A Longitudinal Study of Students’ Perceptions of Using Deep Breathing

Meditation to Reduce Testing Stresses
Gina Paul
Medical/Dental Preparatory Program
Southern Illinois University School of Medicine
Carbondale, Illinois, USA

Barb Elam
Wellness Center
Southern Illinois University Carbondale
Carbondale, Illinois, USA

Steven J. Verhulst
Statistics and Research Consulting
Southern Illinois University School of Medicine
Springfield, Illinois, USA

Background: Stress can impact student performance. Yet few medical schools pro-
vide students with a consistent opportunity to develop and regularly practice stress-
reduction techniques to aid them academically.
Description: A curriculum component designed to assist 64 postbaccalaureate mi-
nority students in developing and practicing a stress-management technique was
implemented on a regular basis from June 2004 to April 2006. Students participated
in Deep Breathing Meditation exercises in two classes and completed pre-, post-, and
follow-up surveys each academic year.
Evaluation: Students reported having perceptions of decreased test anxiety, nervous-
ness, self-doubt, and concentration loss, using the technique outside of the two classes,
and believing it helped them academically and would help them as a physician.
Conclusions: The Deep Breathing Meditation technique was successfully imple-
mented each academic year, and it provided students with a promising solution for
meeting challenging academic and professional situations.
Teaching and Learning in Medicine, 19(3), 287–292 Copyright 
C 2007 Lawrence Erlbaum Associates, Inc.

It is widely accepted that medical school can be is stressful2,3 and that students’ main concerns are aca-
stressful.1−9 Since the late 1980s a growing number demic performance and/or test anxiety.2,5,6,12,14,18−21
of medical schools and universities have offered stu- Test anxiety, a type of distress, has a physiologi-
dents stress-reduction programs.10−14 More recently, cal component. Research studies have found that el-
schools such as Georgetown University, University of evations in corticosteroid levels (hormones released
Maryland School of Medicine, Stanford University, during times of distress) can impair declarative mem-
and University of Massachusetts Medical School have ory, concentration, and learning.22−26 Thus, high lev-
incorporated or introduced the use of mind-body ex- els of stress can make it more difficult for students
ercises into the curriculum to help students develop to concentrate and comprehend information.15 Conse-
stress-reduction techniques.10,12 Although there is an quently, students may have the cognitive ability yet
individual optimal stress level that can enhance one’s perform poorly in testing situations due to stress or a
performance, too much stress or test anxiety can also resulting test anxiety interfering with their concentra-
hinder an individuals performance.15−17 Studies have tion and ability to process information.27 In addition,
revealed that being a student, not just a medical student, there is a psychological component to test anxiety.27,28

We thank Mr. Thomas Shea for the collection of data and Mr. Jerry Passon for his editing skills.
Correspondence may be sent to Gina Paul, Academic Enrichment, School of Medicine, Wheeler Hall, Mailcode 4323, Carbondale, IL
62901-4323, USA. E-mail: rpaul@siumed.edu

