The effectiveness of a stress coping program based on mindfulness meditation

on the stress, anxiety, and depression experienced by nursing students in Korea

Yune Sik Kang
a
, So Young Choi
b,
*
, Eunjung Ryu
c
a
Department of Preventive Medicine, Institute of Health Science, School of Medicine, Gyeong-Sang National University, 92 Chilam-dong, Chinju 660-751, Republic of Korea
b
College of Nursing, Institute of Health Science, Gyeong-Sang National University, 92 Chilam-dong, Chinju 660-751, Republic of Korea
c
Department of Nursing, Konkuk University, 322 Danwol-dong, Chungju 380-701, Republic of Korea
a r t i c l e i n f o
Article history:
Accepted 2 December 2008
Keywords:
Meditation
Stress
Anxiety
Depression
Nursing students
s u m m a r y
This study examined the effectiveness of a stress coping program based on mindfulness meditation on
the stress, anxiety, and depression experienced by nursing students in Korea. A nonequivalent, control
group, pre-posttest design was used. A convenience sample of 41 nursing students were randomly
assigned to experimental (n = 21) and control groups (n = 20). Stress was measured with the PWI-SF
(5-point) developed by Chang. Anxiety was measured with Spiebergers state anxiety inventory. Depres-
sion was measured with the Beck depression inventory. The experimental group attended 90-min ses-
sions for eight weeks. No intervention was administered to the control group. Nine participants were
excluded from the analysis because they did not complete the study due to personal circumstances,
resulting in 16 participants in each group for the nal analysis. Results for the two groups showed (1)
a signicant difference in stress scores (F = 6.145, p = 0.020), (2) a signicant difference in anxiety scores
(F = 6.985, p = 0.013), and (3) no signicant difference in depression scores (t = 1.986, p = 0.056). A stress
coping program based on mindfulness meditation was an effective intervention for nursing students to
decrease their stress and anxiety, and could be used to manage stress in student nurses. In the future,
long-term studies should be pursued to standardize and detail the program, with particular emphasis
on studies to conrm the effects of the program in patients with diseases, such as cancer.
2008 Elsevier Ltd. All rights reserved.
Introduction
The educational goals of nursing at the university level are to
cultivate students creative and critical thinking abilities and pro-
mote continuous self-development. In this way, nurses are trained
with the knowledge, attitude, and techniques to scientically
intervene in patients health problems in a multitude of nursing
situations (Jang, 2001). To accomplish these educational goals, the-
oretical education and practical education should be combined.
Thus, nursing students must not only endure burdensome theoret-
ical learning, but also experience clinical practice. Nursing students
endure both the professional stress of exposure to unfamiliar envi-
ronments in clinical practice and personal stress, which can in-
clude personal relationships, sense of values, religion, prospects
and future, academic problems, and the nancial problems all stu-
dents experience during their college life (Burnard et al., 2007).
Clinical practice is particularly stressful, giving students the heavy
burden of responsibility for patients as well as serious anxiety and
tension due to their lack of knowledge and experience and the
unfamiliar hospital environment (Randle, 2003).
Adequate stress not only brings about proper learning motiva-
tion, but also helps to maintain physical and mental health; how-
ever, too much stress can have a negative inuence. Frequent high-
level stress and long durations of stress, depending on the individ-
uals ability to adapt to it, can cause the individual to become mal-
adjusted. Anxiety and depression are believed to be general factors
for measuring mental health status. Stress can cause several phys-
ical and emotional problems including dissatisfaction with ones
self and a sense of failure, severe anxiety and tension, and frustra-
tion and depression (Ko et al., 2003; Won and Kim, 2002). Thus, if
the stress experienced by nursing students is not properly relieved,
it can be internalized and negatively inuence the health of the
nursing students themselves, holistic patient care, and profession-
alism in nursing; these can then become obstacles to optimal
learning and nursing performance (Lindop, 1993; Park and Lee,
2004). Therefore, development of a stress management program
in which nursing students can efciently manage and cope with
their stress is urgently needed.
