Nurse Education Today 29 (2009) 538–543

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Nurse Education Today

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The effectiveness of a stress coping program based on mindfulness meditationon 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 Koreab College of Nursing, Institute of Health Science, Gyeong-Sang National University, 92 Chilam-dong, Chinju 660-751, Republic of Koreac 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 s u m m a r y

Article history:Accepted 2 December 2008

Keywords:MeditationStressAnxietyDepressionNursing students

0260-6917/$ - see front matter � 2008 Elsevier Ltd. Adoi:10.1016/j.nedt.2008.12.003

* Corresponding author. Tel.: +82 55 751 8881; faxE-mail address: csy4214@hanmail.net (S.Y. Choi).

This study examined the effectiveness of a stress coping program based on mindfulness meditation onthe stress, anxiety, and depression experienced by nursing students in Korea. A nonequivalent, controlgroup, pre-posttest design was used. A convenience sample of 41 nursing students were randomlyassigned 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 Spieberger’s 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 wereexcluded from the analysis because they did not complete the study due to personal circumstances,resulting in 16 participants in each group for the final analysis. Results for the two groups showed (1)a significant difference in stress scores (F = 6.145, p = 0.020), (2) a significant difference in anxiety scores(F = 6.985, p = 0.013), and (3) no significant difference in depression scores (t = 1.986, p = 0.056). A stresscoping program based on mindfulness meditation was an effective intervention for nursing students todecrease 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 emphasison studies to confirm 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 tocultivate students’ creative and critical thinking abilities and pro-mote continuous self-development. In this way, nurses are trainedwith the knowledge, attitude, and techniques to scientificallyintervene in patients’ health problems in a multitude of nursingsituations (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 studentsendure 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, prospectsand future, academic problems, and the financial problems all stu-dents experience during their college life (Burnard et al., 2007).Clinical practice is particularly stressful, giving students the heavyburden of responsibility for patients as well as serious anxiety andtension due to their lack of knowledge and experience and theunfamiliar hospital environment (Randle, 2003).

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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 influence. Frequent high-level stress and long durations of stress, depending on the individ-ual’s ability to adapt to it, can cause the individual to become mal-adjusted. Anxiety and depression are believed to be general factorsfor measuring mental health status. Stress can cause several phys-ical and emotional problems including dissatisfaction with onesself and a sense of failure, severe anxiety and tension, and frustra-tion and depression (Ko et al., 2003; Won and Kim, 2002). Thus, ifthe stress experienced by nursing students is not properly relieved,it can be internalized and negatively influence the health of thenursing students themselves, holistic patient care, and profession-alism in nursing; these can then become obstacles to optimallearning and nursing performance (Lindop, 1993; Park and Lee,2004). Therefore, development of a stress management programin which nursing students can efficiently manage and cope withtheir stress is urgently needed.

Recently, several studies have been conducted on the effects ofmeditation 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 tothe generation of theta waves, which are associated with a

Y.S. Kang et al. / Nurse Education Today 29 (2009) 538–543 539

pleasant, relaxed mood (Chang, 2004). Among the many methodsof meditation, mindfulness meditation is a nonjudgemental aware-ness of moment-to-moment experiences (Thich, 2001). Recently,researchers studied the effects of mindfulness meditation on thegeneral public in Korea (Bae andChang, 2006; Choo, 2005). Fewstudies, however, have evaluated its effects on nursing students,for whom poor stress management can negatively influence thestudents’ health, and can also affect the students’ ability to providecomprehensive nursing care for patients. This study was per-formed to develop a program for stress management in nursingstudents on the basis of mindfulness meditation, to verify its ef-fects on nursing students, and to evaluate the possible applicationof mindfulness meditation as part of intervention training innursing.

Background

Stress develops from the relationship between the environmentand an individual who recognizes a threat to their well-being inrelation to their resources. Different methods of coping with stresshave different results on stressed individuals. It is important, then,for an individual to evaluate their stress level and to establish acoping strategy for their stress even if it differs from that of otherscoping with the same external stimulus. Inappropriate or poorestablishment of these two processes can cause stress-related dis-eases (Lazarus and Folkman, 1984). Therefore, strategies to im-prove an individual’s cognitive evaluation and coping response tostress can be used to help them manage their stress (Lazarus andFolkman, 1984). Programs for stress management include cogni-tive behavioral problem-solving and relaxation induction. Newertechniques to induce relaxation include meditation, autogenictraining, muscle relaxation, and biofeedback. Among these, medi-tation not only improves psychological and physical symptomsthrough relaxation, but also helps reduce anxiety, improve resis-tance to stress, and promote effective coping skills by approachingthe individual’s problem from different points of view and chang-ing the individual’s conventional thinking about the source ofstress 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 boththe general populace and patients alike. Its effects have been pro-ven in patients who experience chronic pain, panic attacks, andchronic headaches. This program is provided by more than 100hospitals in the US along with chronic treatment (Astin, 1997; Ka-bat-Zinn, 1990). A study by Bae and Chang (2006), which showedthe effects of a six-week application of mindfulness meditationon college students, reported that those students who used theprogram had a noticeable reduction in restlessness, depression,and negative emotions afterwards.