287

fall piration. the presence or absence of academic stresses and their The purpose of this article is to describe a 10-month use of DBM. and in the 2nd year build a strong science founda- aphragmatic breathing showed significant increases in tion to prepare them for medical school matriculation. MCAT. PAUL. and June Methods 28. two items regarding their current use of combined study groups comprised 53 women and 11 DBM. as it is a technique to develop con.31 management. blood pressure. and spring semesters of the students’ discomfort. MED- exam to be a challenge or has low self-confidence from PREP courses include Biology. through April 13.7.30. anatomy. The VR course meets during the summer. and gastric (two sections). he or she may experience Career and Professional Development. Results from research stud. The Posttest Hispanic. ELAM. students’ academic learning and achievement. ical schools to help students learn effective coping strategies to alleviate the academic stresses associated Study Design with negative performance. and study/test-taking Many in academic medicine have called for med. genetics).17.. South- ern Illinois University School of Medicine’s Medi.” four items to ipated in the study. for Group 2. Verbal Reason- the physiological symptoms previously discussed in ing (VR). 2004. Thus.15. 4 daily DBM to help them academically. there were 58 Black. this is a descriptive a coping technique to manage their perceived academic study of MEDPREP students’ perceptions regarding stresses and/or test anxiety. the two groups assess the MEDPREP students’ perceived symptoms were surveyed at three different times using an instru- and beliefs regarding the stresses associated with test. at the con- (DBM) as a tool to counter the symptoms associated clusion of the summer semester 6 weeks later (Posttest) with testing stresses. the “self” during an exam rather than the task. for Group 1. we examined administered immediately prior to each group’s first the changes in their use of Deep Breathing Meditation MEDPREP course of the summer semester. The DBM Pretest was ing situations and academics.5. medicine to prepare for the MCAT during the 1st year ies that examined students who meditated or used di. and one item to determine their belief of using men. & VERHULST The worry or emotional arousal that can accompany seven percent of the students had taken the Medical test anxiety causes the student to become centered on College Admission Test (MCAT) prior to enrollment. ing as a stress management strategy. survey also included a belief question regarding the 288 . ment developed by the authors. physiology. Seventy. During their 1st academic year. and 1 Native American.29 All of the students begin their 1st academic year in Diaphragmatic breathing is known to counteract the June as a cohort. In addition. mer. and VR classes during the summer. muscle tension. The AE course has one section in the sum- diaphragmatic breathing is central to any meditation mer and fall. and Academic Enrichment (AE). enrolled in MEDPREP at Southern Illinois University All three surveys consisted of a definition of DBM as School of Medicine during the academic years of “several minutes of quiet time to focus on your breath- 2004–05 (Group 1) and 2005–06 (Group 2) partic. time management.Meditation can also be used to counteract 1st year and addresses the skill development for the stressful situations. students develop such skills as stress practice. The DBM instrument comprised questions with Participants forced-choice options using a 10-point Likert-type scale from 1 (never) to 10 (all the time) to track any Sixty-four postbaccalaureate premedical students changes in students’ perceived feelings and beliefs. 2006. this covered the period of June 29. 1 Asian. and in April 2005 and 2006 after each group had taken the MCAT (Follow-up). thus possibly negatively influencing future academic per- MEDPREP formance if no coping techniques are adopted.e. stu- fight or flight response symptoms that are often asso. Because the students are enrolled in the same AE cal/Dental Preparatory Program (MEDPREP) has ini. 2005. dents take MEDPREP courses and usually one cam- ciated with anxiety.12. The symptoms. through April 19.13. The latter addition to the symptoms associated with the fight or four courses have only one section during the sum- flight response that include increased heartbeat.18 students should use MEDPREP is a 2-year postbaccalaureate pro- diaphragmatic breathing during exams in attempts to gram designed to assist students underrepresented in calm or center themselves.32−34 Therefore. According to Harris and Coy. 2005. Chemistry.11. skills. 32 students participated in each assess feelings of negative test anxiety and associated academic year for a total of 64 participants. previous testing experiences.30 When a student perceives the pus course (i. Verbal Reasoning and Writing Sample sections of the centration and awareness to produce a calming effect. we were unable tiated a curriculum component to help students develop to have a control group. longitudinal study conducted over a 2-year period to During each 10-month study period. Of these participants. res. Physics.