Recently, several studies have been conducted on the effects of
meditation on the physiological activity of the brain and as preven-
tive care and treatment of various stress-related illnesses (Benson,
2003; Kabat-Zinn, 1990). The effects are believed to be related to
the generation of theta waves, which are associated with a
0260-6917/$ - see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2008.12.003
* Corresponding author. Tel.: +82 55 751 8881; fax: +82 55 751 8711.
E-mail address: csy4214@hanmail.net (S.Y. Choi).
Nurse Education Today 29 (2009) 538543
Contents lists available at ScienceDirect
Nurse Education Today
j our nal homepage: www. el sevi er . com/ nedt
pleasant, relaxed mood (Chang, 2004). Among the many methods
of meditation, mindfulness meditation is a nonjudgemental aware-
ness of moment-to-moment experiences (Thich, 2001). Recently,
researchers studied the effects of mindfulness meditation on the
general public in Korea (Bae andChang, 2006; Choo, 2005). Few
studies, however, have evaluated its effects on nursing students,
for whom poor stress management can negatively inuence the
students health, and can also affect the students ability to provide
comprehensive nursing care for patients. This study was per-
formed to develop a program for stress management in nursing
students on the basis of mindfulness meditation, to verify its ef-
fects on nursing students, and to evaluate the possible application
of mindfulness meditation as part of intervention training in
nursing.
Background
Stress develops from the relationship between the environment
and an individual who recognizes a threat to their well-being in
relation to their resources. Different methods of coping with stress
have different results on stressed individuals. It is important, then,
for an individual to evaluate their stress level and to establish a
coping strategy for their stress even if it differs from that of others
coping with the same external stimulus. Inappropriate or poor
establishment of these two processes can cause stress-related dis-
eases (Lazarus and Folkman, 1984). Therefore, strategies to im-
prove an individuals cognitive evaluation and coping response to
stress can be used to help them manage their stress (Lazarus and
Folkman, 1984). Programs for stress management include cogni-
tive behavioral problem-solving and relaxation induction. Newer
techniques to induce relaxation include meditation, autogenic
training, muscle relaxation, and biofeedback. Among these, medi-
tation not only improves psychological and physical symptoms
through relaxation, but also helps reduce anxiety, improve resis-
tance to stress, and promote effective coping skills by approaching
the individuals problem from different points of view and chang-
ing the individuals conventional thinking about the source of
stress through cognitive reconstruction, as is the case in other cog-
nitive therapies (Teasdale et al., 1995; Choo, 2005). Mindfulness-
based stress reduction, a stress management program using mind-
fulness-based meditation designed by Kabat-Zinn at the Massa-
chusetts School of Medicine, is intended to relieve stress in both
the general populace and patients alike. Its effects have been pro-
ven in patients who experience chronic pain, panic attacks, and
chronic headaches. This program is provided by more than 100
hospitals in the US along with chronic treatment (Astin, 1997; Ka-
bat-Zinn, 1990). A study by Bae and Chang (2006), which showed
the effects of a six-week application of mindfulness meditation
on college students, reported that those students who used the
program had a noticeable reduction in restlessness, depression,
and negative emotions afterwards.
Methods
Research design
This study investigated the effects of a meditation-based stress
management program on the stress, anxiety, and depression of
nursing students using a nonequivalent control group pretest
posttest design.
Sample
Study participants were juniors and seniors in the Department
of Nursing at a single university. The participants were recruited
and notied of the purpose of the study from March 10 to March
28, 2006. A total of 41 students met the selection criteria and were
willing to participate in the study. Twenty-eight subjects were
needed, fourteen each for the experimental and control groups,
with a signicance level of 0.5, power of 80%, and an effect size
of 0.5 by Cohen (1988). The selection criteria for this study were
having achieved a junior or senior level status as a nursing student,
participating in clinical training, no history of mental disease, and
agreement to participate in the study. This program was opened
only to female students in a nursing practicum at a nursing school,
since Randle (2003) reported that nursing interns are highly sensi-
tive to stress.
