The effects of mindfulness‐based stress reduction on mindfulness and stress levels of nursing students during first clinical experience

Abstract

Purpose:
The purpose of the study was to examine the effects of mindfulness-based stress reduction (MBSR) on stress levels and mindfulness of nursing students.

Methods:
The study was quasi-experimental and included pretest-posttest control groups.

Results:
No differences were detected between the pretest scores of the scales of the students of both groups. Students in the intervention group demonstrated increased mindfulness and decreased stress levels (p < 0.05).

Practical implications:
MBSR applied in the present study effectively reduced the stress of nursing students and increased their mindfulness.

Full text

Received: 18 October 2021
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Revised: 12 March 2022
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Accepted: 16 April 2022
DOI: 10.1111/ppc.13104
ORIGINAL ARTICLE
The effects of mindfulness‐based stress reduction on
mindfulness and stress levels of nursing students
during first clinical experience
Nurcan Uysal PhD
1
|Behice Belkıs Çalışkan MSc
2
1
Nursing Department, Istinye
University Faculty of Health Sciences,
Istanbul, Turkey
2
Nursing Department, Beykent
University Faculty of Health Sciences,
Istanbul, Turkey
Correspondence
Nurcan Uysal, PhD, Nursing Department
Faculty of Health Sciences, Istinye University,
Istanbul, Turkey.
Email: nurcan.uysal@istinye.edu.tr;
uysalnurcan@gmail.com
Abstract
Purpose: The purpose of the study was to examine the effects of mindfulness‐based
stress reduction (MBSR) on stress levels and mindfulness of nursing students.
Methods: The study was quasi‐experimental and included pretest−posttest control
groups.
Results: No differences were detected between the pretest scores of the scales of
the students of both groups. Students in the intervention group demonstrated
increased mindfulness and decreased stress levels (p< 0.05).
Practical Implications: MBSR applied in the present study effectively reduced the
stress of nursing students and increased their mindfulness.
KEYWORDS
mindfulness, nursing student, stress, stress reduction
1|INTRODUCTION
Nursing students face stressful situations from the first moments of their
professional education. One of the situations in which they experience
intense stress is going to clinical practice for the first time. Clinical settings
cause students intense stress and anxiety (BahadırYılmaz, 2016; Li et al.,
2020; Sü et al., 2018) and students experience intense stress in clinical
practice due to their lack of professional knowledge and skills, as well as
due to the responsibility they bear for patient care, the time pressure they
experience, and their lack of motivation and inability to cope (Sü et al.,
2018). Studies including a systematic review (Bhurtun et al., 2019)that
examined the stress of nursing students and their coping methods during
clinical training determined that students experience moderate and high
levels of stress (BahadırYılmaz, 2016; Graham et al., 2016; Hwang et al.,
2021; Labrague et al., 2018). Long‐term stress and the presence of more
than one stressor have negative effects on the physiological, psychologi-
cal, and social health of such individuals. It was determined that high
levels of stress in these students impair the concentration, memory, and
problem‐solving skills needed for success (Pun et al., 2018;Süetal.,2018)
and may impair immune function and cause weight gain, alcohol/drug
use, and depression (Kinsella et al., 2020). Y. W. Chen and Hung (2014)
reported that there was a significant and positive relationship between
the perceived stress and reactions of nursing students (Y. W. Chen &
Hung, 2014). Meaning that when students perceived high levels of stress,
they were at higher risk of developing physical or psychiatric illnesses or
exhibiting poor social behaviors (Y. W. Chen & Hung, 2014; Sü et al.,
2018) According to the results of this study, the period of undergraduate
education is one of the most sensitive periods in the lives of student
nurses.