Methods

Research design

This study investigated the effects of a meditation-based stressmanagement program on the stress, anxiety, and depression ofnursing students using a nonequivalent control group pretest–posttest design.

Sample

Study participants were juniors and seniors in the Departmentof Nursing at a single university. The participants were recruited

and notified of the purpose of the study from March 10 to March28, 2006. A total of 41 students met the selection criteria and werewilling to participate in the study. Twenty-eight subjects wereneeded, fourteen each for the experimental and control groups,with a significance level of 0.5, power of 80%, and an effect sizeof 0.5 by Cohen (1988). The selection criteria for this study werehaving achieved a junior or senior level status as a nursing student,participating in clinical training, no history of mental disease, andagreement to participate in the study. This program was openedonly 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 randomlyassigned to the experimental group, and 20 were assigned to thecontrol group. For the randomization procedure, each participantdrew a number. The number was only known to that individual,ensuring that the privacy of the participant was protected. Oddnumbers were assigned to the experimental group and even num-bers to the control group. Thirty-two participants were included inthe final analysis; 16 in the experimental group and 16 in the con-trol group. Four participants were eliminated from the experimen-tal group and five from the control group because they missed theprogram more than twice and insufficiently answered the surveyquestionnaire during the study period.

Development of a stress coping program based on mindfulnessmeditation

The stress coping program performed in this study was devel-oped with mindfulness meditation as the central axis, with theaddition of self-reflection and physical stretching as the auxiliaryaxes. Mindfulness meditation consists of a body scan, breathingmeditation, and walking meditation followed by self-reflection,including recognizing one’s good points, fostering a sense of grati-tude, and coming to terms with one’s mortality. At the beginning ofeach 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 BuddhistVipassana meditation. Sensation, feeling, thinking, and phenomenaare used as objects of observation, but mostly breathing and walk-ing are used (Kabat-Zinn et al., 1985). During meditation, theobservation is made on the basis of breathing or walking, but ifthinking or feeling is conceived, then the object of observationshifts and then returns to the original. This meditation was intro-duced to the Western world by Thich Nhat Hanh, a VietnameseBuddhist monk. It has been clinically used on the general publicand patients with chronic diseases in an eight-week systematizedstress management program called MBSR (mindfulness-basedstress reduction) developed by Kabat-Zinn at the University ofMassachusetts Medical School (Kabat-Zinn, 1990). In this study, astress coping program is based on the MBSR program model (Ka-bat-Zinn, 1990) and it was modified properly in this study by re-searcher. When performing the actual program, the investigatorexplained 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 meditationused in this study was conducted by a researcher who had receivedprofessional 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 inprogram management procedures and methods, as well as pretest–

Table 1Stress coping program based on mindfulness meditation.

Session Content Session Content

1 Quiet rest 5 Q & AIntroducing participants StretchingIntroducing procedures Music meditation and happy

memoriesStretching Walking meditationBody scan meditation Guidance and performanceQ & A Sharing impressions

2 Q & A 6 Q & AStretching StretchingBody scan Breathing meditationMy good point scan Walking meditationSharing impressions Sharing impressions

3 Q & A 7 Q & ABody scan StretchingStretching Body scanBreathing meditation Sitting meditationGuidance andperformance

Loving kindness meditation

Sharing impressions Sharing impressions

4 Q & A 8 Q & AStretching My funeralBreathing meditation Sitting meditationThanks scan Sharing impressionsSharing impressions New start

540 Y.S. Kang et al. / Nurse Education Today 29 (2009) 538–543

posttest measurements. Study assistants were blinded to theexperimental and control groups while these groups were beingassessed.

The study subjects from both the experimental and controlgroups were required to listen to a 1.5-h lecture on stress and cop-ing. Following the lecture, the participants filled out a preliminarysurvey and their blood pressure and pulse were taken. After thepreliminary survey, subjects were randomly assigned to groups.Participants in the experimental group were required to attend atotal of eight weekly sessions in a stress coping program basedon mindfulness meditation that lasted for 1.5 to 2 h each, fromApril 15, 2006 when the clinical training started, to June 20,2006. In this program, voice recorded files and an instructor’s man-ual were prepared and used as standard procedures for the pro-gram. The control group received no other interventions after thepreliminary meeting and survey questionnaire. The program wasconducted 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 boththe experimental and control groups the week after the end ofthe program. The survey was a self-administered questionnaire,and personal information, with the exception of the participant’snumber, was unknown to the investigator.

