Effects of laughter yoga practiced by the first year nursing students before clinical practice on their perceptions of stress and meaning of life: a randomized controlled trial
Laughter yoga has a positive effect on the person’s mental/general health, life satisfaction and psychological well-being and enables the person to cope with stress.
Objective
This randomized controlled study was conducted to determine the effect of laughter yoga practiced by first year nursing students before clinical practice on their perceptions of stress and meaning of life.
Method
In this experimental randomized and controlled study including a control group, we administered a pre-test, post-test one and post-test two to the participating students. Ninety nursing students who met the inclusion criteria comprised the study sample. The students in the intervention group took part in eight sessions of laughter yoga for four weeks, twice a week. The Descriptive Information Form, Perceived Stress Scale, and Meaning and Purpose of Life Scale were administered to collect the study data.
Results
The mean age of the students in the intervention and control groups was 19.65 ± 2.27 and 19.18 ± 1.01 years, respectively. Of the participants in both groups, 91.1% were women, and 97.8% were single. The difference between the mean scores obtained from the Perceived Stress Scale and the Meaning and Purpose of Life Scale by the students in the intervention group at the pre- and posttest were statistically significant (p < 0.05).
Conclusion
Laughter yoga positively affects nursing students’ perceptions of stress and meaning and purpose of life.
Trial registration
Trial Registration number and Date of registration: NCT06042959 / 09/14/2023 06:17.
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Publisher’s Note
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Introduction
Nursing is a health discipline that requires theoretical knowledge and clinical practice skills. Nursing education consists of theory and practice that complement each other. During the education process, theoretical knowledge given in the classroom is transferred to the skill applications performed in the laboratory and clinical setting. Clinical education, the most important part of nursing education [1, 2], ensures the integration of theoretical knowledge and practice, and enables students to learn by doing and experiencing in an actual setting. In addition, nursing students perceive the clinical experience period during clinical training as the most stressful period throughout their education [2‐7]. The clinical education is affected many factors, such as the physical environment, patients, instructors, clinic nurses, and other healthcare professionals [1, 2]. Fear of harming the patient due to lack of theoretical knowledge or skills in practical applications, requirements of emergency intervention, the patient's death, fear of making a mistake, unclear expectations of the trainer, thoughts such as being exposed to negative reactions, low self-confidence, inability to establish adequate communication and empathy can cause students to suffer from clinical stress and they try to cope with this stress [3, 5, 6, 8‐10]. Nursing students’ stress and anxiety levels increase as they put their theoretical knowledge into the clinical work and deal with their first patients in new environments while they are observed by their clinical instructors and their peers [7]. In the literature, it is reported that nursing students experience higher levels of stress than do students in other disciplines [7, 11, 12]. In the literature, it is also reported that stress and anxiety experienced by students especially in clinical setting affect their learning and performance and are an important factor that reduces the effectiveness of education [3, 5], and that they reduce students’ quality of life, and negatively affect their professional identity development and health [3, 5, 12].
If a student is to complete the nursing education and gain professional knowledge and skills at the targeted level, it is important for him or her to manage the stress he or she suffers [10]. The first clinical practice can be characterized by irregularities, urgencies, visits to special clinics and fear of making mistakes. Therefore, nursing students who are considered at high risk for stress should use different approaches to reduce the level of stress caused by various reasons. One of these approaches is laughter yoga.
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Laughter, defined as a phenomenon that is seen in the organism, has universal and unique social functions [13], and is a natural part of our life. It is a natural, sincere, innate and natural response to a humorous stimulus [14, 15]. Laughter is known as an activity that can change one’s emotional state, increase his or her attention, and provide mental relaxation [16].
Laughter yoga developed by Kataria in 1995 is a non-pharmacological and non-invasive complementary therapy method that combines unconditional laughter and breathing techniques [16‐19] Laughter yoga and laughter therapy are mostly used to mean the same in the literature [15, 18]. Laughter therapy sessions include hand clapping, warm-up exercises, deep breathing exercises, childish games and laughing exercises [15, 20, 21]. Laughter yoga has a positive effect on the person’s mental/general health, life satisfaction and psychological well-being, mitigates the level of stress hormones and enables the person to cope with stress [15, 16, 22‐26].