After the preliminary investigation, 21 students were randomly
assigned to the experimental group, and 20 were assigned to the
control group. For the randomization procedure, each participant
drew a number. The number was only known to that individual,
ensuring that the privacy of the participant was protected. Odd
numbers were assigned to the experimental group and even num-
bers to the control group. Thirty-two participants were included in
the nal analysis; 16 in the experimental group and 16 in the con-
trol group. Four participants were eliminated from the experimen-
tal group and ve from the control group because they missed the
program more than twice and insufciently answered the survey
questionnaire during the study period.
Development of a stress coping program based on mindfulness
meditation
The stress coping program performed in this study was devel-
oped with mindfulness meditation as the central axis, with the
addition of self-reection and physical stretching as the auxiliary
axes. Mindfulness meditation consists of a body scan, breathing
meditation, and walking meditation followed by self-reection,
including recognizing ones good points, fostering a sense of grati-
tude, and coming to terms with ones mortality. At the beginning of
each session, moderate physical motion and stretching are per-
formed to improve body-awareness and to prepare for meditation.
Mindfulness meditation is the nonjudgmental awareness of mo-
ment-to-moment experiences, which originates from the Buddhist
Vipassana meditation. Sensation, feeling, thinking, and phenomena
are used as objects of observation, but mostly breathing and walk-
ing are used (Kabat-Zinn et al., 1985). During meditation, the
observation is made on the basis of breathing or walking, but if
thinking or feeling is conceived, then the object of observation
shifts and then returns to the original. This meditation was intro-
duced to the Western world by Thich Nhat Hanh, a Vietnamese
Buddhist monk. It has been clinically used on the general public
and patients with chronic diseases in an eight-week systematized
stress management program called MBSR (mindfulness-based
stress reduction) developed by Kabat-Zinn at the University of
Massachusetts Medical School (Kabat-Zinn, 1990). In this study, a
stress coping program is based on the MBSR program model (Ka-
bat-Zinn, 1990) and it was modied properly in this study by re-
searcher. When performing the actual program, the investigator
explained and demonstrated the meditation method and per-
formed meditation together with the subjects.
The details of the program by session are listed in Table 1.
Experiment procedures
The stress coping program based on mindfulness meditation
used in this study was conducted by a researcher who had received
professional training in mindfulness meditation, and who had lec-
tured on meditation for eight years. Pretest and posttest measure-
ments were performed by research assistants who were trained in
program management procedures and methods, as well as pretest
Y.S. Kang et al. / Nurse Education Today 29 (2009) 538543 539
posttest measurements. Study assistants were blinded to the
experimental and control groups while these groups were being
assessed.
The study subjects from both the experimental and control
groups were required to listen to a 1.5-h lecture on stress and cop-
ing. Following the lecture, the participants lled out a preliminary
survey and their blood pressure and pulse were taken. After the
preliminary survey, subjects were randomly assigned to groups.
Participants in the experimental group were required to attend a
total of eight weekly sessions in a stress coping program based
on mindfulness meditation that lasted for 1.5 to 2 h each, from
April 15, 2006 when the clinical training started, to June 20,
2006. In this program, voice recorded les and an instructors man-
ual were prepared and used as standard procedures for the pro-
gram. The control group received no other interventions after the
preliminary meeting and survey questionnaire. The program was
conducted in a quiet place after school hours to prevent contami-
nation of the experiment. A post-experimental survey was given,
and blood pressure and pulse measurements were taken in both
the experimental and control groups the week after the end of
the program. The survey was a self-administered questionnaire,
and personal information, with the exception of the participants
number, was unknown to the investigator.
All those enrolled in this study were compensated with a gift of
nominal value, in appreciation of their participation.
Research instruments
Stress
The stress level of the subjects was measured with the psycho-
social wellbeing index-short form (PWI-SF) questionnaire devel-
oped by Chang (2000). This questionnaire includes eighteen
questions, and each question is answered on a 5-point scale from
0 to 4 points, with higher scores indicating higher levels of stress.
A feasibility study of PWI-SF was made on Korean laborers and the
general public (Chang, 2006).
The internal consistency (Cronbachs a coefcient) of the PWI-
SF was 0.90 in the study by Chang (2000) and 0.883 in this study.
