply the Four-Season Symphony.

 

The intervention package was enriched with a variety of spiritual and aesthetic practices to reduce anxiety and enhance self-efficacy among nursing students. It was conducted over a period of 16 weeks, with a total of 32 sessions (16 sessions for second-semester students and 16 sessions for third-semester students). Sessions were held four times per week—on Monday and Wednesday for first-year students and Tuesday and Friday for second-year students. Each session lasted 40 minutes, and feedback was collected at the end of every session. In alignment with the Four-Season Symphony (I SEA) framework, the following activities were incorporated:

•        Spiritual Activities: Recitation and reflection on Asma ul Husna, listening to Ar-Rahman murrotal and selected Quranic verses, guided meditation, and reflective journaling. These activities were intended to cultivate inner peace, mindfulness, and spiritual resilience.

•        Aesthetic Activities: Engagement in creative expression through music, art, painting, drawing, calligraphy, and technical decoration. These practices were designed to foster relaxation, creativity, and positive emotional experiences in clinical training.

 

Post-interventional phase

After the completion of 16 Weeks interventions the study participants were assessed for anxiety and self-efficacy by using same validated tool.

 

Data Analysis Procedure

The data was analyzed by Statistical Package for Social Science (SPSS) version 25 statistical software. Descriptive statistics was used (mean and standard deviation) for continuous variables and frequency and percentage to describe the demographic and clinical variables of the study participants. A dependent t-test was used to evaluate the differences in mean scores within the group for pre and post results. A p-value of ≤ 0.05 was considered indicative of statistical significance.

 

Ethical Considerations

All participants were provided written informed consent. The study has approved by Institute Research Ethics Board (IREB) at The University of Lahore(UOL/IREB/25/07/0047). All information and data collected was kept confidential. Participants were remained anonymous throughout the study. Participants were informed that there will be no disadvantages or risks associated with the study procedures and were made aware that they can withdraw from the study at any time without penalty.

PART I: Socio-Demographic Characteristics of the Participants

In this study all the participants were female (100%), with no male representation. A large majority of the respondents were single (91.7%), while only a small fraction was married (8.3%). Age distribution showed that the most represented group was those aged 22–26 years (45.0%), followed by individuals aged 18–22 (41.7%), and a smaller portion aged 26–30 years (13.3%). No respondents were aged 30 and above. In terms of religious affiliation, the majority identified as Muslim (95.0%), with a small minority being Christian (5.0%). The family structure of the respondents revealed that most came from two-parent families (78.3%), while 15.0% were from single-parent households and 6.7% from extended families. Academic status data revealed that respondents were evenly split across years in their current grade, with 50.0% in their first year and the other 50.0% in their second year. Likewise, the semester distribution was balanced, with half of the respondents in their second semester and the remaining half in their third. This demographic composition suggests a relatively homogenous group in terms of gender and religion but displays moderate variation in age and family background. The concentration of single females in their early twenties with a strong religious affiliation highlights a specific socio-cultural context. These factors are essential in interpreting the study’s findings, as they may influence perspectives and behaviors being investigated. Further details are mentioned in table 1.

 

Table 1: Socio-demographic characteristics of the participants

  PART II: Descriptive Statistics of Pre and Post Anxiety Intervention

                                                     

Table 2: Zung Anxiety Self-Assessment Scale

 

The data in the Table 2 and 3 revealed the effectiveness of Four-Season Symphony incorporating the spiritual and aesthetic dimension applied to 60 nursing students during their clinical rotations. As shown in Table 2, participants showed a gradual decline in anxiety after the intervention. The mean scores for the 20 items prior to the intervention ranged from 2.85 to 3.27, reflecting moderate levels of anxiety. Mean scores after the intervention ranging from 1.73 to 1.97 indicated a marked decrease in anxiety.

 

The significant decline noted for the item “I get upset easily or feel panicky (MD = - 1.48)” reported, which reduced from mean scores of 3.15 to 1.67. Reported mean scores for the second largest reduction, “I feel more nervous and anxious than usual (MD = - 1.35),” the third largest reduction, “I feel like I’m falling apart and going to pieces (MD = - 1.34),” and the fourth largest reduction, “I feel calm and can sit still easily (MD = - 1.32),” were in similar ranges. “My arms and legs shake and tremble (- 1.15),” “I am bothered by dizzy spells (- 1.11),” and “I have fainting spells or feel faint (- 1.03).” The consistent levels of reduction across emotional, cognitive, and somatic indicators indicate that the intervention as a whole contributed to the anxiety experienced during clinical rotations.

