Self-Care for Nurses Who Care for Others: The Effectiveness of Meditation as a Self-Care Strategy

Abstract

Self-care is how nurses promote their own physical and mental health. Effective self-care is any strategy practiced on a regular basis to prevent stress and anxiety and to enhance the health and well-being. Self-care ranges from getting more rest to seeking professional help. Meditation practice is known to be an effective self-care strategy. The purpose of this study is to assess the effect of meditation as a self-care strategy among Korean nurses. Two groups of nurses at the university hospital, one with meditation experience and the other without, were selected as study participants, and their depression and resilience were analyzed. The results of the study show that, first, depressive symptoms were more prevalent among the nurses in the non-meditative group (62.2%) than the ones in the meditative group (15.6%), and resilience positivity was higher in the meditative group (4.01 ± 0.44) than in non-meditative group (3.04 ± 0.41). Second, nurses with depressive symptoms demonstrated particularly low resilience in both groups, indicating that resilience is inversely associated with other metal disorders. Third, after one and a half years since the study, the turnover rate of the non-meditative group (17.8%) was twice that of meditative group (8.9%). As stated in the earlier self-care literature that stressed the benefits of meditation, this study confirms that consistent meditation experience on a regular basis has an effect on nurses’ well-being via lower depression and promotes higher psychological well-being via resilience. This study is expected to provide the data collected from the field, including personal narratives, to establish more effective self-care strategies in personal and professional settings.

1. Introduction

Recently, work-related distress and exhaustion among Korean nurses have been critically related to the series of national and international incidents. At the national level, suicide cases of nurses in 2018 and 2019 brought the taeum (burn-to-ashes) culture to the surface which refers to the hazing practice in Korean nursing culture (Kim et al. 2020). In a working environment where even small mistakes are not permissible, senior nurses are given higher privileges, permitting them to harass junior nurses and especially new staff with hierarchic leverage and control in the process of teaching or handing over tasks (Jeong 2018). The Korea Labor Institute reported that instances of the bullying of nurses are 41.3% higher than those in other occupations, and 65% of nurses have experienced bullying while on duty (Kim and Sim 2021). At the international level, since the outbreak of COVID-19, nurses, while diagnosing and treating symptomatic patients and asymptomatic carriers of the virus, also struggle with their own heightened exposure to the infection and the resulting mental distress (Biber et al. 2022). Mental distress adversely impacts not only nurses’ own physical and mental health, causing increased disability and absenteeism, but it also results in poorer patient outcomes, including medical errors and low patient satisfaction (Patel et al. 2018). The turnover rate of Korean nurses well reflects the stressful and intense working environment. The national average turnover rate in nursing was 15.2% in 2021, more than three times higher than entire industrial groups (4.9%) (Korean Health and Medical Workers’ Union 2022). Moreover, the average turnover rate of nurses’ first-year employment equated to 45%, meaning one out of two nurses quit after less than a year, and turnover intention of the three-shift nurses reached 80.1%, meaning four out of five three-shift nurses considered leaving (M.-J. Kim 2021).

Self-care for healthcare workers is defined as a proactive, holistic, and personalized approach to the promotion of health and well-being through a variety of strategies in both personal and professional settings, intended to enhance capacity for care of patients and their families (Mills et al. 2018). Effective self-care is any strategy practiced regularly and incorporates self-discipline, self-awareness, accountability, and motivation (Hofmeyer et al. 2020). Being more than pursuing pleasurable activities, personal self-care practices can include getting more rest, spending time alone or in reflection, seeking professional therapy, life coaching, or any activity that supports, energizes, soothes, or inspires (Hofmeyer et al. 2020). Meditation practice is an effective self-care strategy in both personal and professional settings (Mills et al. 2018).

The purpose of this study is to assess the effects of meditation as a self-care strategy among Korean nurses. To do so, two groups of 45 registered nurses, one with meditation experience and the other without, were selected as study subjects and tested on the depression and resilience scale. Based on earlier self-care literature which stresses meditation’s benefits, it is assumed that consistent meditation experience on a regular basis would have an effect on nurses’ well-being through lower depression and also higher psychological well-being through resilience. This study also follows up on the turnover status of the nurses after 18 months of the study. It is understood that the acquired benefit of meditation would be related to the frequency of turnover. This study is expected to provide the data collected from the field, including personal narratives, to establish more effective self-care strategies for the well-being of nurses in personal and professional settings.

