Journal of Nursing Education

Major Article 

Effects of a Stress Management Training Program With Mindfulness-Based Stress Reduction

Aysel Karaca, PhD; Nuriye Yıldırım Şişman, PhD

Abstract

Background:

The purpose of this study is to evaluate the effectiveness of a mindfulness-based stress reduction program applied to a sample of Turkish nursing students.

Method:

The study was designed as a randomized controlled trial. Program sessions of 90 to 95 minutes were given twice per week for 12 weeks. Data were collected using the Nursing Education Stress Scale, the Mindfulness Scale, and the Stress Management Styles Scale.

Results:

A statistically significant difference was found in the mean posttest and mean follow-up scores obtained by the control group and the experimental group on the Nursing Education Stress Scale and its subdimensions. On the Mindfulness Scale, a statistically significant difference was found between the mean pretest and posttest scores obtained by the experiment and control groups.

Conclusion:

The results derived from this study suggest that the mindfulness-based stress reduction program is effective in reducing the stress experienced by students during nursing education, increasing their mindfulness, strengthening their coping mechanisms for stress, increasing their use of self-confident and optimistic approaches, and decreasing their use of the helpless approach. [J Nurs Educ. 2019;58(5):273–280.]

Abstract

Background:

The purpose of this study is to evaluate the effectiveness of a mindfulness-based stress reduction program applied to a sample of Turkish nursing students.

Method:

The study was designed as a randomized controlled trial. Program sessions of 90 to 95 minutes were given twice per week for 12 weeks. Data were collected using the Nursing Education Stress Scale, the Mindfulness Scale, and the Stress Management Styles Scale.

Results:

A statistically significant difference was found in the mean posttest and mean follow-up scores obtained by the control group and the experimental group on the Nursing Education Stress Scale and its subdimensions. On the Mindfulness Scale, a statistically significant difference was found between the mean pretest and posttest scores obtained by the experiment and control groups.

Conclusion:

The results derived from this study suggest that the mindfulness-based stress reduction program is effective in reducing the stress experienced by students during nursing education, increasing their mindfulness, strengthening their coping mechanisms for stress, increasing their use of self-confident and optimistic approaches, and decreasing their use of the helpless approach. [J Nurs Educ. 2019;58(5):273–280.]

University life can be a stressful period, as students are not only faced with the challenge of acquiring a profession but also with having to cope with new circumstances, such as living in a different place and forming new friendships. In a study conducted with university students, it was determined that factors such as benefit-based relationships (90.5%), discrimination of teaching staff toward students (89.3%), and intensity of lessons and courses (89.1%) were the main stress factors (Ascı et al., 2015).

Stress is a serious problem for nursing students. Relevant literature shows that nursing students at the undergraduate level have a higher risk of developing depression, anxiety, and stress compared with the general population and other health science students (Song & Lindquist, 2015; Timmins et al., 2011). For the past 20 years, mindfulness-based stress reduction (MBSR), a group intervention program, has been commonly recommended, as it is recognized as being the most effective at reducing stress levels. The concept of mindfulness is defined as the acceptance of momentary experiences without the burden of subjecting them to the influence of possible alternative experiences or feelings previously or currently planned for the future (Bishop et al., 2004). In other words, mindfulness is the strict concentration of attention on the moment, or the present, and the judgement-free acceptance of this lived experience. John Kabat-Zinn was the first to apply the concept of mindfulness, with positive results, on patients to relieve their chronic pain and the stress caused by chronic diseases (Ogel, 2015). Results from the many studies conducted on the use of MBSR and involving a variety of groups, including healthy individuals, patients with various diseases and conditions (e.g., fibromyalgia, cancer, anxiety disorders, and depression), and people with high stress levels, such as prison workers and medical school students, have shown it to be effective at reducing stress (Carmody & Baer, 2008; Grossman, Niemann, Schmidt, & Walach, 2004; Kuyken et al., 2015; Shapiro, Schwartz, & Bonner, 1998; Speca, Carlson, Goodey, & Angen, 2000). In a randomized controlled study with Korean nursing students who attended an 8-week MBSR program for 2 hours per week, it was found that the program decreased students' depression, anxiety, and stress levels. The literature review conducted for this study found MBSR programs including 3- to 10-week sessions. The most common length of MBSR programs are 8-week sessions (Baer, Carmody, & Hunsinger, 2012; Bamber & Schneider, 2016; Erogul, Singer, McIntyre, & Stefanov, 2014; Pepping, Walters, Davis, & O'Donovan, 2016; Phang, Mukhtar, Ibrahim, Keng, & Sidik, 2015). The current study included an 11-week MBSR program.

