The effect of emotional freedom technique on stress and anxiety in nursing
students: a pilot study

Susan L. Patterson

PII: S0260-6917(16)00061-7
DOI: doi: 10.1016/j.nedt.2016.02.003
Reference: YNEDT 3201

To appear in: Nurse Education Today

Accepted date: 2 February 2016

Please cite this article as: Patterson, Susan L., The effect of emotional freedom technique
on stress and anxiety in nursing students: a pilot study, Nurse Education Today (2016),
doi: 10.1016/j.nedt.2016.02.003

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THE EFFECT OF EMOTIONAL FREEDOM TECHNIQUE ON STRESS

AND ANXIETY IN NURSING STUDENTS: A PILOT STUDY

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Susan L. Patterson DNP, RN, CNE CCM
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Faculty, Carolinas College of Health Sciences, Charlotte, NC

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Visiting Professor, Chamberlain College of Nursing

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624 Barington Place

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Matthews, NC, 28105

704 355 3464/704 321 5833

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Susan.patterson@carolinas.org

word count 6667

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Abstract

Background

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Stress and anxiety have been identified as significant issues experienced by student nurses during

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their education. Some studies have suggested that the stress experienced by nursing students is

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greater than that experienced by medical students, other non-nursing healthcare students, degreed

nurses, and the female population in general. A recently introduced energy type therapy,

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Emotional Freedom Technique (EFT), has shown some success in reducing symptoms of

anxiety, stress and fear in a variety of settings.

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Objective
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The purpose of this study was to determine the efficacy of EFT in decreasing anxiety and stress
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as a potential intervention to assist students in stress management.

Design
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The study used a mixed method design of both qualitative and quantitative measures.

Quantitatively, in a one group pretest-posttest design, participants received group instruction in

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the technique and were encouraged to repeat it daily. Self-reported anxiety was measured at

baseline, and then weekly for four weeks using the Perceived Stress Scale (PSS) and the State

Trait Anxiety Inventory (STAI). The qualitative survey was completed by participants at the

end of the study in order to capture a more subjective experience.

Setting

The pilot study was conducted in a two year college in the southeastern region of the United

States.

Participants
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All enrolled nursing students in an associate degree nursing program were invited to participate.

Participation was voluntary resulting in an original convenience sample of thirty nine nursing

students (N=39)

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Methods

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Data collection instruments included a demographic questionnaire, pretest State-Trait Anxiety

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Inventory (STAI) and Perceived Stress Scale (PSS). A qualitative questionnaire was also

administered at the end of the four weeks. STAI and PSS were administered weekly. Data

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analysis using RMANOVA was performed at the second, third and the fourth week.

Results
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Decreases in anxiety as measured on both the STAI and PSS were statistically significant
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(p=.05). For PSS, STAI state and trait data, the reduction in self-reported stress was statistically
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significant with a mean difference baseline to week 4. Qualitative data suggested that nursing

students experienced a decrease in feelings of stress and anxiety including a decrease in somatic
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symptoms.

Conclusions
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Overall, findings suggested that EFT can be an effective tool for stress management and anxiety

relief in nursing students.

Key words: Emotional Freedom Technique, stress, anxiety, nursing students

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INTRODUCTION

Psychological stress has long been identified to be an unfortunate consequence of a

career in nursing. Conditions which contribute to this are increased job demands, inadequate

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staffing, increased acuity of patients, lack of administrative support, a rapidly changing

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healthcare environment, and the emotional challenges of working with the sick and dying. Stress

and anxiety have also been identified as significant issues experienced by student nurses during

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their education. In fact, some studies have suggested that the stress experienced by nursing

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students is greater than that experienced by medical students, other non-nursing healthcare

students, degreed nurses, and the female population in general (Baldwin, 1999; Beck, Hackett,
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Srivastava, McKim, & Rockwell, 1997; Rhead, 1995). Nursing students have identified major

areas of stress as coursework, clinical experiences, and personal issues (Jones & Johnston 1997;
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Lindop, 1999; Jones & Johnston, 2000; Timmins & Kaliszer, 2002; Elliott, 2002; Rhead, 1995;

Jimenez, Navia-Osorio, & Diaz, 2009).

