Nurse Education Today 35 (2015) 86–90

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Effects of mindfulness-based stress reduction on depression, anxiety,

stress and mindfulness in Korean nursing students
Yeoungsuk Song a,⁎, Ruth Lindquist b,1
a
Kyungpook National University, College of Nursing, Daegu, South Korea
b
University of Minnesota, School of Nursing, Minneapolis, MN, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Nursing students often experience depression, anxiety, stress and decreased mindfulness which
Accepted 30 June 2014 may decrease their patient care effectiveness. Mindfulness-based stress reduction (MBSR) effectively reduced
depression, anxiety and stress, and increased mindfulness in previous research with other populations, but
there is sparse evidence regarding its effectiveness for nursing students in Korea.
Keywords: Objectives: To examine the effects of MBSR on depression, anxiety, stress and mindfulness in Korean nursing
Mindfulness-based stress reduction
students.
Depression
Anxiety
Design: A randomized controlled trial.
Stress Participants/Setting: Fifty (50) nursing students at KN University College of Nursing in South Korea were
Mindfulness randomly assigned to two groups. Data from 44 students, MBSR (n = 21) and a wait list (WL) control (n =
23) were analyzed.
Methods: The MBSR group practiced mindfulness meditation for 2 h every week for 8 weeks. The WL group did
not receive MBSR intervention. Standardized self-administered questionnaires of depression, anxiety, stress and
mindfulness were administered at the baseline prior to the MBSR program and at completion (at 8 weeks).
Results: Compared with WL participants, MBSR participants reported significantly greater decreases in
depression, anxiety and stress, and greater increase in mindfulness.
Conclusion: A program of MBSR was effective when it was used with nursing students in reducing measures of
depression, anxiety and stress, and increasing their mindful awareness. MBSR shows promise for use with
nursing students to address their experience of mild depression, anxiety and stress, and to increase mindfulness
in academic and clinical work, warranting further study.
© 2014 Elsevier Ltd. All rights reserved.

Introduction Anxiety and depression are often experienced simultaneously. De-

Over 29% of college students reported depression in Korea and the
United States (American College Health Association-National College
Health Assessment [ACHA-NCHA], 2013; Chung and Kim, 2010).
Depression is known to lead to societal problems or to suicide. Indeed,
suicide is a serious problem in Korea and is the leading cause of death
of Koreans in their twenties (Statistics Korea, 2012). In the U.S., to iden-
tify effective depression prevention strategies, the American College
Health Association (ACHA) has implemented the nationwide mental
health needs of college students and promoted the health programs
(Buchanan, 2012).
⁎ Corresponding author at: Kyungpook National University, College of Nursing, 101
Dongin-dong, Jung-gu, Daegu 700-422, South Korea. Tel.: +82 53 420 4978; fax: +82
53 421 2758.
E-mail addresses: asansong@knu.ac.kr (Y. Song), lindq002@umn.edu (R. Lindquist).
1
Tel.:+1 1 1 612 624 5646; fax: +1 1 1 612-625-7180.
pression affects about 67% of college students with anxiety, and anxiety
was a major predictor of depression for nursing students (Mahmoud
et al., 2012; Song, 2011). Anxiety has been shown to be affected by
emotion-oriented coping styles including emotional responses, self-
preoccupation, and fantasizing reactions; thus, it is likely that an adap-
tive coping program such as mindfulness-based stress reduction
(MBSR) program may decrease depression, anxiety, and stress (Shikai
et al., 2009; Warnecke et al., 2011).
Stress is an important psycho-social factor in the educational process
that may influence academic performance and student well-being
(Jimenez et al., 2010). Significantly profound stress is experienced by
nursing students as they work with patients in the clinical setting. The
most stressful aspect of student nurses' clinical practice was seeing the
pain and suffering of the patients (Jimenez et al., 2010). However, for
nursing students, the level of academic stress was even higher than
that of clinical stress (Chan et al., 2011). Nursing students who graduate
from nursing schools often take positions as nurses in stressful or
anxiety-provoking roles in the provision of patient care; furthermore,