Anxiety
The state trait anxiety inventory (STAI) developed by Spieberger
(1983) was used to measure the subjects degree of anxiety. The
Spieberger (1983) STAI is a widely used, validated measure of anx-
iety. The state anxiety scale consists of 20 statements that evaluate
how the respondent feels at the present time. The trait anxiety
scale consists of 20 statements that assess how the respondent
generally feels. The internal consistency (Cronbachs a coefcient)
of the STAI was 0.90 in the study of Spieberger (1983) and 0.92 in
this study.
Depression
The Beck depression inventory (BDI) (Beck et al., 1961) was
used to measure the level of depression of the participants. The
BDI is a validated, reliable (r = 0.93), 21-itemsurvey intended to as-
sess the burden of depressive symptoms. Higher scores represent
more severe symptoms (American Psychiatric Association, 2000).
The internal consistency (Cronbachs a coefcient) of the BDI was
0.87 in this study.
Ethical considerations
The students were informed of the purpose of the research, how
long the study would take, that they were free to decide whether
or not to participate, and that they could withdraw at any time.
It was stressed that participation in this study was not part of
the school curriculum. It was also explained that the questionnaire
used in this study would not disclose the name of the respondent,
but would instead use serial numbers and pseudonyms. All partic-
ipants provided written informed consent.
Data analysis
Descriptive statistics were used for age, blood pressure, and the
life-style behaviors (smoking, exercise, alcohol consumption) of
the subjects. The verication of homogeneity for general character-
istics, stress, anxiety, and depression of the subjects were analyzed
using the Chi-square test and an independent t-test. Normal distri-
bution was conrmed after performing the normality test through
the KolmogrovSmironov test using major variables.
To compare the post-experimental effects between the experi-
mental and control groups, an analysis of covariance (ANCOVA)
was performed with pre-intervention variables as control variables
if the pre-experimental variables were not homogeneous. A t-test
was performed if the pre-intervention variables were homoge-
neous. A paired t-test was performed to compare the changes be-
fore and after the intervention in both the experimental and
control groups.
Results
Homogeneity test of subjects
Homogeneity test of characteristics at baseline
The results of the verication of homogeneity for age, blood
pressure, pulse, smoking, exercise, and alcohol consumption are
listed in Table 2. All participants in the study were females. The
average age of the experimental group was 22.69 years and that
of the control group was 22.25 years, with no signicant age differ-
ence between the two groups. There were no signicant differ-
ences in blood pressure and pulse between the experimental and
control groups. None of the participants were smokers and no sig-
nicant differences were found in weekly exercise or alcohol
consumption.
Table 1
Stress coping program based on mindfulness meditation.
Session Content Session Content
1 Quiet rest 5 Q & A
Introducing participants Stretching
Introducing procedures Music meditation and happy
memories
Stretching Walking meditation
Body scan meditation Guidance and performance
Q & A Sharing impressions
2 Q & A 6 Q & A
Stretching Stretching
Body scan Breathing meditation
My good point scan Walking meditation
Sharing impressions Sharing impressions
3 Q & A 7 Q & A
Body scan Stretching
Stretching Body scan
Breathing meditation Sitting meditation
Guidance and
performance
Loving kindness meditation
Sharing impressions Sharing impressions
4 Q & A 8 Q & A
Stretching My funeral
Breathing meditation Sitting meditation
Thanks scan Sharing impressions
Sharing impressions New start
540 Y.S. Kang et al. / Nurse Education Today 29 (2009) 538543
Homogeneity test of dependent variables in pretest
The dependent variables of both groups are listed in Table 3.
The pre-experimental stress score average was 23.69 in the exper-
imental group, which was signicantly higher than the average
score of 19.50 in the control group (t = 2.185, p = 0.037). The mean
anxiety score in the experimental group was 44.93, which was
signicantly higher than the score of 38.69 in the control group
(t = 2.110, p = 0.044). The mean depression score in the experimen-
tal group was 9.93, which was higher than the score of 6.92
in the control group, but not signicantly different (t = 1.526,
p = 0.139).