Our review of the studies conducted with nursing students revealed that studies were mostly carried out about the effects of laughter yoga on exam anxiety and stress, simulation training, employment stress [22, 23, 27]. However, The search for studies in which the effect of laughter yoga on the meaning and purpose of preclinical life and on the reduction of perceived stress was investigated revealed a gap in the literature.
Aim and hypotheses
In the present study, the aim was to investigate the effect of laughter yoga on the first year nursing students’ perceptions of stress, and meaning of life before they carried out clinical practice. Thus, the following hypotheses were tested:
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H1. Laughter yoga reduces the level of stress perceived by students before clinical practice.
H2. Laughter yoga improves students’ perceptions of meaning of life before clinical practice.
Methods
This study is a randomized controlled trial with parallel groups. A pre-test, post-test one and post-test two were administered to the participating students. The study was registered at ClinicalTrials.gov with the identifier NCT06042959.
Ethical consideration
Before the study was started, written approval was obtained from XXXXX faculty’s ethics committee (decision date: February 02, 2023, approval number: 401).Written permission was obtained from the Dean’s Office of the Faculty of Health Sciences of a university to collect the research data. The present study was carried out in accordance with the principles outlined in the Declaration of Helsinki. The participating students gave their written consent indicating that they volunteered to participate in the study after they were informed about the purpose and scope of the study.
Setting and samples
The study's population consisted of 216 first-year students with no clinical experience attending a State University's Nursing Department during the 2022–2023 academic year. First, the Descriptive Information Form was administered to the whole population (n = 216). It was aimed to reach all of the population, but 90 students who met the inclusion criteria constituted the sample. The inclusion criteria were as follows: volunteering to participate in the study, not having any psychiatric disease diagnosis, not having done laughter yoga before and/or not having any clinical experience. Those who did not attend yoga sessions regularly, those who used another relaxation method during this period, those who used antidepressants, those with chronic cough and/or urinary incontinence, those who underwent surgery in the last 3 months, those with neurological diseases such as epilepsy, multiple sclerosis and those who lost a close relative in the last 6 months were excluded from the study.
Ninety first-year nursing students were randomly assigned into the intervention and control groups via https://www.random.org, an actual random number selector website, until the number of students in each group reached 45 by 1:1 distribution.
The population of the study consisted of 216 first-year nursing students studying in the Nursing Department of the Faculty of Health Sciences. Forty students were excluded from the study because they did not meet the inclusion criteria, and 86 students did not want to participate in the study, leaving a potential pool of 90 nursing students. A power analysis was performed for the sample size. With 0.80 effect size, 0.90 power, and 0.05 margin of error, the sample size required for each group to determine whether the difference between the two groups' mean values was different from 0 was calculated as 35. The effect size was set at 0.78 for calculating sample size and was based on a study by Dönmez et al. on stress scores of nursing students [27]. Therefore, taking into consideration possible dropouts, the sample of the study comprised 90 students, 45 of whom were assigned to the intervention group and 45 of whom were assigned to the control group. The study was prepared in accordance with CONSORT guidelines (Fig. 1). No participants or data were lost in the present study.
Fig. 1
CONSORT Diagram
×
Data collection
The data were collected with the Descriptive Information Form, Meaning and Purpose of Life Scale (MPLS) and Perceived Stress Scale (PSS-10).
Descriptive information form
The form includes seven items questioning the students’ sociodemographic characterisitics.