 

PART III: Descriptive Statistics of Pre and Post Self-Efficacy Intervention

 

Table 3: Schwarzer & Jerusalem General Self-Efficacy Scale

 

Table 3 data demonstrated a substantial increase in self-efficacy as a result of the intervention. All 10-item means were low pre-intervention, ranging from 1.70 to 1.85, which indicates reduced self-confidence and perceived ability to cope. Post-intervention scores were considerably higher, ranging from 3.31 to 3.44, with mean differences of +1.53 to +1.73. Three of the highest gains were in items “I can always manage to solve difficult problems if I try hard enough” (MD = +1.73), “If I am in trouble, I can usually think of a solution” (MD = +1.71), and “I am confident that I could deal efficiently with unexpected events” (MD = +1.63). These items demonstrate apparent increases in participants' perceived ability to deal with challenges and clinical situations. Further improvement showed in item, “I can remain calm when facing difficulties because I can rely on my coping abilities” (+1.61) and “I can usually handle whatever comes my way” (+1.61), which shows an increase in confidence in personal resilience and ability to make decisions.

 

Table 4: Comparison of Anxiety before and After Intervention (N=60)

 

Table 4 demonstrates a great reduction in anxiety after the intervention. Participants with high anxiety diminished notably from 53.3% to 10%. Participants with low anxiety increased from 16.7% to 60%. This consistent finding reflects substantial decrease in anxiety overall. Participants reporting high anxiety (p. < 0.001) improved most significantly (M reduced by 6.0 points), followed by moderate (M reduced by 2.0 points), and lastly low anxiety (M reduced by 4.5 points). This showed that participants with high, moderate and low anxiety benefitted from the intervention. Post-intervention, the reduction in standard deviations illustrates even more consistency in the outcomes. The statistically significant findings (p < 0.001) demonstrate the reliability and effectiveness of the intervention to reduce anxiety.

 

Table 5: Comparison of Self-Efficacy before and After Intervention (N=60)

 

Table 5 illustrates a larger shift in self-efficacy levels post-intervention. The percentage of participants classified as low self-efficacy dropped significantly from 63.3% to 10%, while the high self-efficacy participants increased from 10% to 66.7%, representing an extensive positive shift. The high self-efficacy participants registered the largest average gain of +2.5 points, while the low- and moderate self-efficacy groups also gained +2.0 points. This suggests that the intervention increased participants' confidence and awareness relating to their ability to manage challenges. Furthermore, lower standard deviation of post-intervention scores (a decrease from 2.8 to 2.1 in the low self-efficacy group) suggest fewer unpredictable and varied outcomes. Statistically significant changes (p < 0.001) also indicated that the intervention excitedly had an impact in increasing self-efficacy.

 

Table 6: Anxiety and Self-Efficacy Before and After Intervention

 

Table 6 shows the comparison of anxiety and self-efficacy scores among participants (N = 60) pre- and post-intervention. The comparative results reveal a significant decrease in anxiety from 3.04 (SD = 0.95) pre-intervention to 1.82 (SD = 0.86) post-intervention demonstrating a mean difference of -1.22, t (59) = 6.343, p < 0.001, using a paired t-test. Self-efficacy scores confirmed significant increase pre- and post-intervention from 1.77 (SD = 0.82) to 3.48 (SD = 0.74) supported by the mean difference of +1.71, t (59) = -8.723, p < 0.001 using a paired t-test.

 

The study indicates that the intervention successfully reduced anxiety scores and increased self-efficacy scores. Statistically significant results reinforce possible efficacy of the intervention as supporting the emotional regulation and confidence of the participants.

The results of the current quasi-experimental study indicated a statistically significant decrease in anxiety and increase in self-efficacy for nursing students who participated in the Four-Season Symphony intervention - an integration of the spiritual and aesthetic. These findings provide evidence to support the alternative hypothesis and reinforce the importance of the therapeutic potential of spiritually and aesthetically-informed settings or practice to promote emotional resilience and psychological readiness in high-pressure or high-stress clinical environments.