2. Materials and Method

2.1. Study Design

Data collection for the general survey and depression and resilience questionnaires were conducted during 8 days between 13 April 2021 and 20 April 2021 for 149 healthcare workers, men and women, and doctors and nurses, at D University hospital, Gyeonggi-do. Among the 149 healthcare workers, this study selected and focused on 90 female registered nurses only. This procedure was conducted to reduce the number of variables and to increase the reliability since this study compared the performance of the two groups. General survey questions were employed to identify the characteristics of the participants. Depression and resilience tests were administered, collected, and analyzed.

This study obtained IRB approval (DUIRB-202104-03) from the Dongguk University. Participants were informed about the purpose and content of the study, and data was collected upon their consent to voluntary participation without cost nor risk. Informed content was obtained concerning the access of personal information to manage the results by the researcher. This was to follow up on their turnover case. Participants were informed that the data collected by them was to be used only for the purpose of the study, and that there was no disadvantage due to cancellation. Participants were also informed that the collected data would be stored for three years and then discarded.

2.2. Participants

The subjects of this study were 90 female registered nurses working at a university hospital with 1000 beds. Subjects had both direct and non-direct patient contacts from internal medicine units (gastroenterology, respiratory, endocrinology clinic), surgical units, the nursing department, and hospice and palliative care units. Age was classified into 20s, 30s, and 40s or more, and working experience into from less than 10 years to more than 30 years. Marital status was classified as single or married. Subjects with adequate knowledge, experience, and attitudes who could provide a comprehensive response to the study were recruited. Recruitment was performed using purposive sampling, which is a sampling strategy that selects participants who can provide lucid and truthful answers related to the research question. The equal number of subjects with meditation experience and without were selected to compare the difference in their depression and resilience scale and to investigate the effectiveness of meditation practice as a self-care strategy.

2.3. Participants with Meditation Experience

Study participants who were meditators, whether religious or not, were selected to meet certain criteria of meditation experience. Practice with consistency and regularity was considered. Meditators practiced at least 1 h per day, 3 to 5 days per week, and for more than 6 months. Diversity in meditation practice was also considered as an important characteristic regardless of the familiarity to traditional Korean Buddhist practice. The types of meditation included guided meditation of breathing and relaxation, mindful prostration, sutra copying, and sitting meditation.

2.3.1. Guided Meditation

The advantage to guided meditations is that the narrator or teacher walks you through how to meditate while using smart device applications or video hosting platforms. Thus, it is broadly accessible to people regardless of familiarity to traditional meditation practice. In 2021, the two meditation applications with the largest membership had 760,000 members (Economist n.d.). Of the membership, 30% belonged to the age group of 20s and 30s. Guided breathing meditation and deep relaxation (or body scan) meditation were most accessed among the present study subjects.

2.3.2. Mindful Prostration

Prostration, especially 108 prostrations, is a familiar and popular practice among Korean secular Buddhists. It is a way of paying respect and at the same time of developing humility and sincerity. The 108 prostrations method is called “a dialogue between body and mind” (J. S. Kim 2018). Repeating the same body movement helps one to concentrate on one’s mind. Earlier studies show that 108 prostrations practice improves stability in mind, emotional control, and ability to deal with stress (KBS Production Team of the Secrets of Life, Old age, Illness, Death 2009). Clinical studies also show that 108-prostrations meditation lowers blood sugar levels, improves concentration by development of the cerebral cortex, and maintains a strong immune system (KBS Production Team of the Secrets of Life, Old age, Illness, Death 2009). It takes an average of 20~30 min to complete 108 prostrations.

2.3.3. Sutra Copying

Sutra copying typically involves copying of entire Buddhist sutra. Sutra copying initiates reading by eyes, memorizing by mouth, writing by hand, and finally bearing in mind. Elaborate sutra copying takes time, concentration, and devotion. People confess that completion of sutra copying brings comfort and calmness that rarely experienced before (S.-D. Kim 2017). Sutras that are most copied in Korea are the Diamond Sutra, the Flower Ornament Sutra, and the Lotus Sutra.

2.3.4. Sitting Meditation

Since Gongan Seon was introduced in Korea by Bojo Jinul (1158~1210), it has been established as the most important practice in Korean Buddhism. The form of practice that focuses intently on Gongan’s “critical phrase” or meditative topic (hwadu) is called Ganhwa Seon, “observing the hwadu.” The hwadu is a question that promotes spiritual inquiry and is considered to be the essential theme (Buswell 1992). The meditators usually receive hwadu from a professional Buddhist Seon practitioner whom they consider to be their teacher, and they are instructed to concentrate on a single hwadu continuously and without distraction.