MPLS
Aydın, Kaya, and Peker developed the scale in 2015 to measure how individuals perceive the meaning and purpose of their lives. Responses given to the scale items are rated on a five-point Likert type scale [28]. The scale consists of 17 items, 11 of which are positive and 6 of which are negative statements. The options for the positive statements are scored as follows: strongly agree (5), agree (4), undecided (3), disagree (2), and strongly disagree (1). The negative statements are reverse scored. The options for the negative statements are scored as follows: strongly agree (1), agree (2), undecided (3), disagree (4) and strongly disagree (5). Since the negative statements (Factor II, Negative sub-dimension) in the scale are reverse scored, a high score in this sub-dimension indicates that the person’s perception of the meaning and purpose of life is more positive. While the lowest possible score that can be obtained from the scale is 17, the highest possible score is 85. A high score indicates that the person’s perception of the meaning and purpose of life is more positive whereas a low score indicates the person’s perception of the meaning and purpose of life is more negative. Aydın, Kaya, and Peker used the test–retest, test-half test and Cronbach’s Alpha reliability control methods to check the reliability of the scale. The test–retest reliability coefficient was 0.74; test-half test reliability coefficient was 0.81, and the Cronbach’s Alpha reliability coefficient was 0.91 in their study [28]. In the current study, the Cronbach’s alpha internal consistency coefficient was 0.883.
PSS −10
Cohen et al. developed the 10-item PSS to reveal the perceived stress levels of individuals regarding certain events they experienced [29]. Eskin et al. carried out the reliability and validity study of the Turkish version of the PSS [30]. Responses given to the items are rated on a 5-point Likert-type scale ranging from 0 to 4 (0- Never, 1-Almost Never, 2-Sometimes, 3-Quite often, 4-Very Often). Items 4, 5, 7 and 8 containing positive statements are reverse scored. The minimum and maximum scores that can be obtained from the PSS are 0 and 40, respectively. The higher the score is the higher the level of stress is. The Cronbach’s alpha value of the PSS was 0.82 in Eskin et al.’s study and 0.745 in the current study.
Intervention
The person who implemented the intervention had the certificate. The researcher implemented the intervention by herself. She applied laughter yoga to the intervention group in the activity class. The intervention group took eight sessions of laughter yoga, that is, two sessions per week for 4 weeks. She determined the number of sessions to be held in the present study based on Yazdani et al.'s (2014) and Öztürk and Tezel’s (2021) studies [24, 25]. The review of studies in which the effect of laughter yoga on anxiety and stress was investigated demonstrated that there was a difference in the number of sessions [25, 31‐38].
For instance, in Kim et al.’s [33] and Le Texier’s [31] studies four and five sessions of laughter yoga, respectively were found to be effective on stress and anxiety. Therefore, in the present study, it was aimed to contribute to the literature by evaluating the effectiveness of laughter yoga after the 4th session. Due to the earthquake in Turkey, changes were made in the academic calendar of universities. Therefore, laughter yoga could be practiced for a maximum of 8 sessions since there was a 4-week period between the start of the theoretical and laboratory education and the time the student went to the clinic. As a matter of fact, there are studies in the literature supporting the present study in which laughter yoga was applied for more than 8 sessions [32, 35, 36]. Each laughter yoga session lasted about 40–45 min. The participants in the intervention group were asked to fill in the data collection tools before the laughter yoga sessions and after the 4th and 8th yoga sessions. The participants in the control group also filled in the data collection tools without undergoing any intervention.
Application of laughter yoga
Laughter yoga mainly includes stretching-relaxation techniques, laughter, and deep-breathing exercises. Laughter yoga sessions begin with light warm-up techniques consisting of stretching and stretching movements, songs, clapping, and body movements. A laughter yoga session is about 40–45 min long and consists of four parts. These sections are hand clapping and warm-up exercises (10 min), deep-breathing exercises (10 min), childish games (10 min), and laughter exercises (10–15 min). In each laughter yoga session, the first three parts are the same, and the laughter exercises in the fourth part vary. Laughter yoga sessions were held face-to-face.