Nursing students must use positive coping methods to function
within the stressful situations they face in clinical practice. Ineffective
coping methods may affect their health, academic achievement, and the
quality of the healthcare services they provide to patients (Li et al.,2020;
Pun et al., 2018;Süetal.,2018). It has been reported that effective use of
coping strategies protects health. However, some studies of nursing
students have shown that students do not make use of effective coping
strategies against stress (Karaca, 2017; McCarthy et al., 2018; Sü et al.,
2018). There are several other studies showing that they use positive
coping strategies (Bhurtun et al., 2019;Hwangetal.,2021;Labrague
et al.,2018; Pun et al., 2018;Younas,2016). In the literature, interventions
to reduce nursing students' stress (i.e., mindful awareness, building
hardiness, spiritual development, individualized clinical support, changing
Perspect Psychiatr Care. 2022;1–7. wileyonlinelibrary.com/journal/ppc © 2022 Wiley Periodicals LLC.
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belief systems, and exercise) include the Mindfulness‐Based Stress
Reduction program (MBSR) (McCarthy et al., 2018; Ratanasiripong
et al., 2015; Song & Lindquist, 2015; van der Riet et al., 2018).
The definition of mindfulness commonly used is, “non‐judgmental
awareness, cultivated by paying attention in a specific way, that is, in the
present moment, and as non‐reactively, as non‐judgmentally, and as
openheartedly as possible”(Kabat‐Zinn, 2015). Mindfulness applications,
now widespread as a result of studies and research, are used by nursing
students to cope with negative situations such as anxiety and stress and
to increase academic success by improving awareness (Sanko et al., 2016;
Schwarze & Gerler, 2015; Song & Lindquist, 2015;Yüksel&Bahadır
Yılmaz, 2020). A systematic review reported that mindfulness applications
are effective in managing academic stress and anxiety by increasing the
awareness capacities of mindfulness initiatives of students; it was also
stated that they are effective in developing a state of physical and mental
calmness and result in more focused work in the clinical field (Kinsella
et al., 2020). It was reported that mindfulness‐based cognitive therapy
programs applied to nursing students improved mindful attention
awarenessandreducedstresslevelsinstudents(Ratanasiripongetal.,
2015; Song & Lindquist, 2015; van der Riet et al., 2018;Yüksel&Bahadır
Yılmaz, 2020) and improved the ability to concentrate, shift attention, and
pay selective attention (Spadaro & Hunker, 2016). Mindfulness‐based
practices are adopted widely for personal and professional development
because they help manage physical and psychological reactions to stress.
Reducing the stress levels of students in clinical practice with the
support of nursing educators may reduce the negative effects of stress on
students. Identifying the stress levels of students and the causes of stress
is necessary to develop the coping skills of students and change their
behaviors in response to stress (Sü et al., 2018). Previous studies report
that mindfulness practices are effective in coping with nursing students'
negative experiences in their academic lives, but studies examining the
stress reduction experienced in the clinic and its effects on the physical,
psychological, and social health of students are limited. A meta‐analysis
conducted by Li et al. (2020) found that studies that applied mindfulness
meditation practices to nursing students were few, and the effects of
mindfulness meditation on nursing students are not well known (Li et al.,
2020). We expect the results of the present study will provide important
information on the effects of MBSR on the physical, psychological, and
social health of students in their first clinical experience.
It is already known that nursing students entering into clinical
practice for the first time experience intense stress that negatively
impacts their physiological bodies. The purpose of this study was to
examine the effects of an MBSR program applied to nursing students
entering into clinical practice for the first time and its effects on their
physical, stress levels and psychological, and social health.
2|METHODS
2.1 |Study sample and design
The study was planned as a nonrandomized and quasi‐experimental
study with pretest and posttest control groups. The study population
consisted of 71 first‐year undergraduate nursing students attending a
foundation university in Istanbul. The study was conducted with first‐
year students because these students will enter clinical practice for
the first time. The study included students scheduled to enter clinical
practice for the first time who had not participated in the MBSR
program before and who voluntarily agreed to participate in the
study. Missing more than two sessions and using sedative drugs were
exclusion criteria; 12 students who are health vocational high school
graduates and 7 nonvolunteer students were not included in the
study. The study sample consisted of 52 students, 17 included in the
intervention group and 35 in the control group. Students in the
control group reported that they found the MBSR program intense
and long and that they thought they would miss more than two
sessions.