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A variety of stress management approaches for nursing students have been suggested and

tested. Jones and Johnston (2000) made a strong endorsement for a multifaceted approach to
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stress reduction using problem solving, time management, relaxation techniques, as well as other

interventions. This same study also emphasized the need for interventions that dealt with the

interface between student nurses and the healthcare organization. Galbraith and Brown (2011), in

their comprehensive literature review of successful interventions for managing stress, identified

that the most successful interventions had a strong theoretical basis and included, “cognitive

reappraisal of maladaptive cognitions, as well as relaxation”(p.718).

Although the role of complementary therapies in the treatment of stress and anxiety is not

new, there has been increased interest in the role of energy or biofield therapies in reducing
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anxiety and promoting feelings of well-being. Biofield therapy is described by the National

Institutes of Health‟s National Center for Complementary and Alternative Medicine (2011) as

“the manipulation of various energy fields to affect health” (p.1). A recently introduced energy

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type therapy is Emotional Freedom Technique (EFT). While similar to other energy based

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therapies such as Reiki and Healing Touch, EFT may have more in common with acupuncture, a

well-known Chinese medicine technique (Church, 2010). EFT combines the tapping of meridian

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points with a focus on the feared object or negative emotion to provide desensitization to the

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fear. In addition, there is repetition of a statement of self-acceptance, suggested to contribute to

cognitive restructuring, a well-known psychotherapeutic technique, where the individual

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identifies and corrects negative thoughts (Church, 2010). Tapping the meridian points relieves

stress, and through the application of this non-traumatic physical stimulus while also introducing
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the fear with self-acceptance, the negative somatic response that is associated with that memory

and all similar memories is interrupted (Craig, 2010).

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EFT is currently receiving much attention in the treatment of compulsive behavior,

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phobias, anxiety, and post-traumatic stress disorder. Therapeutic results and relief of symptoms
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are often quick and dramatic, demonstrating rapid improvement in the participant‟s ability to

tolerate stress.

REVIEW OF THE LITERATURE

An examination of the literature was performed to better understand the prevalence of

anxiety reported by nursing students and the effectiveness of a variety of interventions. The

review focused on three main questions: (1) Has anxiety been identified as a significant issue for

nursing students? (2) What particular interventions have been successfully applied to reduce
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anxiety? and (3) Has EFT been identified as a potential intervention for decreasing anxiety in

nursing students or other groups?

A literature search was performed using the Cumulative Index to Nursing and Allied

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Health Literature database (CINAHL) for the period of October 2000 through 2011. This

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database was chosen due to its extensive coverage of nursing, biomedicine, health sciences, and

alternative/complementary medicine. Search elements included anxiety, stress, nursing students,

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complementary therapies, energy therapies, and emotional freedom technique (EFT). In the case

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of EFT, since only a scant number of articles were recovered from the CINAHL search, an EFT

website, http://www.eftuniverse.com/ was also used to identify peer reviewed articles.

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A limited number of articles were generated regarding stress and anxiety in nursing

students requiring an expansion of the search to 1995. This may reflect current lack of interest
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in this topic as a research focus even though in the contemporary nursing education

environment students report stress and anxiety as concerns. Deary, Watson, and Hogston
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(2003) examined a cohort of nursing students to better understand causes of stress, burnout, and
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attrition using six different instruments and concluded that stress and the use of negative coping
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skills increased as the nursing program progressed and psychological symptoms increased.

Watson et al. (2008) found that life changes and stress contributed to distress, and that newly

qualified nurses had a higher reported stress than nursing students. Gibbons, Dempster, and

Moutray (2008) identified sources of distress to include new clinical experiences, lack of support

from staff, and a number of stressors regarding coursework demands and grades. Jimenez et al.

(2010) uncovered three kinds of stressors in nursing students, clinical, academic, and external,

with clinical rotations the most intense source of stress.

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Interventions for relieving the stress and anxiety usually focused on a multifaceted

approach. Charlesworth, Murphy, and Beutler (1981) evaluated a five week stress management

program for nursing students and found that those enrolled in the program experienced a

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reduction in test anxiety. Boutin and Tosi (1983) compared the effects of hypnosis and the

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combination of hypnosis and cognitive restructuring against a control and placebo group and

noted better results from the group receiving the combined approach. Jones and Johnston (2000)

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designed a six session stress management intervention, which included a presentation on coping

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skills, problem solving strategies, cognitive techniques, time management skills, and relaxation

techniques, showing anxiety was less in those students receiving the intervention. Hamrin,
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Weycer, Pachler and Fournier (2006) reported that a peer-led support group demonstrated self-

reported reductions in anxiety and improved coping. Hsiao, Chien, Wu, Chiang, and Huang
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(2010) found that spiritual health was negatively associated with clinical practice stress and

depressive tendency.
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Although there was no information available regarding the use of EFT in nursing
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students, the literature did suggest that EFT might be successful in decreasing anxiety and
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feelings of distress in a variety of populations and settings. Wells, Polglase, Andrews,