Data analysis
In this study, students were randomly assigned to the intervention and control groups, and the data were recorded in the SPSS (Statistical Package for Social Science) 22.00 program by a person other than the researcher. A statistician performed statistical analyses and data reporting. That's why the person who did the statistical analysis was blinded instead of the researchers and students. In the analysis of the data, The descriptive statistics (mean, percentage and standard deviation) were performed. Independent samples t-test was used to evaluate quantitative variables between groups. ANOVA was used to test the changes in quantitative variables over time. Pearson correlation coefficient Post Hoc test was used to determine the level of correlation between the changes observed in the scales over time. Statistical significance was accepted as p < 0.05.were performed. Skewness and kurtosis values were determined to find out whether the data were normally distributed. Skewness and kurtosis values ranged between −1.96 and + 1.96. Therefore, in the analysis of the data, the parametric analysis was performed in groups whose number (N) exceeded 30 [39]. The statistical significance level was considered p < 0.05.
Results
The data on the sociodemographic characteristics of the participating nursing students were presented in Table 1. The mean age of the students in the intervention group was 19.65 ± 2.27 years. While 91.1% of them were women, 97.8% were single, 46.6% perceived their physical health as good, 53.3% perceived their mental health as moderate. The mean age of the students in the control group was 19.18 ± 1.01 years. While 91.1% of them were men, 97.8% were single, 66.6% perceived their physical health as good, and 50% perceived their mental health as moderate (Table 1).
Table 1
Socio-demographic characteristics of the students in the intervention and control groups (n = 90)
Age
\(\overline{X}\) ± SD
Intervention n1
Controln2
19.65 ± 2.27
19.18 ± 1.01
n
%
n
%
Sex
Men
4
8.9
41
91.1
Women
41
91.1
4
8.9
Marital status
Married
1
2.2
1
2.2
Single
44
97.8
44
97.8
Current place of residence
With family
12
26.7
7
15.6
State dormitory
33
73.3
38
84.4
Economic status
Income more than expenses
9
20.1
2
4.4
Income less than expenses
5
11.1
18
40.0
Income equal to expenses
31
68.8
25
55.6
Perceived physical health status
Poor
3
6.8
1
2.2
Moderate
21
46.6
5
11.1
Good
21
46.6
39
66.6
Perceived mental health status
Poor
11
24.5
12
26.6
Moderate
24
53.3
24
53.3
Good
10
22.2
9
20.0
n1 = 45 n2 = 45
There was a negative significant moderate relationship between the PSS-10 and the MPLS scores (p < 0.05). These findings suggest that the MPLS score decreases as the Purpose of Life Scale score increases (Table 2).
Table 2
Relationship between the Mean Scores obtained from the Perceived Stress Scale and Meaning and Purpose of Life Scale
Perceived Stress Scale
r
p
Meaning and Purpose of Life Scale
-.426
.000
Gr
Inter-group comparison of the mean scores obtained from the PSS-10 and the MPLS at the pre-test demonstrated that there was no statistically significant difference between the intervention and control groups in terms of their scores. At the posttest-1 administered after the students in the intervention group completed the 4th session of laughter yoga practice, no statistically significant difference was observed between the groups in terms of the mean scores they obtained from the PSS-10 and the MPLS. However, at the posttest-2 administered after the students in the intervention group completed the 8th session of laughter yoga practice, a statistically significant difference was observed between the groups in terms of the mean scores they obtained from the PSS-10 and the MPLS (p < 0.05) (Table 3).
Table 3
Comparison of the intervention and control groups in terms of the mean scores they obtained from the Perceived Stress Scale and Meaning and Purpose of Life Scale at the pre-test, post test1 and post-test 2
Intervention Group (n = 45)
Control Group (n = 45)
t/p
Intervention Group (n = 45)
Control Group (n = 45)
t/p
Meaning and Purpose of Life Scale
Meaning and Purpose of Life Scale
Perceived Stress Scale
Perceived Stress Scale
\(\overline{X}\) ± SD
\(\overline{X}\) ± SD
t
p
\(\overline{X}\) ± SD
\(\overline{X}\) ± SD
t
p
1) Pre-test
62.13 ± 8.65
60.09 ± 7.67
1.198
.234
22.02 ± 4.04
22.47 ± 4.62
-.496
.621
2) Post-test-1
(4. session)
62.78 ± 9.78
60.91 ± 7.98
.999
.320
20.61 ± 4.35
22.04 ± 5.19
−1.431
.156
3) Post-test-2
(8. session)
65.83 ± 7.46
61.78 ± 8.63
2.392
.019
17.74 ± 4.45
26.58 ± 8.26
−6.336
.000
F/p
F = 2.409
p = .094
F = .489
p = .614
F = 12.132
p = .000
F = 7.270
p = .001
-
-
1–2 > 3
3 > 1–2
The mean scores the students in the intervention group obtained from the PSS-10 at the posttest-1 and the posttest-2 were lower than the scores they obtained at the pretest (F = 12.132). However, the mean scores the students in the control group obtained from the PSS-10 at the posttest-1 and the posttest-2 were higher than the scores they obtained at the pretest (F = 7.270). There was a statistically significant difference between the two groups. The difference stemmed from the mean scores they obtained at the posttest-2 (Table 3).