2.4. Measurements

2.4.1. Depression

In 2018, major depressive disorder, among the top 20 diseases, ranked 10th high disease burden in Korea (Jung et al. 2021). Depression and suicidal ideation were most noticeable among age group of 20s and 30s, and depression risk is close to 20%, meaning 1 out of 5 people is exposed to possible depressive disorder (Ministry of Health and Welfare 2021). In 2021, 6 out of 10 late adolescents aged between 19 and 24 showed depressive symptoms: 33.4% of mild symptoms; 21.3% of moderately severe symptoms; 4.2% of severe symptoms (Im et al. 2021).

This study adopted the integrated version of CES-D (Center for Epidemiologic Studies Depression Scale, Radloff, 1977) for Koreans (Chon et al. 2001). The Korean integrated CES-D selected 20 questions after performing three studies and revealed 0.91 internal consistency (Chon et al. 2001). It is a self-report evaluation tool that correspond to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders. Scores are calculated by summing up the items on how often 16 depressive symptom-related and 4 inverse statuses have been experienced in the past one week. Its scoring uses a 4-point Likert scale: “never or rarely” (1 point); “sometimes” (2 points); “often” (3 points); and “always” (4 points). Scores are placed between 20 and 80. The higher the score, the higher the severity of depressive symptoms. Regarding depressive symptoms, 36 out of a total of 80 points were set as the cut-off point.

2.4.2. Resilience

Definitions of resilience have evolved over time, but fundamentally it is understood as referring to positive adaptation, or the ability to maintain or regain mental health despite experiencing adversity (Herrman et al. 2011). The complex nature of resilience is now widely discussed, and determinants of resilience include a host of biological, psychological, social, and cultural factors that interact with one another to determine how one responds to stressful experiences (Southwick et al. 2014).

For resilience measure, the Korean Resilience Quotient (KRQ) was employed (J.-H. Kim 2011). KRQ-53 was modified from the index first developed by Reivich and Shatte (Reivich and Shatte 2003). This test comprises 53 questions and is divided into three sub-categories of personal regulation, interpersonal relation, and positivity. Self-regulation contains 18 items that evaluate emotion control, impulse control, and cause-analysis abilities. Interpersonal relation includes 18 items that evaluate communication, empathy, and self-expanding abilities. Positivity comprises 17 items that evaluate self-optimism, life satisfaction, and gratitude. Each item is rated on a 5-point Likert scale ranging from “not at all” (1 point) to “strongly agree” (5 points). A higher score indicates a higher level of resilience. The 24 inverse questions were calculated by converting them into inverse scoring questions; the total score ranges from 53 to 265 points (J.-H. Kim 2011). Participants obtaining more than 195 out of a total of 265 points were categorized as the high-resilience group, while others formed the low-resilience group (J.-H. Kim 2011).

2.5. Statistical Analysis

The chi-square test was performed for categorical variables. Descriptive analyses were conducted to find out the descriptive statistics of the variables. Continuous variables were summarized using means, SDs, medians, and ranges. The difference between the two groups was analyzed by the t-test. The Pearson correlation coefficient was analyzed to measure the linear relationship between the variables. The linear regression analysis was conducted to evaluate the relationship between the dependent variables of depression and resilience, including its sub-categories, and the independent variable of meditation experience. Statistical significance was set at p < 0.05.

3. Results

3.1. Depression and Resilience by General Characteristics (Table 1)

General characteristics of the participants were summarized using frequency analysis. As a result of purposive sampling, 90 female nurses were selected as study participants. The participant numbers of each age group are 35 (38.9%), 29 (32.2%), 17 (18.9%), and 9 (10%) in the 20–29, 30–39, 40–49, and 50 or more age groups, respectively. Of all study subjects, 54 (60%) were single and 36 (40%) were married. The participant numbers of each total working experience are 50 (55.6%), 27 (30%), 11 (12.2%), and 2 (2.2%) in less than 10 years, 11~20, 21~30, and more than 31 years, respectively. Among the 90 study subjects, 62% (n = 56) was three-shift nurses. The participants who had meditation experience numbered 45 (50%), and participants without the experience also numbered 45 (50%). Meditators regularly continued different kinds of meditation practice. Guided meditation including breathing, relaxation, and self-compassion were most popular types, and 24 (53.1%) participants benefitted from them. Furthermore, 10 (22.2%) prostrated regularly, 8 (18%) copied different kinds of Buddhist sutras, and 3 (6.7%) observed the hwadu while doing sitting meditation.