Effects of a stress coping program based on mindfulness meditation
Post-experimental scores of stress, anxiety, and depression of
the subjects are shown in Table 4. The mean stress score in the
experimental group was 23.69 before the intervention and 17.27
after the intervention, which was a signicant decrease. The mean
stress score in the control group was 19.50 before the intervention
and increased to 21.40 after the intervention. After analyzing the
pre-intervention stress score as a covariate, there was a signicant
difference in the post-intervention stress scores between the
experimental and control groups (F = 6.145, p = 0.020).
The mean anxiety score in the experimental group was 44.93
before the intervention and 39.38 after the intervention, which
was a signicant decrease. The mean anxiety score in the control
group was 38.69 before the intervention and increased to 43.75
after the intervention, but the increase was not signicantly differ-
ent. After analyzing the preliminary anxiety score as a covariate,
because the pre-intervention anxiety score was not homogeneous,
there was a signicant difference in the post-intervention anxiety
scores between the experimental and control groups (F = 6.985,
p = 0.013).
The mean depression score in the experimental group was 9.93
before the intervention and 4.56 after the intervention, a signi-
cant decrease. The mean depression score in the control group
was 6.92 before the intervention and increased to 7.88 after the
intervention, but the increase was not signicantly different. There
were no signicant differences in the mean post-intervention
depression scores between the experimental and control groups
(t = 1.986, p = 0.056).
Discussion
This study was performed to develop a stress coping program
based on mindfulness meditation, with the addition of self-reec-
tion and physical movement, to apply a developed program to
nursing students and to investigate the effects of such a program
on the stress, anxiety, and depression of nursing students.
In this study, an eight-week stress coping program based on
mindfulness meditation showed signicantly reduced stress levels,
while stress levels in a control group signicantly increased over
the same period. Study participants experienced the stressful situ-
ation of starting clinical practice and experienced increased psy-
chological tension during this period, but those participating in
the stress coping program had decreased stress scores. Mindful-
ness meditation was particularly effective in stress reduction by
reducing repetitive and persistent thinking (Jain et al., 2007). Also,
Paul et al. (2007) reported that an eight-week mindfulness medita-
tion program reduced stress and increased college students sense
of control, which is consistent with the results of the current study.
The results of this study were consistent with those of similar pre-
vious studies, suggesting that a meditation-based stress manage-
ment program is effective in stress management. Also, the results
of this study showed that the developed program signicantly re-
duced the anxiety score in the experimental group. The control
groups mean anxiety score increased, and there was a signicant
difference in mean anxiety levels between the two groups after
controlling for pre-experimental values. This is consistent with
the study of Kabat-Zinn et al. (1992) in which the MBSR was
Table 2
Homogeneity test for characteristics at baseline.
Characteristics Experimental group (n = 16) Control group (n = 16) t or x
2
p
Mean age (years) 22.69 1.49 22.25 0.86 1.017 0.317
Systolic blood pressure (mmHg) 107.81 6.83 110.06 10.07 0.740 0.465
Diastolic blood pressure (mmHg) 68.06 7.22 71.69 10.13 1.166 0.253
Pulse (per minute) 76.44 7.47 77.94 9.97 0.482 0.633
Smoking Yes, n(%) 0(0.0) 0(0.0) . .
No, n(%) 16(100.0) 16(100.0)
Exercise 63 days/week (%) 15(93.8) 12(75.0) 2.133 0.333
>3 days/week (%) 1(6.2) 6(25.0)
Alcohol 61 time/week (%) 12(75.0) 10(62.5) 0.582 0.704
P2 times/week (%) 4(25.0) 6(37.5)
Table 3
Homogeneity test of dependent variables in pretest.
Experimental group
(n = 16)
Control group
(n = 16)
t p
Stress 23.69 5.12 19.50 5.70 2.185 0.037
Anxiety 44.93 8.96 38.69 7.49 2.110 0.044
Depression 9.93 5.25 6.92 5.15 1.526 0.139
Table 4
Comparison of stress, anxiety, and depression between the experimental and control groups after a meditation-based stress management program.