These results indicate that Laughter Yoga applied to the participants in the intervention group had a positive effect on their perceived stress levels. On the other hand, perceived stress levels gradually increased in the participants in the control group who did not undergo any intervention.
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Discussion
The present study was conducted to determine the effect of laughter yoga practiced by the first-year nursing students before they carried out clinical practice on the scores they obtained from the PSS-10 and Meaning and Purpose of Life Scale. In the present study, stress levels of the students who received laughter therapy, no statistically significant difference was found in the stress levels of students receiving laughter therapy after the fourth session (post-test 1). In studies conducted with different sample groups in the literature, laughter yoga was found to be effective on anxiety and stress after the fourth [33] and fifth session [31]. The results of the present study are not consistent with those in the literature. It is thought that the earthquake experienced in our country, Turkey, affected this result. After 8 sessions of laughter yoga, it was observed that the stress level of the students decreased statistically significantly (post-test 2). This finding supports hypothesis H1. Laughter yoga reduces the level of stress perceived by students before clinical practice. In the literature, it is stated that laughter therapy helps students to decrease their stress and anxiety [16, 17, 19, 27, 31]. In their study, Arıkan Dönmez et al. reported that laughter yoga helped nursing students decrease their anxiety and perceived stress levels related to simulation training [27]. In another study in which the effect of laughter yoga on exam anxiety of the first-year nursing students before they took the clinical practice exam was investigated, the mean scores they obtained from the Test Anxiety Scale decreased after the laughter yoga practice, but the difference was not statistically significant [22]. On the other hand, the results of a study Öztürk and Tekkas Kerman conducted to investigate the effects of an online laughter therapy, based on stress, anxiety, and depression of nursing students during the COVID-19 pandemic in Turkey in 2022 revealed a significant difference between the groups in terms of their depression scores after the intervention, but had no effect on the anxiety and stress levels of the participants in the intervention and control groups [14]. This result was probably because laughter yoga was practiced online during the pandemic. These findings suggest that laughter yoga positively affected stress of nursing students, which is almost consistent with the results of the present study. Laughter yoga can be a good practice in the management of care by helping nursing students who will practice this profession in the future to provide quality care services and to improve their and their patients’ well-being. In studies in which the effect of laughter yoga on nurses’ and healthy adults’ stress levels was investigated, laughter yoga was reported to reduce their stress and burnout levels and to be an effective method in improving their psychological and physiological conditions [19, 40]. These results are consistent with those of the present study. The quest to make life meaningful, which has a fundamental motivating power in human life, is considered a positive personality trait, which is a sign of psychological well-being and facilitates adaptation to major stressful events in life. The meaning of life gains importance especially in situations in which very challenging stressful life events take place [41]. In the present study, the meaning and purpose of life levels of the participating students who received laughter therapy increased significantly after the eight sessions. This finding supports hypothesis H2 “Laughter yoga improves students’ perceptions of meaning of life before clinical practice”. The change in the current living conditions of students due to the pandemic that lasted more than 3 years all over the world and the earthquake which hit Turkey negatively affected the perceived well-being towards the meaning and purpose of life. It is stated that laughter reduces loneliness and self-esteem, renews energy and hope, and promotes empowerment [42]. Considering that the students moved away from the environments where the mentioned problems were experienced and entered a new social and academic environment, it can be said that this result was expected. There are no studies in the literature in which the effectiveness of laughter therapy on nursing students’ perception of the meaning of life was investigated. However, in several studies, the effect of laughter therapy on nursing students’ life satisfaction, psychological well-being, and general health has been investigated. Eraydın ve Ecevit Alpar (2022) revealed that laughter therapy positively affected nursing students’ life satisfaction, and psychological well-being [16]. Yazdani et al. reported that laughter yoga had a positive effect on nursing students’ general health and decreased their anxiety and depression [25]. Sis Çelik ve Kılıç (2022) found that laughter yoga was an effective method that can be used to improve life satisfaction in nursing [19]. The results of the present study are consistent with those of studies in the literature.