Table 1. Depression and resilience by general characteristics.

Variables		N (%)	Depression			Resilience
			M ± SD	t or F/p	Scheffe	M ± SD	t or F/p	Scheffe
Age	20~29 (a)	35 (38.9)	2.02 ± 0.38	10.073/ 0.000 **	(a,b) > (c,d)	3.26 ± 0.38	12.769/ 0.000 **	(d,c) > (b,a)
	30~39 (b)	29 (32.2)	1.98 ± 0.44			3.29 ± 0.40
	40~49 (c)	17 (18.9)	1.52 ± 0.34			3.76 ± 0.33
	50s≤ (d)	9 (10.0)	1.40 ± 0.21			3.91 ± 0.23
Marital Status	Single	54 (60)	2.30 ± 0.39	3.535/ 0.001 **	-	3.30 ± 0.39	−3.790/ 0.000 **	-
	Married	36 (40)	1.78 ± 0.43			3.63 ± 0.43
Years at work	≥10	50 (55.6)	2.32 ± 0.39	5.378/ 0.002	-	3.28 ± 0.38	7.011/ 0.000	-
	11~20	27 (30)	1.92 ± 0.49			3.52 ± 0.46
	21~30	11 (12.2)	1.49 ± 0.33			3.84 ± 0.32
	31≤	2 (2.2)	1.47 ± 0.10			3.81 ± 0.24

** p < 0.01.

Table 1. Depression and resilience by general characteristics.

Variables		N (%)	Depression			Resilience
			M ± SD	t or F/p	Scheffe	M ± SD	t or F/p	Scheffe
Age	20~29 (a)	35 (38.9)	2.02 ± 0.38	10.073/ 0.000 **	(a,b) > (c,d)	3.26 ± 0.38	12.769/ 0.000 **	(d,c) > (b,a)
	30~39 (b)	29 (32.2)	1.98 ± 0.44			3.29 ± 0.40
	40~49 (c)	17 (18.9)	1.52 ± 0.34			3.76 ± 0.33
	50s≤ (d)	9 (10.0)	1.40 ± 0.21			3.91 ± 0.23
Marital Status	Single	54 (60)	2.30 ± 0.39	3.535/ 0.001 **	-	3.30 ± 0.39	−3.790/ 0.000 **	-
	Married	36 (40)	1.78 ± 0.43			3.63 ± 0.43
Years at work	≥10	50 (55.6)	2.32 ± 0.39	5.378/ 0.002	-	3.28 ± 0.38	7.011/ 0.000	-
	11~20	27 (30)	1.92 ± 0.49			3.52 ± 0.46
	21~30	11 (12.2)	1.49 ± 0.33			3.84 ± 0.32
	31≤	2 (2.2)	1.47 ± 0.10			3.81 ± 0.24

** p < 0.01.

The depression and resilience scale differed according to age, marital status, and years at work. The participants in 20s and 30s were more depressed and less resilient. Married participants were revealed to be less depressed and more resilient than single participants. The participants with longer careers were less depressed and more resilient. The Scheffe test showed that a statistically significant difference was revealed in age category (Table 1). This result is in line with earlier findings provided by the Korean Ministry of Health and Welfare and National Youth Policy Institute that depressive symptoms are more prevalent among the younger generation (Ministry of Health and Welfare 2021; Im et al. 2021). The result suggests that effective self-care strategy for younger nurses should be initiated to promote healthy workplace environment for both health service providers and recipients.

3.2. Meditators vs. Non-Meditators

Correlations and descriptives (means, 95% confidence intervals, and standard deviations) are displayed in

Table 2. Zero-order correlations: meditators.

	Depression	Self-Control	Interpersonal Relation	Positivity	Resilience
Depression	1
Self-regulation	−0.333 *	1
Interpersonal relation	−0.104	0.408 **	1
Positivity	−0.568 **	0.504 **	0.467 **	1
Resilience	−0.418 **	0.780 **	0.792 **	0.827 **	1

* p < 0.05, ** p < 0.01.

and

Table 3. Descriptives for outcomes of meditators and non-meditators.