At the end of each study concerning stress and test performance to create period 10 months later. Response previously listed (see Appendix). and self-doubt.32 The HeartMath device gaged in DBM are illustrated in Table 2. prior to and during the MCAT exam. PERCEPTIONS USING DEEP BREATHING MEDITATION use of DBM as helpful in medical school. Dur- ness. we also asked Group 2 stress management technique they could use whenever (N = 32) if they used DBM when starting to lose con- they perceived themselves to have feelings of distress centration during exams other than AE and VR. The students also began using diaphragmatic breathing central to DBM. before quizzes in classes other than AE and VR. The greatest changes occurred the remaining components of Benson’s Relaxation within the first 6 weeks during the summer semesters. the data were analyzes the heart rate and rhythm as a measure that derived from the April Follow-up surveys only to de- reflects either a shallow breath from the chest or deep termine if students utilized DBM outside of the AE and diaphragmatic breathing. our course component. script written and conducted by one of the authors The changes in mean scores in the six areas assessed who is a licensed counselor specializing in stress for each survey over the 10-month study period are il- management at the university. using a mental DBM before entering MEDPREP (data not shown) re- device such as concentrated breathing to direct one’s vealed that 67% (n = 43) of the students responded attention. California. this was followed anxiety. and during exams in classes other than AE and VR.e. mental state. 43 times during each fall semester. (n = 22) responded they used DBM to counteract that The AE and VR semester courses began with approx. greatest decrease occurred from the time between the To verify that students were able to fully elicit the Posttest to Follow-up. students performed period. 10-min session with and believed using DBM would help them academi- the counselor using the HeartMathR Stress Manage. 22% (n = 14) had practiced DBM receptive attitude. as recommended by Benson. and one item to identify all of the situations in which students utilized DBM since matriculating into MED.31 The first MEDPREP class that all only as needed. and paired.At the start All six areas changed significantly during that time of the second AE summer class.31 His technique has four basic compo. The data their use of DBM in the future and to what extent analyses of the three surveys were completed using the they became engaged in the DBM component during Statistical Analysis System to determine frequencies.31 outside of VR. This script incorporates lustrated in Table 1. cally. All of the students were able VR courses. The Follow.31 to associated with the AE or VR classes where it was reg- create a receptive attitude for using DBM as part of ularly practiced. asked the students to use the scale of 1 (not at all) to and 22 times during each spring semester for a total of 10 (completely) to tell us about their beliefs regarding 95 DBM sessions over each academic year. loss of concentration. nervousness. taining to the question regarding students practice of nents: working in a quiet environment. and having a duced to it in class. Although there of stress on learning and the body and results of was a significant decrease in students’ perceived feel- experimental studies that utilized meditation to ings of self-doubt during exams in the first 6 weeks. we summer semester. in addition to in- by a 1-hr lecture regarding the physiological effects creased concentration during exams. or anxiety symptoms and aid them in developing a ing the second year (2005–06). 100% of the students reported the awareness that this is an experience shared by using DBM at least once in a situation (MCAT) not students5 and. standard deviations.. 69% (i. two tests between surveys. DBM is based on Benson’s Relaxation The analysis of the Pretest to Follow-up data per- Response. and 11% (n = 7) performed DBM an of the students attended (AE) presented information average of 2 days per week. two-tailed t up survey consisted of the aforementioned items. 58% (n = 37) used it only as needed. Another 38% (n = 12) responded that imately 5 min of DBM each time the classes met. the AE and VR classes. self-doubt). The majority of them used it prior to ini- to elicit the diaphragmatic breath reflective of neustress tiating their practice verbal reasoning passages in and and Benson’s Relaxation Response. they used DBM before studying when alone. Results PREP through their MCAT test-taking experience. signed to assist students in decreasing any perceived Almost half of the students reported engaging in DBM feelings of negative academic performance. being in a comfortable position where they had never engaged in DBM prior to being intro- most of the body weight is supported. The DBM curriculum component was primarily de. students participated in DBM 30 times during each In the Follow-up surveys only in both years. ment System produced by the Institute of HeartMath The various situations in which the students en- in Boulder Creek. nervous. the students perceived significantly less test approximately 5 min of DBM. nervousness. means. The students reported they 289 . additional belief questions regarding future use. the improve academic scores. Students were also taught and 42% (n = 27) practiced DBM an average of 4 days how to perform diaphragmatic breathing through a per week on their own. each student DBM during exams in courses other than AE and VR was evaluated during a private.