 

One of the most significant findings was the dramatic decline in overall levels of anxiety shown by program participants. Prior to the experience (pre-intervention), over half (53.3%) of the students indicated high levels of anxiety, compared with only 10% after (post-intervention). Meanwhile, the percentage of students with low overall levels of anxiety increased from 16.7% pre-intervention to 60% post-intervention. This dramatic change demonstrates that the Four-Season Symphony helped students successfully regulate their emotional experiences of clinical stress. This decline is not only statistically significant (p < 0.001), but practically, very large changes in student perceptions and experience of stress occurred. These results closely parallel the findings of García-Velasco et al and Anisi et al who also indicated that structured interventions prior to clinical placements can reduce student stress levels, 18,19 but current intervention, with its unique mixture of spiritual, auditory, and visual elements, provided students an even richer experience. In comparison to standard CBT or PMR procedures 20 this method seemed to be softer, richer, and possibly more meaningful for students with spiritual backgrounds. By incorporating beauty, spirituality, and rhythm, it may help to create an internal environment where anxiety could reduce and self-efficacy grow simultaneously.

 

The statement "I get upset easily or feel panicky" showed one of the largest item-level changes, decreasing from a mean of 3.15 to 1.67 (MD = –1.48). This indicates a large improvement in emotional regulation and stress response. Similar emotional benefits were observed in a study conducted by İnangil et al where music therapy was used to reduce anxiety levels before clinical practice; however, there was no spiritual or visual component to the intervention.8 The current study drew upon both classic and spiritual auditory stimuli (e.g., Vivaldi's Four Seasons and recitation of Surah Ar-Rahman) that may have provided the greater emotional soothing.

 

Participants also displayed significant decreases in physical symptoms of anxiety. For instance, "My arms and legs shake and tremble" decreased mean rating by 1.15 and "I am bothered by dizzy spells" decreased by 1.11. This indicates that the intervention also had an effect on somatic symptoms of anxiety, and not only on emotional or cognitive surfaces. Other studies, too, have found similar effects. Son and colleagues reported a decrease in test anxiety for nursing students from music therapy combined with aromatherapy.21 Gosselin et al. reported increased emotional regulation and self-efficacy after a 15-minute music therapy session before simulation. These two studies indicate similar benefits with music therapy and supporting psychological well-being.22 This current study is consistent with these studies and adds new findings by suggesting that adding nature imagery and religious auditory input, in a spiritual context, may increase the breadth of the therapy. In fact, calmness and restfulness were reflected as significant improvements, since the items "I feel calm and can sit still easily" and "I fall asleep easily and get a good night's rest" decreased mean rating by 1.32. This indicates that, unlike a traditional music therapy experience alone, the spiritually-based nature in distinction not only addressed daytime anxiety but established a state of nighttime relaxation and physiological restoration, in a more comprehensive way.

 

The results strongly suggest that the Four-Season Symphony intervention is effective in reducing anxiety and enhancing self-efficacy for nursing student transitioning to clinical rotations. When comparing to other alternatives such as mobile interventions conducted with this nursing cohort Wang et al. (2022) 23 educational orientations Anisi et al. 19 or simulated-based learning by Kassabry, (2023) 24 this intervention seems quite different in terms of emotional depth and cultural context. The combination of classical music, Quranic recitation, natural images, and positive affirmations may have served to stimulate both the cognitive and affective pathways and affecting a more enduring change in psychological state. In addition to the dual effect of reduction in stress and increase in self-efficacy, the Four-Season Symphony presents as an effective strategy for supporting students at this important transition into clinical environments.

 

The results for the item related to calmness and sleep had shown like, "I feel calm and can sit still easily" and, "I fall asleep easily and get a good night's rest" with a mean difference of -1.32. These results illustrated not only that the intervention assisted with performance anxiety but also incorporated some aspects of the students' emotional regulation in their daily lives and their physiological rhythms. Wahid and Nashori (2021) demonstrated that the recitation of Surah Ar-Rahman had no negative degenerative effect on the caregivers' emotional states even if they didn't understand all of the meaning behind the reading. The results of this study provided evidence that spiritual auditory stimuli possess calming properties.25 It is also found consistent effects in improving psychological functioning and stress reduction.26 In this study, the participants were provided with different varieties of spiritual audio and visual stimuli dealing with the specific type of spirituality. It is possible that the audio and visual nature of the study offered an inner sense of calmness that included, and promoted rest and sleep, which can fortify resilience in their clinical practice.