Variables	Meditators		Non-Meditators		t	p
	M	SD	M	SD
Depression	1.59	0.400	2.10	0.340	−6.756	0.000
Self-regulation	3.55	0.377	3.04	0.368	6.447	0.000
Interpersonal relation	3.72	0.424	3.23	0.310	6.250	0.000
Positivity	4.01	0.444	3.04	0.412	10.749	0.000
Resilience	3.76	0.331	3.11	0.268	10.210	0.000

. Depression and the rest of variables showed clear negative correlation. When depression increased, positivity decreased greater than self-regulation, interpersonal relation, and resilience. On the contrary, resilience and its sub-categories showed strong positive correlation; increasing resilience had a greater impact on positivity than self-regulation and interpersonal relation (Table 2).

The depression and resilience scales between the meditators and non-meditators differed notably. The mean depression scale of non-meditators (2.10 ± 0.340) was greater than that of meditators (1.59 ± 0.400). The meditators’ average depression point (30.51) was lower than the cut-off point of 36, whereas the non-meditators’ (40.82) was above. The mean of self-regulation, interpersonal relation, positivity, and the resilience scale was higher among meditators than non-meditators: 3.55 > 3.04, 3.72 > 3.23, 4.01 > 3.04, and 3.76 > 3.11, respectively. Among the resilience and its sub-categories, positivity showed the greatest difference between the two groups. A t-test result to compare the two groups showed a significant statistical difference in depression (t = −6.756, p = 0.000), self-regulation (t = 6.447, p = 0.000), interpersonal relation (t = 6.250, p = 0.000), positivity (t = 10.749, p = 0.000), and resilience (t = 10.210, p = 0.0000) (Table 3).

Among the 45 meditators, 7 (15.6%) exhibited depressive symptoms, and 19 (42.2%) showed low resilience. Among the 45 non-meditators, 28 (62.2%) exhibited depressive symptoms, and 44 (97.8%) showed low resilience. When 57.8% (n = 26) of the meditators was highly resilient, only 2.2% (n = 1) of the non-meditators was highly resilient. Of the meditators, 73.3% (n = 33) showed high positivity, the greatest scale among the sub-categories of resilience. The majority of non-meditators showed low self-regulation (n = 41, 91%), low interpersonal relation (n = 43, 95.5%), and low positivity (n = 42, 93.3%). Individuals with depressive symptoms and high resilience in the meditative group accounted 7% and 57.8% of the sample, respectively, while individuals in the non-meditative group accounted 62.2% and 2.2%, respectively (

Table 4. Depressive symptoms and resilience by meditators and non-meditators.

Variable		Meditators		Non-Meditators		Total
		N	%	N	%	N (90)	% (100)
Depression	Depressive symptom	7	15.6	28	62.2	35	38.9
	Non-depressive symptom	38	84.4	17	37.8	55	61.1
Resilience	Low	19	42.2	44	97.8	63	70
	High	26	57.8	1	2.2	27	30
Self-regulation	Low	20	44.4	41	91	61	67.8
	High	25	55.6	4	0.9	29	32.2
Interpersonal Relation	Low	22	48.9	43	95.5	65	72.2
	High	23	51.1	2	4.5	25	27.8
Positivity	Low	12	26.7	42	93.3	54	60
	High	33	73.3	3	6.7	36	40

).

Among the 7 individuals with depressive symptoms in meditative group, 5 (71.4%) were low resilient; among the 28 individuals with depressive symptoms in non-meditative group, 27 (96.4%) demonstrated low resilience. As the more severe the depression, the lower the resilience, depressive symptoms were significantly associated with low resilience for both groups. When 26.3% (n = 5) of 19 low resilient individuals in meditative group had depressive symptoms, 7.7% (n = 2) of 26 high resilient individuals in the same group had depressive symptoms. Even among the meditators whose depression and resilience performed better, depressive symptoms and low resilience were closely related. This is similar to the findings in a recent study which suggests low resilience groups show significant association with depressive symptoms (Lee et al. 2021).