N ≈ 64. believed using DBM would be helpful in medical nique meant to reduce the physiological and psycho- school (M = 8.57) 6.32) 4.61* –0. FU) To what extent do you currently Experience test anxiety (rapid 6. d = (mean3 – mean1) / standard deviation of the pretest.73* 0.66* 0.04) 4. ELAM.15 place it with a behavior that is empowering.86* 0. the student now un- At the start of each MCAT sectiona 40 67 derstood why it was helpful and came to thank us for During the MCAT sectionsa 39 65 including it in the curriculum. Overall.16 (2.42* –0.31) 4.05 with paired t-test. SD = 1. it Before quizzes in classes other than AE and VR 31 48 may take longer to become receptive and participate As a start to a study group 10 16 in the DBM component. PAUL.17. We believed that the successful implementation of ings suggest that significant behavior changes occurred the DBM component necessitated a full explanation when MEDPREP students were given a continuous of the science supporting the inclusion of this compo- opportunity to practice a 5-min stress reduction tech. ∗ p < . 290 .98 (2.63) 8. N ≈ 64.42* –0.3) 3.13) 0. 9 months into the 1st year of the study. VR = Verbal Reasoning. Overall.99) 7.84* Use DBM if you become 2. DBM = Deep Breathing Meditation. SD = 1. to ac- unit. From student comments. who might not acknowl- agement strategies during orientation or as an isolated edge or understand the consequences of stress.19 (2.29) 5. For some students. In March 2005. MCAT = students the opportunity to learn a technique and allow Medical College Admission Test.71).45* –1.08* anxious/upset during an exam Believe that using DBM on a daily 6.25 (2.02 (2. SD = 1.94). nent so that students would be receptive and engage in the DBM sessions. it appeared that Student Usage of DBM (Check All That Apply) n % the students became engaged in the DBM component. butterflies.89) and as a physician logical effects that can be associated with academic (M = 8. FU = Follow-up.25) 4.85 (2.37 The DBM course it is not enough to lecture students about stress man.13) 6.22) –0. d = (mean3 – mean2) / standard deviation of the pretest.32.5 (2.98 (2.97 (2. Post) d (Post.04* heartbeat. they also anticipated using it stress.0) 3.95 (2.87* Lose concentration during exams 5. SD = 2. students must be provided with regular quire and utilize a coping mechanism to call on as opportunities to develop and practice a strategy as it stressful situations occurred and triggered the fight or takes time to abandon an ineffective behavior and re. Rather.33.5. it has been suggested in the literature that medical students be pro- Conclusion vided with educational interventions that teach them effective coping strategies as a proactive measure to This research study was based on the premise that counteract distress. & VERHULST Table 1.09) 3. flight response.3 (2. a Before the MCAT starteda 57 95 student apologized for not engaging in the DBM com- Before class practice VR passages 60 95 Before exams in classes other than AE and VR 52 81 ponent and for always silently questioning why we had Before doing practice VR passages not in VR class 48 75 this as part of the class. headache.93* Have self-doubt during exams 6. Students Use of DBM (April 2005 and 2006 the HeartMath monitor to evaluate their ability to elicit Follow-up Only) diaphragmatic breathing helped to verify whether they were breathing deep enough.44* –0. use a stress reduction technique as a regular part of the curriculum for all students.92 (2.92 (2.12. in the future (M = 7. using Table 2. worry about failing) Become nervous during exams 5.83.11 However. a common human phenomenon. we recommend that stress man- = Academic Enrichment.57* –0.06) –0. it is important to offer Note. for all students.16 0.16 (1. AE for continued practice.27.16) 1.7. DBM = Deep Breathing Meditation. students To our knowledge.83 (2.89).61* basis can help you improve academically Note. Thus.36.16 (2. Our find. FU) d (Pre.23) –0.67 (2. d = (mean2 – mean1) / standard deviation of the pretest.28. agement components be integrated into the curriculum a N = 60 students took the MCAT in April 2005 and 2006.02 –0. Change in Students’ Perceptions and Use of DBM Over Time Pretest M (SD): Posttest M (SD): FU M (SD): Survey Questions June August April d (Pre. however. component allowed students.03 (2.27) –0.35* 2. only a limited number of medi- reported becoming very engaged in the DBM segment cal schools provide opportunities to fully develop and during the VR and AE classes (M = 8.

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