2.2 |Instruments
Data were collected using Perceived Stress Scale (PSS), Physio
−Psycho−Social Response Scale (PPSRS), and Mindfulness Attention
Awareness Scale (MAAS). The PSS was developed by Sheu et al.
(1997) to determine nursing students' perceptions of stress and was
adapted into Turkish by Karaca et al. (Karaca et al., 2015; Sheu et al.,
1997). The Cronbach's alpha coefficient of the Turkish version of the
scale was found to be 0.93 with a two‐week test−retest reliability of
0.96. The scale is a 5‐point Likert‐type scale consisting of six
subdimensions. The score obtainable from the scale ranges from 0 to
116, with a high score correlating to a high level of stress.
The PPSRS developed by Sheu et al. (1997) contains 21 items
about symptoms relating to the student's physical, psychological, and
social health; it was adapted into Turkish by Karaca et al. (Karaca
et al., 2015; Sheu et al., 1997). The Cronbach's alpha coefficient of
the Turkish version was found to be 0.91 with a two‐week test
−retest reliability of 0.92. The scale is a 5‐point Likert‐type scale
consisting of three subdimensions. The total scores ranged from 0 to
84, where high scores indicated a greater prevalence of symptoms
and poorer physio−psycho−social status. The MAAS was developed
by Brown and Ryan (2003).
The MAAS is a 15‐item instrument that measures people's
tendency to be mindful of moment‐to‐moment experiences. Thus,
the instrument focuses on the presence or absence of attention and
awareness of what occurs in the present. This scale has been shown
to relate to various aspects of well‐being and to how effectively
people deal with stressful life events. MAAS has a single factor
structure and gives a single total score. Respondents are asked to
indicate how frequently they have the experience described in each
of the 15 statements using a 6‐point Likert scale from 1
(almost always)to6(almost never). The score obtainable from the
scale ranges from 15 to 90, where a high score reflects more
mindfulness. The Turkish adaptation, validity, and reliability of the
scale were made by Özyeşil et al. (2011) and the Cronbach's alpha
internal consistency of the scale was 0.82 (Brown & Ryan, 2003;
Özyeşil et al., 2011).
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UYSAL AND ÇALIŞKAN

2.3 |Data collection
The study was conducted between February 15 and March 28, 2019.
Written consent was obtained from the students in the control group
after the purpose of the study was explained; then the pretest
application of the study scales was performed. In the first session
(February 15, 2019), MBSR was applied to the students in the
intervention group; the contents of the program were explained,
written consents were obtained, and the pretest scales were applied.
The students in the control group continued their lessons at school.
The last session of MBSR was administered on March 15, 2019.
Before entering the clinics on March 28, students gathered in a
classroom and post‐tests were administered to both groups.
2.4 |Intervention
The present study utilized a modified MBSR program based on the
MBSR program developed by Kabat‐Zinn (2003). The researcher
(B. B. C.) who implemented the program had been trained in the use
of MBSR. The MBSR program was applied for eight sessions over 1
month for 2 days a week for 2‐h sessions; 17 students made up the
intervention group. MBSR practices included focusing on the breath,
breathing and body exercises, body scanning, seated meditation,
mindful walking, mindful yoga, affection meditation, and creating a
calendar of pleasant and unpleasant moments. Starting from the
second session students were asked at the beginning of each session
to share their experiences while doing their homework. They were
asked about the situations where they had difficulty in doing the
activities and what kind of awareness these activities gave them.
2.4.1 |The contents of the MBSR program
Week 1, Day 1: Providing information on mindfulness after meeting
and pretests, application of raisin meditation. Students were asked to
try mindful eating for 1 week as a homework assignment.