The amount of research conducted on the effect of MBSR-based coping programs on nursing students, in terms of their mental health and ability to cope with stress, has increased (Danitz & Orsillo, 2014; O'Driscoll et al., 2017; Song & Lindquist, 2015). It is known that the stress levels of nursing students in Turkey are very high (Güler & Çınar, 2010) and that intervention efforts aimed at improving their ability to cope with stress are needed.

The current study is a limited study evaluating the effectiveness of MBSR in reducing stress levels of nursing students. In addition, no study examining the effects of MBSR of nursing education stress on nursing students was found. This study aims to evaluate the effect of MBSR on the stress of nursing education (clinical and theoretical) and the coping skills toward stress factors. A different aspect of this study is that the MBSR program applied in the study is longer than those used in similar studies (3- to 10-week sessions). Additionally, it includes students' subjective evaluations. Therefore, this study contributes to the nursing education process as it introduced a method that could be used in reducing stress resulting from nursing education.

Aims and Hypotheses

The aim of this study is to determine the effectiveness of the MBSR program applied to nursing students. As part of this study, the following hypotheses were developed: Students constituting the group participating in the MBSR program will have a lower mean score than that of the students in the nonparticipating group, and the evaluations of the students attending the MBSR program will be positive.

Method

Design

The study was designed as a randomized controlled trial (full experimental). The evaluations made by the students who participated in the MBSR program were considered as qualitative data.

Participants

The study sample consisted of second-year nursing students enrolled in the fall semester of the 2017–2018 academic year (n = 190). The students were informed that a MBSR program would be offered as an elective course in the spring term, and they were given information about the content of the course. The participation criteria were being a second-year nursing student, being willing to take the Coping with Stress course, and voluntary participation in the study. The study group was randomly allocated to the experimental and control groups (Akın & Koçoğlu, 2017) by drawing the students' numbers from a bag to give equal opportunity and prevent selection bias and increase the internal validity of the scale (Erdoğan, Nahcivan, & Esin, 2014). The data were collected using the students' numbers. No statistically significant differences were found between the experimental and control groups' perceived academic achievement, smoking status, regular engagement in sports or exercise, stress coping levels, and nursing education stress levels.

The experimental group consisted of 42 students who attended the Coping with Stress course, and the control group consisted of 72 second-year students who did not attend the course (n = 114). Data were not able to be collected from three students in the experimental group and seven students in the control group at the 3-month follow up. In the study, three students in the experimental and three students in the control group were excluded due to absenteeism and four students in the control group did not continue in the study.

According to the results of the independent sample t test that was performed to examine the differences between the experimental group and the control group, the power of the study performed on the sample of 114 students was calculated as 0.05, the level of significance as 0.965, and the effect size as 98.9%. Because the effect size was above 80%, the sample size used for the study was deemed to be sufficient.

Measurements

Personal Information Form. This form, prepared by the researchers, included questions to determine the participants' gender, perceived academic achievement, smoking status, sports activities, coping mechanisms for stress, and other similar variables.

Nursing Education Stress Scale. This scale was developed by Rhead (1995), who created it based on a modification of the Nursing Stress Scale developed by Gray-Toft and Anderson (1981). The Turkish adaptation of the scale was created by Karaca,Yildirim, Ankarali, Acikgoz, and Akkus (2014). For this adapted version, the Cronbach's alpha reliability coefficients were between .81 and .93, the intraclass correlation coefficients between total scale and subdimensions were .76 and higher, and the item total score correlation coefficients had values of over .30. The scale, designed as a quadratic (0 to 3) Likert-type scale, includes 32 items under two subdimensions—application and academic stress. Each subdimension is scored between 0 and 48, which brings the total score of the scale to between 0 and 96. Higher scores indicate higher levels of stress (Karaca et al., 2014).

Mindfulness Scale. This scale was developed by Brown and Ryan (2003) and adapted to the Turkish language by Özyeşil, Arslan, Kesici, and Deniz (2011). It is a 15-item scale that measures the general tendency to be aware of and attentive to each moment of experience in everyday life. High scores obtained on the scale indicate higher levels of mindfulness. The Cronbach's alpha coefficient of the scale and test–retest correlation were calculated to be .80 and .86, respectively (Özyeşil et al., 2011).