http://dx.doi.org/10.1016/j.nedt.2014.06.010
0260-6917/© 2014 Elsevier Ltd. All rights reserved.
 Y. Song, R. Lindquist / Nurse Education Today 35 (2015) 86–90
their patients may be experiencing similar emotions. Thus, nursing
students need to know how to manage their stress and emotions. A
program teaching self-management of stress and anxiety such as
MBSR may provide benefits to the students in their academic pro-
gram and, if practiced, it may enhance their future professional nurs-
ing practice.
Mindfulness is viewed not as something to get or to acquire, but
as an internal resource that already exists, patiently awaiting to be
reawakened (Center for Mindfulness, 2014). Increased mindfulness
has been found to be related to improved psychological functions, and
it led to reductions in suffering; it has been shown to be an important
predictor of depression in nursing students (Baer, 2009; Song, 2011).
MBSR programs have been shown to be effective (Chen et al., 2013;
Dobkin and Zhao, 2011; Warnecke et al., 2011), however, the potential
benefits of MBSR to decrease depression, anxiety, stress and increased
mindfulness are less well-established among nursing students in
Korea. Therefore, the purpose of this study was to examine whether
MBSR is effective, and has potential as an intervention to decrease
depression, anxiety and stress, and to improve mindfulness of Korean
nursing students.
Background
MBSR programs have been studied, and scientific evidence has been
generated demonstrating that they can have a profound benefit via the
mind-body connection; the practice of mindfulness results in an in-
crease of awareness, by purposefully paying attention in the present
moment, and nonjudgmentally unfolding experiences, moment by mo-
ment (Center for indfulness, 2014; Kabat-Zinn, 2003). MBSR was devel-
oped in a behavioral medicine setting for populations with a wide range
of chronic pain and stress-related disorders (Baer, 2009). As pointed out
by Baer, a standard MBSR program is conducted as an 8 to 10-week
course, meeting 2–2.5 h weekly coupled with home practice most
days. An all-day intensive mindfulness session for 7–8 h in one day is
held around the sixth week. Several mindfulness meditation skills are
taught. The body scan is a 45-min exercise in which attention is directed
to any areas of the body while lying down. Sitting meditation is
instructed to sit in a relaxed and wakeful posture with closed eyes and
to pay attention to the sensations of breathing. Hatha yoga is taught to
help one achieve awareness/mindfulness of bodily sensation during
movements and stretches. Participants also practice mindfulness for
walking, standing and eating.
Effects of MBSR on Depression and Anxiety
In previous studies examining the effects of MBSR on depression and
anxiety, about one-half (8 out of 15) of the studies reported a statistical-
ly significant reduction in anxiety or depression after MBSR (Toneatto
and Nguyen, 2007). Hazlett-Stevens (2012) reported that MBSR had
potential beneficial effects in the treatment of anxiety and depression,
and also as an alternative treatment for comorbid anxiety and depres-
sive disorder symptoms. In the literature review of the effects of MBSR
on depression and anxiety research, MBSR was found to be an effective
program for the management of anxiety and depression in clinical
populations (Niazi and Niazi, 2011).
Effects of MBSR on Stress
In a systematic review on the effects of MBSR, most studies found the
positive findings for persons with substance use disorders, breast can-
cer, premed students and health care professionals (Song et al, 2010).
For example, in one small study with 36 nurses, the practice of MBSR
resulted in reduced levels of stress (Bazarko et al., 2013).
87
Effects of MBSR on Mindfulness
In a review of literature on mindfulness studies conducted with sam-
ples from the general population, the practice of MBSR resulted in sig-
nificant increases in mindfulness (Nyklíček and Kuijpers, 2008;
Dobkin and Zhao, 2011; Robins et al., 2012). Shirey (2007) reported
that teaching an evidence-based strategy such as mindfulness may facil-
itate student handling of stress, and mindfulness was negatively related
with depression, anxiety and stress in nursing students (Song, 2011).
Mindfulness studies employing MBSR for nursing students are few
and the effects of MBSR on nursing students are less well-known.
South Korean nursing students similar to U. S. counterparts experi-
ence depression, anxiety, stress and mindfulness which may affect
their academic and clinical performance. Therefore, this study was
designed to examine the effects of the MBSR program on depression,
anxiety, stress and mindfulness of nursing students in South Korea.
Methods
Design and Sample
A two-group randomized controlled, pretest-posttest design was
used. Eligible participants were around 460 undergraduate nursing stu-
dents (1st–4th grades) from KN University College of Nursing in South
Korea. The treatment (MBSR) group participated in an 8-week MBSR
course; the other group comprised a wait-list (WL) control group.
None of the students in either group had been previously exposed to
MBSR. Participants met the following inclusion criteria: no regular med-
itation and yoga practice within the past 6 months; no current psychiat-
ric symptoms; and no physical contraindications to exercise. Sample
size was employed by G*power 3 program which provides improved ef-
fect size calculators (Faul et al., 2007), and had determined the mini-
mum number of subjects to study the effects of intervention. The
required sample size was 26 per group: Significance level (α = .05),
large effect size (d = .80), and power (80%). Fig. 1 shows the flow of
the participants’ enrollment and randomization: 52 nursing students
were needed for this study, however 50 participants responded which
is 10.9% of all nursing students and each group of 25 was randomized
(two participants less than our desired sample size). On the basis of
25 students for the MBSR group, 2 students were excluded that could
not find time or take the class at the designated time to participate in
this program. After intervention, one participant withdrew for religious
reasons and one was withdrawn for not attending intervention session
for more than 3 times in the MBSR group. Two students in WL group
failed to follow-up at 8 weeks. Thus, the analysis was done with 21
participants in the MBSR group and 23 participants in the WL group.
Instruments
Depression, anxiety and stress were measured with the Depression,
Anxiety and Stress Scale-21 (DASS-21; Psychology Foundation of
Australia, 2013). The scale has 21 items in three scales: depression
(DASS-D), anxiety (DASS-A) and stress (DASS-S). DASS-21 is a short
version of the original 42-item questionnaire, comprising 7 items per
scale. The items are scored on a 4-point Likert-type scale of 0 to 3 (0
= not at all, 3 = most of the time), and the total scores for each scale
are to be multiplied by the sum of 2. Possible range for each scale is
from 0 to 42, with higher scores indicating more depression, anxiety
and stress. Cronbach's alphas for depression, anxiety and stress were
found to be .82, .90 and .93, respectively (Henry and Crawford, 2005).
In the present study, Cronbach's alphas were .81, .72 and .80 for de-
pression, anxiety, and stress.
The Mindfulness Attention Awareness Scale (MAAS) Korean version
that was developed by Park (2006) was used as a measure of mind-
fulness. This scale contains four subscales, including present awareness,
concentration, non-judgmental acceptance and de-centered attention;
88 Y. Song, R. Lindquist / Nurse Education Today 35 (2015) 86–90