In the present study, a moderate negative correlation was determined between the scores obtained from the PSS-10 and the Meaning and Purpose of Life Scale. These findings show that the level of perception of meaning and purpose of life decreases as the level of perceived stress increases. The meaning of life, which greatly attracts psychologists’ attention, is positively related to positive life events such as coping with stress, well-being, perceived health, happiness, and life satisfaction but negatively associated with negative life events such as stress and depression [34]. In this context, it can be said that this is an expected result. In fact, as stated in a study, the result that reducing anxiety levels of nursing students with laughter therapy can increase their psychological well-being and life satisfaction supports the result of the present study [16].
Conclusions
The results of the present study conducted to examine the effect of laughter yoga on the stress perceived by nursing students and the meaning and purpose of life, demonstrated that the practice had a positive effect. These results indicate that laughter yoga applied to the participants in the intervention group had a positive effect on their perceived stress levels. On the other hand, perceived stress levels gradually increased in the participants in the control group who did not undergo any intervention. There was a negative significant moderate relationship between the perceived stress and the meaning and purpose of life.We recommend that studies in which the Effects of Laughter Yoga Practiced by First Year Nursing Students before Clinical Practice on Their Perceptions of Stress and Meaning of Life are compared with the other health specialties. It is recommended that this study be conducted longitudinally and/or before and after clinical practice.
Relevance for clinical practice
Laughter yoga can be an effective strategy for improving students’ general health. Based on the findings of this study, further investigation of the effect of laughter yoga on different variables and student groups should be conducted with longer-term repeated measurements before and after clinical practice.
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Limitations
The participants of the present study are the first-year students enrolled in a state university. Therefore, the results are applicable only to the nursing students surveyed and they cannot be generalized to other nursing students. Another limitation was the limited time between the start of face-to-face education and clinical practice due to the earthquake disaster that hit 11 provinces in Turkey on 6 February 2023. The intervention group consisted of female participants, while the control group consisted of male participants.
Response
We did not plan 8 sessions thinking that it would make a difference.
Since at least 8 sessions were performed in the literature, we performed 8 sessions.
We determined the number of sessions to be held in the present study based on Yazdani et al.'s (2014) and Öztürk and Tezel’s (2021) studies.
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In the present study, stress levels of the students who received laughter therapy no statistically significant difference was found in the stress levels of students receiving laughter therapy after the fourth session (post-test 1). In studies conducted with.
Acknowledgements
Author is grateful to all the participants who voluntarily offered their time, conscientiously provided honest and thoughtful responses
Declarations
Ethics approval and consent to participate
Prior to the study, approval was obtained from the ethics committee of Manisa Celal Bayar University Clinical research ethics committee (decision date: February 02, 2023, approval number: 401) and institutional permission was obtained from the Provincial Health Directorate. Participants were informed about the study in accordance with the Declaration of Helsinki and their consent was obtained for the Informed Consent Form. Voluntary participants were included in the study. Volunteers who wanted to participate in the study were asked to fill out an informed consent form, which included the purpose and method of the study and the volunteers' rights regarding the study. Informed consent was obtained from all participants who agreed to participate in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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Effects of laughter yoga practiced by the first year nursing students before clinical practice on their perceptions of stress and meaning of life: a randomized controlled trial