Stress Management Styles Scale. This scale, developed by Folkman and Lazarus in 1980, was adapted to the Turkish language by Şahin and Durak in 1995. The 30-item scale was designed to assess the university students' emotional states such as depression, anxiety, and loneliness, and other psychological stress symptoms. The Cronbach alpha coefficients of the subdimensions of the scale ranged between .47 and .80. The scale consists of five subdimensions: applying for social support approach, self-confident approach, optimistic approach, helpless approach, and submissive approach. The higher the score obtained on any of the subdimensions indicates that the relevant approach is used to a higher degree (Şahin & Durak, 1995).

Procedure

The MBSR program was administered within the scope of the Coping with Stress course, which falls within the curriculum for second-year students. The course was administered 2 hours per week for a total of 14 weeks. The students received three European Credit Transfer System credits in this elective course. The MBSR program, which was conducted as part of the Coping with Stress course, was administered 2 hours per week for 12 weeks. However, the total duration of the program was 14 weeks to complete, as the first week was reserved for the pretest and the final week for the posttest. The topics covered each week included Using Mindfulness to Break Out of Autopilot Mode, Body Scan Meditation, Breathing Meditation, Being Mindful During a Routine Activity (e.g., mindful walking, mindful eating), Pleasant and Unpleasant Events, Calendars, Self-Love Meditation, Bodily Sensations, Emotions or Thoughts, Thought Tracking, Judgment-Free Acting, and Accepting. Each session started out by encouraging the participants to focus their minds—hitherto under the influence of breath meditation, where the mind slips into the past or the future—on the present moment (approximately 5 minutes), followed by an evaluation of the homework (approximately 10 minutes), the introduction and discussion of the main theme of the session (65 minutes), and the assignment of homework for the next week (5 minutes). The sessions were conducted in the classroom and lasted 90 to 95 minutes. Two sessions, which involved mindful walking, hearing, and seeing applications, were performed outside of the classroom in the schoolyard. To evaluate the effects of the program, a pretest was conducted before the MBSR application, a posttest at the end of 12 weeks, and a follow-up test 3 months after the end of the application. A personal information form, Nursing Education Stress Scale, Mindfulness Scale, and Stress Management Styles Scale were used for the preassessment. The Nursing Education Stress Scale, Mindfulness Scale, and Stress Management Styles Scale were also used for the posttest and follow-up assessments. Following the posttest application, the experimental group was asked to evaluate the 12-week MBSR program. This evaluation involved the participants indicating the personal effect the experience of the 12-week MBSR program had on them, the MBSR techniques they were applying, and what they believed was responsible for the changes they experienced. The students from the control group took the pre-test, posttest, and follow-up test at the same time as the students from the experimental group, but no other applications were performed on these control group students.

To administer the MBSR program, the students from the experimental group were arranged in three different groups (separate groups of 13, 14, and 15 students) by the researcher. The researcher responsible for administering the program was a cognitive and behavioral therapist with a European Association for Behavioral and Cognitive Therapies/Accreditation Certificate. The researcher was a psychiatric nurse who had a PhD and received mindfulness training and supervision as a part of a 450-hour cognitive and behavioral therapist training. Additionally, the researcher received an 8-week MBSR training. The other researcher had also previously participated in an 8-week MBSR program.

Ethical Considerations

Permission to conduct the study was given by the Directorate of the Health School, and ethical approval was received from the Ethics Committee. Informed consent forms—which, in addition to explaining the research, made clear the principles of volunteering and protection of privacy—were obtained from all of the participating students. It was planned that following the completion of the study, a course on coping with stress would be opened for the participants in the control group.

Data Analysis

SPSS version 22 was used for the analysis of the study data. The G*Power 3.1.9.2 package program was used to perform statistical power analysis. The difference between two independent groups (e.g., experimental-control) was examined using an independent sample t test. Repeated measurements variance analysis was used for the differences between more than two dependent groups. In addition, the Bonferroni test was used to determine which groups were related to each other. Content analysis was conducted on the experimental students' evaluations of the MBSR. The students' opinions were grouped according to semantic similarities, and code names were applied to represent these views. The frequency of the opinions categorized under each code was then determined. Codes were grouped based on the commonality of ideas expressed, with theme names being created to represent these codes. To ensure the validity of the analysis of the data, one expert and five students who took the survey were interviewed, and they were asked whether they found the codes and themes determined by the researchers to be appropriate or not. The themes achieved their final shape after considering the opinions expressed by the expert and students.