Assessed for eligibility (N=52)

did not wish to participate (n=2)

Randomized (N=50)

Intervention group (n=25) Wait-list control group (n=25)

Received intervention (n=23)

Did not receive intervention/ Stayed on wait-list (n=25)
could not find time to
participate (n=2)

Post intervention measurement Post wait-list measurement

(n=21): (n=23):
Withdrawn (n=2) Lost to follow up (n=2)

Analyzed (n=21) Analyzed (n=23)

Fig. 1. Flowchart of participants' enrollment and randomization.

the subscales comprise 5 items each. The full scale comprises 20 items
that are answered on a 5-point Likert-type scale (1 = not at all, 5 = al-
most always). All questions include negative content. Therefore, when
the score of mindfulness is calculated, raw data are recoded from nega-
tive to positive scores. Higher scores indicate more mindfulness. The
Cronbach's alpha at the time of development was .72 (Park, 2006).
The Cronbach's alpha for our sample was .93.
Data Collection and Procedures
The protocol for this study was reviewed and approved by the
Human Ethics Committee of the University in South Korea where the
students were enrolled. Flyers containing detailed information about
the MBSR study with inclusion criteria were posted on the web site
and on the community board in the nursing school. 50 students
responded to the invitation to participate, and written informed consent
was obtained from these students. After consent, students were ran-
domly assigned to either the treatment (MBSR) or the WL control
group. Students in both groups completed a demographic form and
questionnaire on depression, anxiety, stress and mindfulness for the
baseline, prior to starting the MBSR program.
The MBSR intervention was led by a trained instructor with over
10 years of background experience in MBSR. The main contents of the
MBSR program were the standard elements of yoga, sitting, walking,
breath-work, body scan, and eating meditation. This program was pro-
vided on 8 days and each session was 2 h per week for 8 weeks. Par-
ticipants followed a guided instruction on mindfulness meditation
practices, gentle stretching, group discussion and home assignments
during the 8 week course. On the first day, participants were informed
about the MBSR program; they stretched for 30 min, practiced mindful
body scan meditation for 1 h, and shared their feelings for 30 min. The
instructor gave homework at the end of each session which generally
related to what was learned and practiced during that weekly session.
From the second through eighth week, participants discussed the
homework for the first 30 min, stretched and practiced guided instruc-
tions in mindfulness meditation practices including eating (week 2),
breath-work (week 3), sitting (week 4), walking (week 5), yoga
(week 6), combined eating and breath-work (week 7), and combined
walking and yoga (week 8) for 1 h, and then during the last 30 min,
they shared their feelings.
The students assigned to the WL group did not receive MBSR inter-
vention for 8 weeks when participants in MBSR were engaged in the
MBSR intervention. Participants in WL group were reminded to not
 Y. Song, R. Lindquist / Nurse Education Today 35 (2015) 86–90 89