Variables Experimental group (n = 16) Control group (n = 16) F
a
or t
b
p
Stress 17.27 5.18
d
21.40 7.47 6.145
a
0.020
Anxiety 39.38 7.25
d
43.75 9.85 6.985
a
0.013
Depression 4.56 3.42 7.88 5.73 1.986
b,c
0.056
a
Comparison by ANCOVA test.
b,c
Comparison by independent t-test.
d
Covariate variable.
Y.S. Kang et al. / Nurse Education Today 29 (2009) 538543 541
applied to patients with anxiety disorders to reduce their anxiety
and panic symptoms. There were also positive results reported in
Bae and Changs (2006) study in which six-weeks of mindfulness
meditation was performed in college students experiencing an
examination period. However, the level of depression was not sig-
nicantly different between the two groups after application of the
program. The depression score decreased signicantly in the
experimental group after participating in the program; however,
there was no signicant difference between depression scores be-
fore and after the program in the control group, suggesting only a
partial effect of the program.
There are a few domestic studies applying meditation-based
stress management programs. Kim et al. (2004) reported that psy-
chosocial intervention in nursing students reduced the subjects
perception of their stress level, but this was ineffective toward
anxiety and depression. On the other hand, the program applied
in this study effectively reduced stress levels and anxiety. Shapiro
et al. (1998) reported that medical students who performed mind-
fulness meditation improved their psychological symptoms,
including anxiety and depression, increased sympathy, and that
these results were maintained even during the examination period.
In a study in which a stress reduction program with a combination
of breathing, meditation, exercise, stretching, and relaxation was
applied to patients with anxiety disorders, the program signi-
cantly improved the subjects anxiety and depression (Lee et al.,
2007). Rosenzweig et al. (2003) reported that mindfulness medita-
tion helped to improve both stress and negative emotions of med-
ical students. Finally, Beddoe and Murphy (2004) reported positive
results in a study with nursing students. An eight-week course of
mindfulness meditation reduced the stress and anxiety of partici-
pants and increased their sympathy. The mindfulness medita-
tion-based, eight-week stress coping program performed in this
study reduced the stress and anxiety of the subjects when com-
pared with the control group. This study is consistent with the re-
sults of previous studies which reported a change of negative
emotions to positive ones with stress management using medita-
tion. This suggests that meditation is an effective intervention
method for stress management in nursing students. However,
depression did not show signicant differences between the inter-
vention and control groups. This should be investigated in future
studies.
This study was limited to juniors and seniors from the Depart-
ment of Nursing at Korean a single university; thus, it is not com-
pletely representative. Pre-intervention values were not equal
between the two groups despite the random assignment. Also,
the number of subjects was not large, and some subjects were ex-
cluded, possibly suggesting a problem with verication. However,
despite these limitations, the results of this study were consistent
with those of previous studies. The presence of consistency in the
effects of the intervention and the results of this study are consid-
ered acceptable.
Beddoe and Murphy (2004) reported that the ability to cope
with stress and to sympathize with patients is an important factor
in nursing education, and can be promoted through mindfulness
meditation. Meditation is a good method for coping with stress
in various situations if participants are continuously trained. In
addition, the stress coping program evaluated in this study was
effective, not only quantitatively but also by self-report and ex-
tended use of the method after participation in the program. The
positive effects of this program for nursing students were exempli-
ed in statements such as, This program really helped me get
through my training. Therefore, this program should be utilized,
and nursing students should be trained in this method in the fu-
ture. In the future, standardization and elaboration of the program
is needed, as well as studies to conrm the effects of this program
in patients with diseases such as cancer.
This study veried the effectiveness of a stress coping program
based on mindfulness meditation in nursing students and showed
the signicance of including a meditation program as a part of
nursing intervention. However, a further limitation of this study
was the small sample size. Further studies in a larger sample size
will be required for the results to be generalized.
Conclusion
The results of this study conrm that a stress coping program
based on mindfulness meditation is effective in reducing stress
and anxiety in nursing students. Based on the results of this study,
a meditation-based stress reduction program can be distributed
and utilized among nursing students.
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