Results

Quantitative Results of the Study

As seen in Table 1, no statistically significant difference was observed between the mean pretest scores obtained by the experimental group and the control group on the Nursing Education Stress Scale and its subdimensions (p > .05), but there was a statistically significant difference between the mean post-test scores and follow-up scores obtained by the two groups on the Nursing Education Stress Scale and its subdimensions (p > .05); there was no statistically significant difference between the mean follow-up scores obtained by the two groups on the Mindfulness Scale (p > .05), but a statistically significant difference was seen between the mean pretest and posttest scores obtained by the two groups on the same scale (p > .05); and finally, there was a statistically significant difference in the mean pretest scores obtained by the two groups on the subdimensions of applying for social support, self-confident approach, helpless approach, and optimistic approach and in the mean posttest scores and the mean follow-up scores on the helpless approach subdimension (p < .05).

Comparison of Scale and Subdimension Scores of the Experimental Group and the Control Group

Table 1:

Comparison of Scale and Subdimension Scores of the Experimental Group and the Control Group

As seen in Table 2, results from the repeated measures variance analysis of the control group showed that there was no statistically significant difference between the mean scores obtained on the Mindfulness Scale in the pretest, posttest, and follow up or on the subdimensions of application stress, optimistic approach and applying for social support in the pretest, posttest, and follow up (p < .05), but there was a statistically significant difference between the mean scores obtained on the Nursing Education Stress Scale in the pretest, posttest, and follow up and on the subdimensions of academic stress, self-confident approach, helpless approach, and submissive approach in the pretest, posttest, and follow up (p < .01).

Comparison of the Pretest, Posttest, and Follow-Up Scale and Subdimension Scores of the Control Group

Table 2:

Comparison of the Pretest, Posttest, and Follow-Up Scale and Subdimension Scores of the Control Group

Qualitative Results of the Study

The opinions expressed by the students in the experimental group on the effectiveness of the MBSR application were evaluated using content analysis, the results of which identified two main themes.

Effectiveness of MBSR. Under this main theme, the students stated they applied the methods they learned to manage their education and daily life stressors. Among these students, 55% reported that they applied these methods to cope with the stressors they encounter in education, and that these methods proved to be useful; 48% stated that they used these methods to cope with stress-ors they encounter in daily life. One student commented, “This period was very intense, and I felt the pressure of the courses.”

MBSR Techniques Used in Coping With Stressors. Under this theme, which included the MBSR applications used by the students in the experimental group, approximately half of the students stated that they experienced an increased awareness of their own bodies, feelings, and thoughts as a result of applying these methods, and nearly all of the students felt that the application should have lasted another semester to give them the opportunity to convert this awareness into actionable skills. The MBSR techniques used by the students were categorized under the following subthemes:

Staying in the moment. Almost all students (98%) reported that following the session on coping with stress, they were able to experience the awareness of staying in the moment, a phenomenon that prior to taking the course they had only experienced on very few occasions. The students further expressed that with their awareness of staying in the moment, they were able to “exit autopilot mode,” and that their pleasures from daily actions increased as a result. However, among this 98% of students, 48% stated that they needed more time to fully appreciate the awareness of staying in the moment. One student commented, “Even if I am not always successful at it, at least now I know that I have it in me to be able to return to the moment whenever I feel anxiety about the future or stress.”

Body scan meditation. After the awareness of staying in the moment, the students mostly applied (48%) the method of body scan meditation. The students stated that they tended to use body scan meditation to relax after a stressful day. One student commented:

Last night, I had a stomach ache and felt really bad because of it. I wanted to try the body scan application that had been taught to us. I closed my eyes and listened to the pain coming from my body. During the application, I realized that I was not focusing on the pain at all, and after that I was able to put it into the background.

Thought tracking (putting the thought into the background). The intruder metaphor, one of the MBSR applications for coping with ruminative thoughts, was among the most frequently used methods by students for coping with negative thoughts. More specifically, 53% of the students reported that they used this method to cope with the type of negative thoughts that create feelings of distress/anxiety, and that they were able to fend off unpleasant thoughts in this way. One student commented, “When thoughts that constantly stress me come to mind, I say to myself ‘here come my intruders’ and continue with my work.... I then soon realize that they are gone.... In short, this method worked great for me.”