Week 1, Day 2: Being in the moment and living in the moment
were discussed. Body scanning was performed with mindful
breathing exercises. For homework, the participants were asked to
take note of a few memorable moments that they liked, and to think
about how they affected them.
Week 2, Day 3: After the pleasant and unpleasant moments from
the homework were discussed, a mindful yoga exercise was
performed with a meditation of sounds and thoughts aimed to
recognize and question automatic responses. For homework,
students were asked to evaluate their responses at random times
to determine if they were automatic, notice the situations they
preferred to avoid, and create a calendar of pleasant and unpleasant
moments.
Week 2, Day 4: Stress, the effects of stress, and ways of coping
were discussed. Sticking with emotions and mindful walking were
taught in 15 steps. For homework, students were asked to perform
seated meditation 6 days a week, practice mindful walking, complete
breathing exercises three times a day, and note pleasant and
unpleasant moments.
Week 3, Day 5: Establishing a relationship with the body with
conscious awareness, facing difficult things and the concept of self‐
affection (to approach oneself with compassion and kindness) were
discussed. Coping meditation, seated meditation, 3‐min breathing
space, the body in challenging situations, body scanning, and self‐
affection meditation were performed. For homework, students were
asked to perform all applications learned.
Week 3, Day 6: Discovering what gave them pleasure, finding
activities that made them feel good, and looking ahead were
discussed; and mountain meditation, body scanning, and breathing
exercises were performed.
Week 4, Day 7: After talking about negative and positive
thoughts and what we can do with our thoughts, seated meditation,
breathing and body meditation, and sound and thought meditation
were performed; for homework, students were asked to practice
meditations of their choice and note their reactions.
Week 4, Day 8: A day of silence; all meditations were performed
and the implementation was terminated after receiving the feedback
from the students.
2.5 |Data analysis
All analyses were performed using SPSS for Windows (version 22,
SPSS, Inc., 2013). Descriptive statistics, such as percentage, arithme-
tic mean, and standard deviation, were used in the analysis of
features between groups. The mean scores of the scales between the
groups were compared using the Mann−Whitney Utest and the
mean scores of the scales within each group were compared using
the Wilcoxon Signed Ranks Test.
2.6 |Ethics
Permission was obtained from the university, Social and Human
Sciences Ethics Committee (Date: 11.03.2019, No:2019/4), and also
from the students to conduct the study.
3|RESULTS
Table 1presents the sociodemographic characteristics of the
students in the intervention and control groups. No differences were
detected between the two groups in sociodemographic variables
such as age, gender, type of high school graduate, people they lived
with, economic status, reasons for choosing the nursing profession,
and having a healthcare worker in the family (p> 0.05).
No significant differences were found in the pretest mean scores
of the scales of both groups (p> 0.05), but there was a statistical
difference between the posttest mean scores (p< 0.05). When the
UYSAL AND ÇALIŞKAN
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scale pretest and posttest mean scores of the groups were compared,
the PSS (Z=−5.186, p= 0.000) and PPSRS (Z=−5.185, p= 0.000)
posttest scores of the control group increased, and the difference
was statistically significant (p= 0.00). Though the posttest scores of
the students in the intervention group decreased in PSS (Z=−3.622,
p= 0.000), and PPSRS (Z=−3.034, p= 0.020), scores increased in the
MAAS (Z=−3.529, p= 0.001). The results were statistically significant
(Table 2).
4|DISCUSSION
The present study applied MBSR 4 h a week for 4 weeks to nursing
students scheduled to go to clinical practice for the first time, and it
was found that this practice increased the awareness and reduced
the stress levels and negative physio−psycho−social reactions
associated with clinical practice for the students in the intervention
group. The students who participated in the study said that they were
stressed and excited on the first day of clinical practice, and
experienced increased psychological tension. However, the partici-
pants of the MBSR program had a positive effect on perceived stress
levels.