 

The current study revealed significant increase in student self-efficacy. Among participants, 63.3% scored low self-efficacy before the intervention and only 10% after. Meanwhile, the proportion of students scoring high self-efficacy jumped from 10% to 66.7%. this highlights the nature of the intervention: it led to a reduction in anxiety and equally contributed to the sense of confidence that one can navigate challenges. This type of growth is particularly important in clinical education settings where self-efficacy is a strong catalyst toward actual performance. Reyes et al. (2024), reported similar findings, noting increased self-efficacy among students after undertaking mentorship-based programs; 27 however, this study used spiritual and aesthetic stimuli as a non-technical and culturally sensitive way to facilitate empowerment.

 

The current study indicated that the Four-Season Symphony resulted in significant improvements in the self-efficacy. The integration of a spiritual and aesthetic component into a structured and active intervention resulted not only in relief from anxiety but also in students feeling empowered to believe that they could manage their issues. This combination of relaxation and empowerment is especially meaningful in clinical education because confidence affects performance and resilience. The Four-Season Symphony relies on social cognitive processes; therefore, it is likely that empowerment, self-reflection, and positive reinforcement were mechanisms to these outcomes. In comparison to the Four-Season Symphony, Rashwan et al. (2025) reported similar improvements in self-efficacy and capacity for self-care through empowerment-based programs for patients with chronic illness,28 while Chuang and Huang (2025) documented creative and student-led activities with benefits for resilience and overall mental health.29 Accordingly, these preceding studies collectively provide supportive context for the Four-Season Symphony, but the program stands out as an innovative and unique program that leveraged cultural, spiritual, and aesthetic pathways in an attempt to achieve similar or greater outcomes. Consistent with previous recommendations to address workplace stress through education and psychosocial support.30

 

The Four-Season Symphony intervention showed great promise in decreasing anxiety worries and increasing self-efficacy for nursing students. It aligns with previous literature on structured, immersive, and spiritually-based interventions, but contributes additional insights by revealing advantages of multisensory, aesthetic-spiritual derived experience.

Based on these findings, the Four-Season Symphony theoretical perspective effectively facilitates a significant reduction in anxiety and increase self-efficacy for nursing students in the course of clinical rotations. A more robust capacity for emotional regulation and confidence building was shown through overall decreases in anxiety and increases in self-efficacy across the indicators measured in this study. This suggests that this type of holistic, low-cost, culturally relevant approach can help prepare nursing students psychologically for the demands of clinical practice, providing support for both students as people and students as professional nurses in-training.

 

Recommendations

•        The Four-Season Symphony must be a part of nursing education so that students are more supported during clinical rotations.

•        The Four-Season Symphony can help lower student anxiety and help them develop their self-efficacy.

•        The Four-Season Symphony can easily be used to support patients with health-related issues across a broad spectrum of health conditions.

•        The Four-Season Symphony is a low-cost, non-pharmacological, and culturally relevant way to provide support to communities and patients with physical, emotional, and spiritual needs.

•        The Four-Season Symphony is acceptable for use in various clinical settings including hospital, palliative care, and community health.

•        It is recommended policy makers integrate the Four-Season Symphony into their national health and education agendas.

•        Further research needs to involve all aspects of the Four-Season Symphony I SEA Intellectual, Spiritual, Ethical, and Aesthetic to fully explore its impacts.

 

Study Limitations

•        The study was conducted at one institution.

•        There was no comparison or control group.

•        The follow-up was short-term only.

•        The study just measured the spiritual and aesthetic dimensions of Four-Season Symphony I SEA (Intellectual, Spiritual, Ethical, Aesthetic).

 

Acknowledgements

The authors thank the administrative and technical support provided by College of Nursing DHQ, Vehari and the students who participated in the study.

 

Funding Source

There is no funding source which supports this research in the design of the study, data collection, analysis, interpretation, or in writing the manuscript.

 

Conflict of Interest

The authors declare that there is no conflict of interest regarding the publication of this study.

 

Ethics Statement

Ethical approval was obtained from the Institute Research Ethics Board (IREB) at The University of Lahore (Approval No: UOL/IREB/25/07/0047). Written informed consent was obtained from all participants, and participant confidentiality and anonymity were strictly maintained throughout the study

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