Self-love meditation. Under this theme, 61% of the students in the experimental group reported that through self-love meditation they had realized they were being cruel to themselves, particularly in terms of not allowing themselves to make any mistakes. They stated that when they internalized the self-love meditation, they gained more confidence in themselves in being able to cope with stressors. However, only 25% reported that they had started to use self-love meditation at moments when they needed it. One student said that he was not able to apply self-love meditation because he thought there was an obstacle hindering him from it. The student commented:

I am only doing things when I push myself very hard. I feel like a warrior. I thought that if I were to show self-compassion, I would get lazy and not carry out my responsibilities. But when I actually started doing this activity, I realized that I need a lot of compassion. I started to be softer on myself and to care more about myself.

Judgement-free acting and acceptance. Although some of the students (20%) stated that they were able to view the events and behaviors of other people around them with a judgement-free attitude after learning the MBSR application, others (22%) reported they were able to accept their own emotions and thoughts as they were, without running from them. One student commented, “Now I understand the importance of living every emotion. I get even more stressed when I try to run from stress or pain. This awareness has taught me a lot.”

Discussion

The aim of this study has been to determine the effectiveness of the MBSR program on Turkish nursing students. MBSR is defined as a bridge between professional life and inner emotional space. In the case of nursing students, it can be used as a coping strategy to help them cope with stressors that arise during their nursing education and work life (Walker & Mann, 2016).

Following the MBSR program, the mean posttest and follow-up scores obtained by the experimental group on the Nursing Education Stress Scale and the subdimensions were found to be significantly lower compared with the mean post-test and follow-up test scores obtained by the control group on the same scale and subdimensions (p < .05). Many studies in the literature show that the MBSR application reduces stress in nursing students (Danitz & Orsillo, 2014; Erogul et al., 2014; O'Driscoll et al., 2017; Phang et al., 2015; Song & Lindquist, 2015). According to the results obtained from the current study, as well as from those reported in the literature, it can be said that the MBSR application is an effective method for decreasing the stress levels associated with nursing education. In one study involving a 5-week MBSR program given to medical students in Malaysia, it was reported that there was a difference in the perceived stress scores of the students, but in the follow-up study performed 6 months later no differences were observed (Phang et al., 2015). Following an 8-week MBSR program administered to medical students as part of a study, it was reported that there was a significant difference in the perceived stress score of the students and during the follow-up study performed 6 months later (Erogul et al., 2014). MBSR practices have been shown to be highly effective at reducing stress (Khoury, Sharma, Rush, & Fournier, 2015). The effectiveness of the MBSR program depends on many factors, such as the duration, frequency, and content of the program. In this study, the MBSR program lasted for 12 weeks, with two 90- to 95-minute sessions per week and included a follow-up study 3 months after the completion of the program. The MBSR applications reported in the literature vary in duration range from seven to 10 sessions lasting 90 to 150 minutes (Baer et al., 2012; Bamber & Schneider, 2016; Erogul et al., 2014; Phang et al., 2015). Follow-up times after the completion of MBSR applications were also shown to vary between 3 and 9 years in studies from the literature (Erogul et al., 2014; Phang et al., 2015). Although MBSR programs lasting as short as 5 weeks have been shown to reduce stress (Phang et al., 2015), the literature nonetheless reports that as the length of MBSR programs increase, the effect also increases (Baer et al., 2012; Pepping et al., 2016). It has been noted that short MBSR programs may improve psychological health, but to be effective for other problems, such as anxiety, the program has to be longer (Bergen-Cico, Possemato, & Cheon, 2013). More studies that aim to determine the lengths of time for which MBSR applications are most effective need to be conducted (Bamber & Schneider, 2016). The fact that the posttest scores and follow-up scores obtained by the students in the experimental group were similar in this study indicates that the positive effect of the MBSR program still continues after the application.