All those enrolled in this study were compensated with a gift ofnominal value, in appreciation of their participation.

Research instruments

StressThe 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 eighteenquestions, and each question is answered on a 5-point scale from0 to 4 points, with higher scores indicating higher levels of stress.A feasibility study of PWI-SF was made on Korean laborers and thegeneral public (Chang, 2006).

The internal consistency (Cronbach’s a coefficient) of the PWI-SF was 0.90 in the study by Chang (2000) and 0.883 in this study.

AnxietyThe state trait anxiety inventory (STAI) developed by Spieberger

(1983) was used to measure the subjects’ degree of anxiety. TheSpieberger (1983) STAI is a widely used, validated measure of anx-iety. The state anxiety scale consists of 20 statements that evaluatehow the respondent feels at the present time. The trait anxietyscale consists of 20 statements that assess how the respondentgenerally feels. The internal consistency (Cronbach’s a coefficient)of the STAI was 0.90 in the study of Spieberger (1983) and 0.92 inthis study.

DepressionThe Beck depression inventory (BDI) (Beck et al., 1961) was

used to measure the level of depression of the participants. TheBDI is a validated, reliable (r = 0.93), 21-item survey intended to as-sess the burden of depressive symptoms. Higher scores representmore severe symptoms (American Psychiatric Association, 2000).The internal consistency (Cronbach’s a coefficient) of the BDI was0.87 in this study.

Ethical considerations

The students were informed of the purpose of the research, howlong the study would take, that they were free to decide whetheror not to participate, and that they could withdraw at any time.It was stressed that participation in this study was not part ofthe school curriculum. It was also explained that the questionnaireused 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 thelife-style behaviors (smoking, exercise, alcohol consumption) ofthe subjects. The verification of homogeneity for general character-istics, stress, anxiety, and depression of the subjects were analyzedusing the Chi-square test and an independent t-test. Normal distri-bution was confirmed after performing the normality test throughthe Kolmogrov–Smironov 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 variablesif the pre-experimental variables were not homogeneous. A t-testwas 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 andcontrol groups.

Results

Homogeneity test of subjects

Homogeneity test of characteristics at baselineThe results of the verification of homogeneity for age, blood

pressure, pulse, smoking, exercise, and alcohol consumption arelisted in Table 2. All participants in the study were females. Theaverage age of the experimental group was 22.69 years and thatof the control group was 22.25 years, with no significant age differ-ence between the two groups. There were no significant differ-ences in blood pressure and pulse between the experimental andcontrol groups. None of the participants were smokers and no sig-nificant differences were found in weekly exercise or alcoholconsumption.

Table 2Homogeneity test for characteristics at baseline.

Characteristics Experimental group (n = 16) Control group (n = 16) t or x2 p

Mean age (years) 22.69 ± 1.49 22.25 ± 0.86 1.017 0.317Systolic blood pressure (mmHg) 107.81 ± 6.83 110.06 ± 10.07 0.740 0.465Diastolic blood pressure (mmHg) 68.06 ± 7.22 71.69 ± 10.13 1.166 0.253Pulse (per minute) 76.44 ± 7.47 77.94 ± 9.97 0.482 0.633Smoking 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 0.704P2 times/week (%) 4(25.0) 6(37.5)

Table 3Homogeneity 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 0.037Anxiety 44.93 ± 8.96 38.69 ± 7.49 2.110 0.044Depression 9.93 ± 5.25 6.92 ± 5.15 1.526 0.139

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Homogeneity test of dependent variables in pretestThe 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 significantly higher than the averagescore of 19.50 in the control group (t = 2.185, p = 0.037). The meananxiety score in the experimental group was 44.93, which wassignificantly 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 6.92in the control group, but not significantly 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 ofthe subjects are shown in Table 4. The mean stress score in theexperimental group was 23.69 before the intervention and 17.27after the intervention, which was a significant decrease. The meanstress score in the control group was 19.50 before the interventionand increased to 21.40 after the intervention. After analyzing thepre-intervention stress score as a covariate, there was a significantdifference in the post-intervention stress scores between theexperimental and control groups (F = 6.145, p = 0.020).