Of the 90 study participants, 50 (55.6%) worked less than 10 years and 56 (62%) were three-shift nurses. Considering the high turnover rate of the three-shift nurses of less career length, many of the present study participants were also subject to high turnover. After 18 months since the study, not only the turnover result of the study participants, but also the turnover difference between the two groups were found noteworthy. Of the 45 meditators, 41 (91.1%) remained and 4 (8.9%) left, whereas of the 45 non-meditators, 37 (82.2%) remained and 8 (17.8%) left. The turnover rate of non-meditators was twice that of meditators. Overall, 12 (13.3%) individuals of the total 90 study participants left. The turnover rate of non-meditators (17.8%) was slightly higher than the national turnover rate (15.2%). Along with the systemic development and modification to improve the working conditions of nurses, this study suggests that self-care strategies such as meditation programs should be implemented in professional settings.

3.3. Validity of Meditation Experience on Variables (Table 5)

In order to assess the causal association between meditation experience as the independent variable and each outcome (or continuous dependent) variable, linear regression analyses were conducted. Meditation experience was found to have a statistically significant effect with explanatory power of 32.3%, 54.2%, 32.1%, 30.7%, and 56.8% on depression, resilience, self-regulation, interpersonal relation, and positivity, respectively. Positivity, among the sub-categories of resilience, was most affected by meditation experience. Since the value of non-standardized beta (B) was 0.970, positivity increased by 0.506 when meditation experience increased by one unit. The analyses determined the validity of meditation experience as the single independent variable in relation to depression, resilience, self-regulation, interpersonal relation, and positivity as dependent variables. The result supports the effectiveness of meditation on reducing depression and increasing resilience.

Table 5. Validity of meditation experience on variables.

Variable	Depression
	B	Std Err	β	t	p	DW	R2
(Constant)	40.822	1.125		36.294	0.000
Meditation	10.311	1.591	−0.568	−6.482	0.000 **	1.962	0.323
	Resilience
(Constant)	3.107	0.045		69.120	0.000
Meditation	0.649	0.064	0.736	10.210	0.000 **	2.170	0.542
	Self-regulation
(Constant)	3.044	0.056		54.836	0.000
Meditation	0.506	0.079	0.566	6.447	0.000 **	1.875	0.321
	Interpersonal relation
(Constant)	3.235	0.055		58.483	0.000
Meditation	0.506	0.079	0.566	6.447	0.000 **	2.381	0.307
	Positivity
(Constant)	3.038	0.064		47.610	0.000
Meditation	0.970	0.090	0.753	10.749	0.000 **	2.129	0.568

** p < 0.01.

Table 5. Validity of meditation experience on variables.

Variable	Depression
	B	Std Err	β	t	p	DW	R2
(Constant)	40.822	1.125		36.294	0.000
Meditation	10.311	1.591	−0.568	−6.482	0.000 **	1.962	0.323
	Resilience
(Constant)	3.107	0.045		69.120	0.000
Meditation	0.649	0.064	0.736	10.210	0.000 **	2.170	0.542
	Self-regulation
(Constant)	3.044	0.056		54.836	0.000
Meditation	0.506	0.079	0.566	6.447	0.000 **	1.875	0.321
	Interpersonal relation
(Constant)	3.235	0.055		58.483	0.000
Meditation	0.506	0.079	0.566	6.447	0.000 **	2.381	0.307
	Positivity
(Constant)	3.038	0.064		47.610	0.000
Meditation	0.970	0.090	0.753	10.749	0.000 **	2.129	0.568

** p < 0.01.

3.4. Meditation as an Effective Self-Care Strategy

When one is exposed to the distress and suffering of others, one is at a junction where one can feel distressful and trapped in negativity or move forward to more positive and compassionate states of mind (Hofmeyer et al. 2020). One of the key capacities to steer the direction at this junction of empathic distress fatigue and compassion is known to be self–other distinction or emotion regulation (Vachon 2016). Distinguishing and distancing one’s own and others’ emotional and mental state are important for nurses’ mental health. Self-care strategies such as meditation can be effective in regulating one’s emotions to steer the direction from empathic distress to a compassionate state of mind. One nurse explained:

My own comfort and happiness are as important as patients’, guardians’, and co-workers’. In addition, they are the driving force that initiates all the works I face as a healthcare worker. Being mindful on my breathing before starting another hectic day and allowing my body and mind total relaxation before sleep are truly reassuring and comforting for me. Meditation became my daily routine, and I find myself turning more positive. I now try to clear about my own feelings and others’ and aware of the status of my own mind and feelings. The longer I meditate, the more I get used to this process. I now know that deep breathing can calm my anxious and nervous mind. I became more confident when facing situations or people, more energetic, and more thankful.