In this study, which aimed to examine the effectiveness of the MBSR program, the mean pretest score obtained by the experimental group on the Mindfulness Scale was significantly lower than that of the control group, but the mean posttest score obtained by the experimental group on the same scale was found to be significantly higher (p < .05). In the follow up, the mean score obtained by the experimental group on the Mindfulness Scale dropped in comparison to their posttest scores, but this decrease was determined to be not significantly different (p > .05). Nonetheless, the fact that the follow-up scores were higher than the pretest scores shows that the positive effect of the MBSR still lasted. According to studies from the literature, the application of MBSR on nursing students increases their mindfulness (Phang et al., 2015; Song & Lindquist, 2015). Based on this result, it can be said that the MBSR application is an effective method for increasing mindfulness. The qualitative evaluations of the students who participated in the MBSR program also support the quantitative data. Most of the students who evaluated the program stated that they were able to “exit autopilot” as a result of the awareness they had gained of staying in the moment and that they were able to better cope with stressors. They further stated that they practiced body scanning after a stressful day (48%) and were thus able to reduce their stress level. A study involving university students who participated in eight 90-minute sessions reported that the mindfulness levels of the participants increased after they had completed the program, and that this increase was maintained, according to the results of the follow-up test (Kaynak & Güven, 2017). In a study by Sanko et al. (2016), where participants attended an 8-week program, although the results were reported to be positive, the intervention did not change the mindfulness level but did lead to a decrease in negative cognitions and had positive effects on clarity of thought, concentration, and sleep. One study has shown that increased mindfulness may have a decreasing effect on psychological fragility (Sarıcalı & Satıcı, 2017). It has also been reported that mindfulness is effective in decreasing emotional problems and symptoms, such as anger, anxiety, stress, tension, and headaches (Pepping et al., 2016). However, more studies are still needed to better understand the mindfulness values that result from MBSR applications and how to establish their permanence.

There was a significant difference in favor of the experimental group on the self-confident approach and optimistic approach, both of which are subdimensions of the Coping with Stress Scale, as a result of the MBSR program (p < .05). Previous studies have shown that students with high mindful attention awareness had lower stress levels and used passive coping techniques less often (Palmer & Rodger, 2009; Weinstein, Brown, & Ryan, 2009). According to these results, it can be said that MBSR is an effective method for increasing the degree to which nursing students apply positive coping strategies for stressful events. From the evaluations made by the students in the current study, it was found that they used the thought tracking (33%), self-love meditation (15%), and judgement-free acceptance (12%) techniques to manage uncomfortable feelings and thoughts that were difficult to cope with and that these techniques generally had a positive effect on them. These evaluations serve to demonstrate the positive effects of the MBSR program. In another qualitative study from the literature (van der Riet, Rossiter, Kirby, Dluzewska, & Harmon, 2015), students similarly reported that they were able to develop the skill of staying in the moment and learned how to concentrate on the present, to develop their skill of judgment-free acceptance, and to develop their self-awareness through thought tracking, thanks to the MBSR program. As can be seen from the findings of this study, the MBSR applications helped the nursing students to increase their use of a self-confident and optimistic approach in coping with stress and to decrease their use of the helpless approach; however, the MBSR applications had no positive effect on the nursing students' use of a submissive approach or on their willingness to apply for social support.

Conclusion

This study's results have shown that the MBSR program that was applied to Turkish nursing students in weekly sessions of 90 to 95 minutes for 12 weeks reduced their nursing education-related stress, improved their mindfulness, increased their use of self-confidence and optimistic approaches and their ability to cope with stress, and decreased their helpless approach. However, the study also showed that the program had no positive effect on the nursing students' submissive approach or willingness to apply for social support. The opinions of the students in the experimental group on the MBSR program revealed that most of the students increased their ability to stay in the moment and that they started to use the body scan, thought tracking, self-love meditation, and judgment-free acting techniques to cope with stress. Moreover, almost all of the students stated that the course should have continued for another term in order for them to be able to transform their gained awareness into actionable skills. Considering that nursing students experience a high level of stress during their education, MBSR applications should be integrated into the nursing curricula to ensure that students learn how to better cope with their stress.

Limitations

The results of this study may not be generalized to other schools and students because it was conducted at only one nursing school. These results should also not be generalized to male nursing students because the majority of the participants were female. Whether the students in the MBSR group completed their homework was assessed based on self-reporting. The data collection tools in both the quantitative and qualitative parts of the study were also based on self-reporting.