Many studies in the literature report that MBSR increases mindful-
ness and reduces stress in students. In the study examining the effect of
MBSR on mindfulness, anxiety, and stress levels in nursing students, it
was found that the MAAS posttest score of the experimental group was
higher, and the perceived anxiety and stress scores were lower than the
experimental group (Yüksel and BahadırYılmaz, 2020). In their random-
ized controlled study conducted with nursing students, Song and
Lindquist (2015) applied an MBSR program for 2 h a week for 8 weeks
and reported that 21 nursing students had significantly decreased
depression, anxiety, and stress levels, and a greater increase in awareness
in the intervention group (Song & Lindquist, 2015). Burger & Lockhart
(2017), conducted with 52 nursing students, reported that those who
meditated experienced decreased stress and increased mindfulness with
attention and guidance (Burger & Lockhart, 2017). A study that applied an
8‐week mindfulness training program to prelicensure and postgraduate
nurses reported the program increased mindful awareness and ethical
decision‐making (Sanko et al., 2016). Online mindfulness meditation
intervention was applied asynchronously to 26 nursing students for 8
weeks. At the end of program, it was determined that there was a
significant decrease nursing students' stress levels and an increase in
cognitive attention and concentration (Spadaro & Hunker, 2016).
Biofeedback and mindfulness meditation was reported to benefit
TABLE 1 The sociodemographic
characteristics of the students
Characteristics
Control
group (n= 35)
Intervention
group (n= 17) Test pValue
Age (mean ± SD) 18.48 ± 0.90 18.52 ± 0.95 χ
2
= 3.525 p= 0.089
Sex (%)
Female 82.9 82.4 χ
2
= 0.002 p= 1.000
Male 17.1 17.6
High school graduation (%)
General high school 54.3 47.1 χ
2
= 0.239 p= 0.769
Vocational health high
school
45.7 52.9
Living with (%)
Family 68.6 76.5 χ
2
= 0.348 p= 0.747
Friend 31.4 23.5
Economic situation (%)
Moderate 80.0 76.5 χ
2
= 0.085 p= 1.000
Low 20.0 23.5
Choosing nursing
profession (%)
Willingly 48.6 64.7 χ
2
= 2.951 p= 0.229
On suggestion 25.7 5.9
Job guarantee 25.7 29.4
Health worker in family (%)
Yes 40.0 29.4 χ
2
= 0.553 p= 0.548
No 60.0 70.6
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UYSAL AND ÇALIŞKAN

second‐year nursing students who would start clinical training in Thailand,
helping them manage stress and anxiety (Ratanasiripong et al., 2015).
Studies have reported that MBSR has positive effects on the physical,
psychological, and social health of students. Two studies have confirmed
that mindfulness decreases stress symptoms, provides emotional balance,
and improves attention and cognitive skills (Spadaro & Hunker, 2016;van
derRietetal.,2015). In a study there was a significantly positive
relationship between perceived stress and physio–psycho−social
responses and authors expressed that when students perceive a high
level of stress, they might be at risk of suffering from physical or
psychiatric illnesses or demonstrating poor social behaviors (Y. W. Chen &
Hung, 2014). An integrated literature review, a 7‐week stress manage-
ment and awareness program was applied as learning support and stress
reduction method to first‐year nursing and midwifery students. The
application positively affected sleep, concentration, and clarity of thought
and reduced negative cognitions, promoting a sense of well‐being in the
students(vanderRietetal.,2018). It was also found that the systolic
blood pressure of the students in the intervention group decreased more
than in the control group; and they were moderately anxious, which was
associated with the maximum meditation effect. As a meta‐analysis study
investigating the effects of mindfulness‐based interventions on nursing
students reported, mindfulness interventions can reduce anxiety and
depression, lower blood pressure, reduce sensitivity to pain, and improve
student academic achievement (X. Chen et al., 2021). A study by Murphy
et al. (2012) examining the relations between dispositional mindfulness
practice and physical health behaviors (sleeping, eating, and exercise)
followed441studentsfor2years,andreporteddispositionalmindfulness
to relate to healthy eating, good sleep, and optimal health (Murphy et al.,
2012) Our study findings are consistent with previous studies' results that
suggest that MBSR applied to nursing students positively effects stress,
awareness levels, and physical, psychological and social health.