(Kim)

Mindfulness-related literatures confirm that people who focus on living in the present moment are less distressful than those who are focused on the past or worry about the future (Hanh 2012; Kabat-Zinn 2012). Mindfulness-related abilities and practices have been shown to be closely linked to the mechanisms of emotion regulation, relying heavily on aspects of self-awareness (Chambers et al. 2009; Roemer et al. 2015). One nurse explained:

Mindful prostrations don’t change my difficult and stressful environment. Working burden, stressful relationship, and things driving me anxious and confused continue. However, what is surprising to me is that my attitude toward the environment has become more flexible and relaxed. We strive for the future has not yet come. Working for tomorrow is precious but wouldn’t it be better to be happy now here? Mindful prostrations bring me a peace and happiness at this very moment.

(Lee)

The facilitators of effective self-care include positive emotion and self-compassion. Gratitude and taking a positive perspective, even in the face of negative circumstances, enabled self-care, and self-compassion was considered essential to self-care (Hofmeyer et al. 2020). Meditation practice helps one to train oneself to be mindful and to anchor or ground one’s awareness in something on which one can focus. One nurse explained:

With the prolonged COVID-19, I have one more task added in already full to-do list. I need to take care of my mind that is about to collapse. I sit comfortably with eyes closed and try to untangle my emotion of anxiety, depression, resentment, regrets, and failures. As I start copying one word by another of the teachings of the Buddha, my mind of angry waves becomes calm and quiet. I can feel a smile around my mouth and my mind being clear. Copying even few pages gives me a sense of achievement and a chance to thank myself. When sutra copying, I become kind, supportive and understanding toward myself. This is why I continue copying the sutra.

(Park)

Emotion regulation, the ability to focus on the present moment, positivity, and self-compassion were some of the benefits of meditation that meditators confessed. The benefits of meditation as an effective self-care strategy are believed to be associated with the lower depression and higher resilience of nurses.

4. Discussion

Nurses generally experience high levels of stress and are vulnerable to empathic distress fatigue or burnout in acute care settings. Empathic distress fatigue can be reduced with effective interventions, and empathy can be turned into a more positive and compassionate state of mind. Earlier fMRI findings suggest that empathy and compassion are not identical concepts since the two have distinctive neurological pathways (Singer and Klimecki 2014; Vrticka et al. 2017). Empathy is a socioaffective path by which to ‘feel with’ others which increases negative emotions and distress when sharing the suffering of others too much, whereas compassion is a sociocognitive path by which to ‘feel for’ others which is linked to increases in helping, reward, and forgiveness behaviors (Klimecki and Singer 2012). Compassion can be trained through self-care practices (Hofmeyer et al. 2020). Self-care involves a variety of strategies to manage empathic distress fatigue and to promote the health and well-being of both care givers and takers. Meditation is known to be one of the effective self-care strategies.

This study compared two groups of Korean women nurses: one with consistent and regular meditation practice and another without. This study found a noticeable difference in the depression and resilience scales between the groups. Meditators were, on average, less depressed and more resilient. Positivity, among the sub-categories of resilience, was most affected by meditation experience. The results of the study support the hypothesis that meditation has a positive effect on the mental health of nurses as demonstrated via depression and resilience.

It is possible that resilience exists on a continuum that may be present to different degrees across multiple domains of life, meaning an individual who adapts well to stress in a workplace or in an academic setting may fail to adapt well in their personal life or in their relationships or vice versa (Pietrzak and Southwick 2011). However, when resilience is associated with other mental disorders, the presence of different degrees across multiple domains of life is questionable. Previous studies suggest that resilience is inversely related to mental disorders such as depression, anxiety, and somatization (Cal et al. 2015; Roberts et al. 2021; Lee et al. 2022). Our study also found that a majority of individuals with depressive symptoms in both groups demonstrated significantly low resilience. It is reasonable to assume that when one has severe depressive symptoms and low resilience at work, one is hardly highly resilient at home.