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Comparison of Scale and Subdimension Scores of the Experimental Group and the Control Group

ScaleGroupPretestPosttestFollow Up



NMean ± SDt; pNMean ± SDt; pNMean ± SDt; p
Nursing Education Stress ScoreExperimental4264.24 ± 12.1690.970; .3344250.07 ± 16.427−5.952; .000***4150.37 ± 14.284−4.621; .000***
Control7261.41 ± 16.4687267.14 ± 13.7336564.25 ± 15.519
  Subdimension
    Application StressExperimental4232.36 ± 6.5621.047; .2974224.46 ± 7.986−5.615; .000***4125.08 ± 7.417−4.346; .000***
Control7230.72 ± 8.8307232.50 ± 7.0036531.80 ± 7.961
    Academic StressExperimental4231.88 ± 6.7160.769; .4444225.61 ± 9.332−5.616; .000***4125.29 ± 7.537−4.479; .000***
Control7230.69 ± 8.6357234.64 ± 7.6126532.45 ± 8.289
Mindfulness ScoreExperimental4250.29 ± 13.479−3.064; .003*4267.90 ± 11.2815.547; .0004157.51 ± 10.7710.540; .590
Control7257.25 ± 10.5397255.17 ± 12.1216556.15 ± 13.637
Coping with Stress
  Subdimension
    Self-Confident ApproachExperimental4213.73 ± 3.562−0.454; .6564215.60 ± 2.9394.543; .000***3913.87 ± 3.7001.159; .249
Control7214.04 ± 3.3657212.31 ± 4.1066512.95 ± 4.029
    Helpless ApproachExperimental4212.03 ± 4.524−0.727; .469428.39 ± 3.487−4.127; .000***399.15 ± 3.083−2.111; .037*
Control7212.63 ± 4.1277211.86 ± 4.7556510.98 ± 4.856
    Submissive ApproachExperimental427.26 ± 2.613−0.447; .655425.65 ± 2.547−1.104; .272395.79 ± 2.648−0.759; .450
Control727.49 ± 2.662726.28 ± 3.150656.26 ± 3.247
    Optimistic ApproachExperimental429.40 ± 2.7681.020; .3104210.69 ± 2.7804,657; .000***398.72 ± 2.188−0.339; .735
Control728.86 ± 2.760728.04 ± 3.017659.11 ± 6.96
Applying for Social SupportExperimental426.43 ± 2.421−2.979; .004**427.48 ± 2.4720.825; .411397.87 ± 2.0540.865; .389
Control727.79 ± 2.319727.14 ± 1.864657.45 ± 2.628

Comparison of the Pretest, Posttest, and Follow-Up Scale and Subdimension Scores of the Control Group

ScalePretestPosttestFollow UpF; pDifferencea



NMean ± SDNMean ± SDNMean ± SD
Nursing Education Stress Score6561.27 ± 16.7166566.94 ± 13.5916564.25 ± 15.5195.153; .007**1–2
Subdimensions
  Application Stress6530.74 ± 9.0116532.45 ± 6.9166531.80 ± 7.9611.535; .219-
  Academic Stress6530.52 ± 8.6686534.50 ± 7.5396532.45 ± 8.2899.070; .000***2-1.3
  Mindfulness Score57.44 ± 10.73155.44 ± 11.77556.15 ± 13.6370.927; .398-
  Coping with Stress
Subdimensions
  Self-Confident Approach6514.13 ± 3.4446512.32 ± 4.0316512.95 ± 4.0298.820; .000***1–2.3
  Helpless Approach6512.62 ± 4.1626511.90 ± 4.6026510.98 ± 4.8565.827; .004**1–3
  Submissive Approach657.39 ± 2.752656.25 ± 3.206656.26 ± 3.2476.466; .002**1–2.3
  Optimistic Approach658.75 ± 2.818658.14 ± 3.024659.11 ± 6.9600.923; .400-
  Applying for Social Support657.74 ± 2.413657.17 ± 1.917657.45 ± 2.6282.151; .121-
Authors

Dr. Karaca is Faculty of Health Sciences, and Dr. Yıldırım Şişman is Faculty of Health Sciences, Department of Nursing, Duzce University, Duzce, Turkey.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank all the students who participated in the study.

Address correspondence to Nuriye Yıldırım Şişman, PhD, Faculty of Health Sciences, Department of Nursing, Duzce University, 81620, Konuralp/Duzce, Turkey; e-mail: nuriye3@gmail.com.

Received: September 20, 2018
Accepted: January 09, 2019

10.3928/01484834-20190422-05

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