be in contact with students of the MBSR group in their practice of MBSR; Table 2
they were also assured that they would be taught the practice of MBSR Outcomes of ANCOVA for depression, anxiety, stress and mindfulness between the MBSR
group (N = 21) and WL group (N = 23).
in a program after the study was finished. During the eighth week, at the
conclusion of the program, questionnaires were administered again to Variables Pretest Posttest
evaluate depression, anxiety, stress and mindfulness in both groups. MBSR WL MBSR WL F⁎ p
Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Depression 8.3 (5.1) 8.6 (8.9) 4.1 (4.0) 8.5 (7.6) 10.99 .002
Data Analysis Anxiety 6.7 (12.6) 5.9 (6.3) 2.8 (4.1) 5.9 (7.4) 5.61 .023
Stress 34.5 (12.5) 30.0 (12.2) 7.4 (4.9) 13.7 (8.9) 15.31 b.001
The SPSS program was used to analyze the data. Chi-square and t- Mindfulness 69.8 (10.6) 77.7(16.3) 80.6(11.3) 79.0 (12.6) 5.03 .010

tests were employed to compare the baseline measurements of the de- Note: MBSR = mindfulness-based stress reduction; WL = wait-list.
mographic and dependent variables between the two groups. Analysis ⁎ F score is from Analysis of Covariance with pretest scores as covariates.