The mean anxiety score in the experimental group was 44.93before the intervention and 39.38 after the intervention, whichwas a significant decrease. The mean anxiety score in the controlgroup was 38.69 before the intervention and increased to 43.75after the intervention, but the increase was not significantly differ-ent. After analyzing the preliminary anxiety score as a covariate,because the pre-intervention anxiety score was not homogeneous,

Table 4Comparison of stress, anxiety, and depression between the experimental and control grou

Variables Experimental group (n = 16) C

Stress 17.27 ± 5.18d 2Anxiety 39.38 ± 7.25d 4Depression 4.56 ± 3.42 7

a Comparison by ANCOVA test.b,c Comparison by independent t-test.

d Covariate variable.

there was a significant difference in the post-intervention anxietyscores between the experimental and control groups (F = 6.985,p = 0.013).

The mean depression score in the experimental group was 9.93before the intervention and 4.56 after the intervention, a signifi-cant decrease. The mean depression score in the control groupwas 6.92 before the intervention and increased to 7.88 after theintervention, but the increase was not significantly different. Therewere no significant differences in the mean post-interventiondepression scores between the experimental and control groups(t = 1.986, p = 0.056).

Discussion

This study was performed to develop a stress coping programbased on mindfulness meditation, with the addition of self-reflec-tion and physical movement, to apply a developed program tonursing students and to investigate the effects of such a programon the stress, anxiety, and depression of nursing students.

In this study, an eight-week stress coping program based onmindfulness meditation showed significantly reduced stress levels,while stress levels in a control group significantly increased overthe 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 inthe stress coping program had decreased stress scores. Mindful-ness meditation was particularly effective in stress reduction byreducing 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’ senseof 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 resultsof this study showed that the developed program significantly re-duced the anxiety score in the experimental group. The controlgroup’s mean anxiety score increased, and there was a significantdifference in mean anxiety levels between the two groups aftercontrolling for pre-experimental values. This is consistent withthe study of Kabat-Zinn et al. (1992) in which the MBSR was

ps after a meditation-based stress management program.

ontrol group (n = 16) Fa or tb p

1.40 ± 7.47 6.145a 0.0203.75 ± 9.85 6.985a 0.013.88 ± 5.73 1.986b,c 0.056

542 Y.S. Kang et al. / Nurse Education Today 29 (2009) 538–543

applied to patients with anxiety disorders to reduce their anxietyand panic symptoms. There were also positive results reported inBae and Chang’s (2006) study in which six-weeks of mindfulnessmeditation was performed in college students experiencing anexamination period. However, the level of depression was not sig-nificantly different between the two groups after application of theprogram. The depression score decreased significantly in theexperimental group after participating in the program; however,there was no significant difference between depression scores be-fore and after the program in the control group, suggesting only apartial effect of the program.

There are a few domestic studies applying meditation-basedstress 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 towardanxiety and depression. On the other hand, the program appliedin this study effectively reduced stress levels and anxiety. Shapiroet al. (1998) reported that medical students who performed mind-fulness meditation improved their psychological symptoms,including anxiety and depression, increased sympathy, and thatthese results were maintained even during the examination period.In a study in which a stress reduction program with a combinationof breathing, meditation, exercise, stretching, and relaxation wasapplied to patients with anxiety disorders, the program signifi-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 positiveresults in a study with nursing students. An eight-week course ofmindfulness 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 thisstudy 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 negativeemotions to positive ones with stress management using medita-tion. This suggests that meditation is an effective interventionmethod for stress management in nursing students. However,depression did not show significant differences between the inter-vention and control groups. This should be investigated in futurestudies.

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 equalbetween 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 verification. However,despite these limitations, the results of this study were consistentwith those of previous studies. The presence of consistency in theeffects of the intervention and the results of this study are consid-ered acceptable.

Beddoe and Murphy (2004) reported that the ability to copewith stress and to sympathize with patients is an important factorin nursing education, and can be promoted through mindfulnessmeditation. Meditation is a good method for coping with stressin various situations if participants are continuously trained. Inaddition, the stress coping program evaluated in this study waseffective, not only quantitatively but also by self-report and ex-tended use of the method after participation in the program. Thepositive effects of this program for nursing students were exempli-fied in statements such as, ‘‘This program really helped me getthrough 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 programis needed, as well as studies to confirm the effects of this programin patients with diseases such as cancer.

This study verified the effectiveness of a stress coping programbased on mindfulness meditation in nursing students and showedthe significance of including a meditation program as a part ofnursing intervention. However, a further limitation of this studywas the small sample size. Further studies in a larger sample sizewill be required for the results to be generalized.

Conclusion

The results of this study confirm that a stress coping programbased on mindfulness meditation is effective in reducing stressand anxiety in nursing students. Based on the results of this study,a meditation-based stress reduction program can be distributedand utilized among nursing students.

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