In the present study, meditators with depressive symptoms and high resilience accounted 15.6% and 57.8% of the sample, respectively, while non-meditators accounted 62.2% and 2.2%, respectively. This finding is similar to two previously conducted studies. One was among nurses working in respiratory clinical areas, and their depressive symptoms and moderate or high resilience accounted for 17.2% and 65%, respectively (Roberts et al. 2021). Another was among medical staff in a military hospital, and their depressive symptoms and high resilience accounted for 8.8% and 61.9% of the sample, respectively (Lee et al. 2022). Nurses generally experience more depression, anxiety, and stress compared to other staff groups in hospitals (Mattila et al. 2021). This study notes that the rate of individuals with depressive symptoms in the non-meditative group is particularly higher than the two studies previously mentioned, and the rate of individuals with high resilience in the non-meditative group was significantly low. Even though 40% of the study subjects fell into age group of 20s which is generally considered to have higher depression and lower resilience, individuals in the non-meditative group showed significantly low resilience, self-regulation, interpersonal relation, and positivity.

Empathic distress fatigue is closely associated with nurses’ turnover (Monroe et al. 2021). The turnover rate of Korean nurses new at work (less than a year) reached 45%, tertiary reached 43.5%, general reached 48%, and secondary and primary reached 34% in 2020 (Kim et al. 2021). Although Korea produced the largest number of nursing college graduates among OECD countries, the number of active nurses remains lower than the OECD average (Kim et al. 2021). Irregular working hours and heavy work burdens related to three-shift and night work are considered to be the main reason (Ministry of Health and Welfare 2018). In addition, the demand for high-quality medical care is increasing as the knowledge and awareness of rights of medical consumers have recently increased (Nam 2017). The increasing demand for medical services without improving the working environment, such as manpower and salaries, increases the intensity of nurses’ work, and the resulting serious stress encourages nurses to change jobs (Kwon 2019). The turnover rates of the present study participants were 8.9% and 17.8% in the meditative and non-meditative groups, respectively. Self-care considered as a shared responsibility between staff and healthcare services may have an impact on job satisfaction reduce turnover (Mills et al. 2018).

This study has several limitations. First, the quality and level of stress depending on the age and career of the study subjects are complex and need to be evaluated with sensitivity. Younger nurses with less years at work are found to be more depressed and less resilient. However, this does not mean that older nurses with longer careers have less stressors; they also expressed their burden in the survey and such difficulties as being in charge of greater responsibilities including decision making and human resource management. Second, empathic distress fatigue is not solely the responsibility of the personnel. Meditation as a self-care strategy seems to be understood as solely residing within the personal domain. However, it is important that healthcare services implement self-care strategies, including meditation, and provide an environment where individuals benefit from them easily. For example, hospitals can provide a space for meditation or sponsor meditation application services. Third, the efficacy of meditation research, especially in the scene of MBSR, comes with reporting bias and too many positive trials (Lahtinen and Salmivalli 2020). The present study selected only female nurses as study participants from both meditative and non-meditative groups; it selected 90 study subjects who were different in age, career length, and job-specific characteristics. For future studies, it is recommended that researchers recruit study subjects of similar age groups, career lengths, and job-specific characteristics to examine the effectiveness of a specific intervention.

Nevertheless, this study is meaningful in several aspects. First, the variables in the study subjects were reduced to the same gender and occupation. In addition, instead of a few weeks’ course of standardized mindfulness or a meditation program, the study recruited the participants with longer and consistent meditation experience. Second, personal narratives were collected in the survey to hear ways in which meditation experience helped the participants in order to highlight the relationship between meditation experience and the depression and resilience scales. Third, at the beginning of the study, participants consented to their personal information being accessed by the researcher and the nursing department. After more than one year since the study was conducted, the turnover status of the study participants was shared in the study.

5. Conclusions

This study examines the association between meditation experience and the depression and resilience scales among female nurses. In addition, the study assesses the effectiveness of meditation as a self-care strategy to combat work-related distress and exhaustion. Depression and resilience were tested among 90 registered nurses, one half with meditation experience and the other half without. Meditators were less depressed and more resilient than non-meditators. Only 7 out of 45 meditators showed depressive symptoms, whereas 28 out of 45 non-meditators showed depressive symptoms. Emotional regulation, the ability to focus on the present moment, positivity, and self-compassion were some of the benefits of meditative practice mentioned by the meditators. More than one year after the study was conducted, 8.9% (n = 4) of the meditators and 17.8% (n = 8) of the non-meditators no longer worked at the same hospital. The findings of the present study confirm that meditative practice can be considered an effective self-care strategy in both personal and professional settings, not only for intervening and alleviating nurses’ work-related distress and exhaustion, but also for reducing the turnover rate.