of covariance (ANCOVA) was used to compare depression, anxiety,

stress and mindfulness scores between the MBSR and WL groups.
Discussion

Results Compared with the WL group, the MBSR program resulted in sig-
nificantly greater decreases in depression, anxiety and stress, and
Sample Description increases in mindfulness in the present study.
In our study of the effectiveness of MBSR on depression, anxiety and
Table 1 shows socio-demographic variables of nursing students; stress the mean scores of the MBSR group decreased more than the
there were no significant differences between the MBSR and WL groups. mean scores of the WL, in which group the scores had little change.
Four participants in each group were males, and more than 81% of each This finding is consistent with the study of Nyklíček et al. (2014)
group were females. The mean age was 19.6 years. (SD 1.7) in the MBSR which examined the effects of MBSR on 107 percutaneous coronary in-
group and 19.5 (SD 2.0) in the WL group. Participants reported specific tervention patients. Nyklíček et al. reported that an MBSR program com-
religious affiliation as Christian, Buddhist, Catholic, and none; 52.4% of prising instructions of 90–120 min for just three sessions weekly (a brief
MBSR group and 60.9% of WL group had no religious belief. MBSR program) was effective in reducing depression, anxiety and
stress. Chen et al. (2013) found anxiety and depression that decreases
in anxiety scores were significantly greater in the MBSR group than in
Outcomes of Pretest and Posttest Between the two Groups the WL group. Meanwhile, it was not significant for depression between
the two groups. For Chen et al., the study program on MBSR was prac-
At the baseline, there were no significant differences between the ticed for 30 min daily for 7 consecutive days; the possible reason for
groups in depression, anxiety, stress and mindfulness. To examine the this negative finding was that the short-length intervention program
treatment effects between groups, ANCOVA, using pre-test scores as in comparison with the full-length MBSR program did not have any in-
the covariates, was used. Table 2 presents results of the scores and fluence on depression.
statistics for each outcome variable. Scores of depression in the MBSR In prior research on MBSR using 32 nursing students, the MBSR pro-
group were decreased by more than half (from 8.3 to 4.1) and those gram was provided for 1.5–2 h weekly for 8 weeks (Kang et al., 2009). In
of depression in the WL group were slightly decreased (from 8.6 to another study, the MBSR program was practiced for 2.5 h each week for
8.5), and there was a significant difference between the two groups 8 consecutive weeks, and it demonstrated significant reductions in de-
(F = 10.99, df = 1, p = .002). Mean anxiety in the MBSR group was re- pression and stress for 83 chronically ill patients (Dobkin and Zhao,
duced by 3.9 points, whereas scores in the WL group were unchanged; 2011). It is possible that the duration of the MBSR programs (per one
there was a statistically significant difference between the two groups session) should be at least 1.5 h in order to have any significant effects
(F = 5.61, df = 1, p = .023). Mean stress in the MBSR group decreased on psychological symptoms such as depression, anxiety and stress.
by 27.1, and stress decreased by 16.3 in the WL group; there was a Our study supports that a standard MBSR program having 2–2.5 h per
statistically significant difference between the groups (F = 15.31, week of practice can decrease depression, anxiety and stress for nursing
df = 1, p b .001). The effect of MBSR on mindfulness was also significant. students. Therefore, for the effects on depression, anxiety and stress, the
Mindfulness increased an average 10.8 in the MBSR group, versus 1.3 in length of the MBSR program needs to be attained from a program of
the WL group (F = 5.03, df = 1, p = .010). standard intensity.
With respect to mindfulness, the mean score of the MBSR group
had increased 10.8 points, however the mean was increased by only
1.3 points in WL group; there was a statistically significant difference
Table 1 between groups in the present study. In prior studies, mindfulness
Demographic comparisons of nursing students in the MBSR (N = 21) and WL (N = 23) scores post-MBSR were significantly increased while the score of the
groups. WL groups decreased for patients with symptoms of distress and adults
Characteristic MBSR WL χ2 (t) p
(Nyklíček and Kuijpers, 2008; Robins et al., 2012). In addition, the
n(%) or M ± SD n(%) or M ± SD current findings of the positive effects of MBSR are consistent with the
reports from Dobkin and Zhao (2011) in which mindfulness was posi-
Gender
17(81.0) 19(82.6) .02 .887 tively changed post-MBSR for 83 chronically ill patients. Through at-
Female
tending in the MBSR program, this study shows that nursing students
4(19.0) 4(17.4)
Male may control and improve their mindfulness. In so doing, they can direct
Age 19.6 ± 1.7 19.5 ± 2.0 .33 .744 their energy and attention to support patients and to provide high qual-
Religion ity, patient-centered care.
10(47.6) 9(39.1) .32 .570 In this study, 84% of participants were analyzed in the MBSR group.
Yes
11(52.4) 14(60.9) Of those who completed and were analyzed, compliance was good
None
and the data supported the feasibility of providing an MBSR program
Note: MBSR = mindfulness-based stress reduction; WL = wait-list. for the nursing students. The present study provides supporting
90 Y. Song, R. Lindquist / Nurse Education Today 35 (2015) 86–90
evidence that an MBSR program can help to improve mindfulness as
well as manage and decrease depression, anxiety and stress of nursing
students. Our study supports that consideration for the implementation
of a program on MBSR for nursing students is a reasonable approach
which may have positive effects when there is concern about students'
depression, anxiety, stress or limited mindfulness. However, our
study should be replicated, and evaluated in future research with
samples representing the population of students interests. If MBSR
programs are used clinically, apart from research, in educational set-
tings, evaluations of effects are warranted to assess the impact.
Limitations. The results of this study cannot be generalized to other
settings due to the small and non-representative sample. Most partici-
pants were females in this study. In South Korea, nursing students are
typically female, thus findings should not be generalized to male nurs-
ing students. In our study, participants in the MBSR group were given
homework and whether they actually did their homework was not
confirmed. We did not check contamination that might have occurred
between the two groups (e.g., WL participants observing or participat-
ing in MBSR homework or conversations related to MBSR). Extraneous
variables that may affect stress, anxiety and depression, such as year,
credit hours, or clinical practicum were not considered, and ANCOVA
was employed to statistically control baseline differences between
two groups in this study.
Conclusions
This study found that a standard MBSR program had salutary effects
on depression, anxiety, stress and mindfulness of Korean nursing
students. MBSR is a non-pharmacological approach; and mindfulness
can be practiced virtually at anytime and anywhere. We suggest that
the use of MBSR programs could be expanded to medical students or
to other health providers including practicing nurses, doctors and so
on, and to improve psychosocial status and mindful attentiveness to pa-
tients' needs.
As nursing students and nurses are exposed to MBSR in the early
nursing socialization, they can learn coping skills and then the number
of nurses to give up on becoming a nurse in a time of nursing shortage
will be decreased. We recommend the research that MBSR is affected
on nurse retention as a longitudinal study.
The MBSR program in the current study was performed for 8 weeks.
Some MBSR studies using shorter or abbreviated programs were not as
effective; however the current study outcomes appear to be affected by
the use of a brief-MBSR program. More research is needed to explore
ways that shorter programs (which consume less time and resources)
can be maximized to generate positive effects.
Mindfulness is the same as present awareness and it seems to mean
positive psychology or spirit. This concept is similar to resilience, which
is the capacity to move into a positive way from a negative experience in
physiology and psychology (Jackson et al., 2007).
Future research needs to be done to further examine the potential
for mindfulness training of healthcare providers to benefit patients
and providers themselves.
Acknowledgments
This research was supported by the Basic Science Research Program
through the National Research Foundation of Korea (NRF) funded by the
Ministry of Education, Science and Technology (2011-0013101). We
wish to acknowledge the student participants in this work who are
diligent in their work preparing for their future to serve as professional
nurses in South Korea.
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