5|LIMITATIONS
Since the present study was conducted with first‐year students of the
nursing department of a single foundation university, it does not
represent the universe completely. The intervention and control groups
were formed on a voluntary basis and not with random assignment, so
the number of students in the intervention group was relatively small.
When briefed about the study, students found the MBSR program
content intense and lengthy. Those who stated that they could not attend
the program regularly from beginning to end opted to stay in the control
group.
6|IMPLICATIONS FOR PSYCHIATRIC
NURSING PRACTICE
The MBSR program had positive effects on the mindfulness, stress
levels, and physical, psychological, and social health status of the
nursing students entering clinical practice for the first time. Based on
the results of the present study, nurse educators can use MBSR to
help nursing students cope with stress. To uncover the long‐term
TABLE 2 Comparison of in‐group and
intergroup comparison of pretest−posttest
mean scores of PSS, PPSRS, and MAAS of
the intervention and control groups Scale
Control group
(n= 35)
Intervention
group (n= 17)
Test value pValueMean ± SD Mean ± SD
PSS
Pretest 61.60 ± 19.19 59.47 ± 14.79 U= 277.000 p= 0.689
Posttest 67.71 ± 17.97 54.29 ± 15.3 U= 191.500 p=0.038
Test Z = −5.186 Z=−3.622
pp=0.000 p=0.000
PPSRS
Pretest 34.40 ± 12.97 35.05 ± 9.05 U= 279.000 p= 0.718
Posttest 40.42 ± 12.76 33.00 ± 9.99 U= 165.500 p=0.009
Test Z=−5.185 Z=−3.034
pp=0.000 p=0.020
MAAS
Pretest 56.45 ± 10.09 57.35 ± 9.40 U= 281.500 p= 0.755
Posttest 56.54 ± 10.07 62.74 ± 9.08 U= 164.500 p=0.008
Test Z=−1.732 Z=−3.529
pp= 0.083 p=0.001
Note: Bold values are statistically significant.
Abbreviations: MAAS, Mindful Attention Awareness Scale; PPSRS, Physio−Psycho−Social Response
Scale; PSS, Perceived Stress Scale; U, Mann−Whitney Utest; Z, Wilcoxon test.
UYSAL AND ÇALIŞKAN
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effects of the MSBR program, we recommend further studies with
longer MBSR programs and follow‐up measurements; these should
include larger sampling to generalize the results. The results of the
present study offer insights. Nursing students experience significant
stress during their professional education and because universities,
lecturers, and students themselves may not be fully aware of the
issue of stress, educational interventions that promote awareness
and provide strategies to reduce stress are needed. MBSR is a
nonpharmacological approach and mindfulness can be practiced
virtually at any time and anywhere. Psychiatric nurses can take an
active role in implementing MBSR programs to reduce student stress.
At the same time, they can teach MSBR to other faculty members.
AUTHOR CONTRIBUTIONS
Both the authors designed the study, searched the literature, analyzed the
data, prepared the article, and approved the final version for submission.
ACKNOWLEDGMENTS
The authors would like to thank their participants.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
DATA AVAILABILITY STATEMENT
Data available on request due to privacy/ethical restrictions. The data
that support the findings of this study are available from the author
upon reasonable request.
ORCID
Nurcan Uysal http://orcid.org/0000-0002-1325-9826
Behice Belkıs Çalışkan https://orcid.org/0000-0001-7249-2954
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How to cite this article: Uysal, N. & Çalışkan, B. B. (2022). The
effects of mindfulness‐based stress reduction on mindfulness
and stress levels of nursing students during first clinical
experience. Perspectives in Psychiatric Care,1–7.
https://doi.org/10.1111/ppc.13104
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