Carrington, and Baker (2003) found that EFT was more effective in reducing human phobias of

small animals than a comparative group using deep breathing. Waite and Holder (2003)

compared EFT against other methods and a control group and found EFT to be just as effective

at reducing fear as the other interventions, but more effective than the control group. Rowe

(2005) compared a group using EFT pre-treatment to post treatment, finding a statistically

significant decrease in all components of psychological distress. Brattberg (2008) demonstrated a

statistically significant improvement in pain, anxiety, depression, vitality, social function, and
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performance in a group of women with fibromyalgia who received EFT. Church, Geronilla, and

Dinter (2009) examined the effects of EFT on psychological symptoms in a sample of veterans

finding a statistically significant improvement in symptoms. Church (2009a) studied the effect of

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EFT on athletic performance in basketball players which demonstrated an improvement in the

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number of free throws, but not jump height. Additional studies by Church (Church, 2009b;

Church et al., 2010), on small groups of veterans suffering from post-traumatic stress disorder

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(PTSD) indicated significantly less psychological symptoms when compared to control groups.

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Church and Brooks (2010) investigated the effects of multiple rounds of EFT with healthcare

workers on physical discomfort, emotional childhood experiences and substances craved finding
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a reduction in symptoms. Church, DeAsis and Brooks (2012) undertook a study on EFT and its

effect on depression among college students with lower depression scores for those using EFT.
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Church, Yount and Brooks (2012) investigated the effect of EFT on the salivary production of

cortisol and found that the EFT group had significantly less production of cortisol than other
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study groups.
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To summarize the literature, stress and anxiety have been identified as areas of concern
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for nursing students. A variety of stress management approaches have been suggested and tested

with the most successful interventions having a basis in cognitive reappraisal and relaxation.

EFT has been recently introduced and is currently receiving much attention in the treatment of

compulsive behavior, phobias, anxiety, and post-traumatic stress disorder. With the gap in the

literature on the use of EFT in nursing students, the purpose of this project was to determine the

efficacy of Emotional Freedom Technique (EFT) in decreasing anxiety and stress in nursing

students enrolled in an associate degree nursing program.

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METHODS

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The research proposal, study design and all participant related content was reviewed and

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approved by the university and healthcare system Institutional Review Boards (IRB). In

observance of IRB guidelines, all participants were provided a description of the study and how

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privacy and confidentiality would be maintained; written, informed consent was obtained. All

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participants selected a unique confidential identifier to further provide confidentiality.

STUDY DESIGN
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This study was a mixed design with both quantitative and qualitative approaches. Quantitatively,

a quasi-experimental, time series, pretest-posttest design was selected and qualitatively, a post-
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study, short answer questionnaire was chosen.

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SETTING
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The setting was a hospital based associate degree nursing program in the southeast region of the
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United States with a nursing student body of approximately 250 students. Only nursing students were
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included. Group sessions were held in classrooms at the college with access only to those participants

admitted to the pilot in order to provide participants with confidentiality.

SAMPLE /RECRUITMENT

Participants in the pilot study were a convenience sample of associate degree nursing students

recruited by a variety of means including college newsletter announcements, email invitation,

electronic, and paper poster displays. Exclusion criteria included those currently being professionally

treated for anxiety and those who were already regular users of EFT. The rule of 30 was applied to

determine the sample size for the pilot study. Burns and Grove (as cited in White, 2012) suggest that

in quantitative research at least 30 participants are needed in each group being studied. Melnyk and
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Cole (2011) also state that pilot studies are conducted with smaller sample sizes of perhaps 30-40

participants. The initial sample size was 39 participants, one participant dropped out of the study

the second week and a duplicate case was identified in the demographic data sample and was

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removed. This resulted in a final demographic sample of 37. During data analysis it was noted

that there were additional duplicate cases and that some participants did not complete the PSS,

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STAI trait and state survey every week. Additional duplicate cases were removed and cases

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without full data sets for week 0, week 2 and week 4 were also removed. This resulted in

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an sample size of n= 31 for PSS and a sample of n=30 for STAI state and trait.

STUDY INTERVENTION MA
The EFT technique, The Basic Recipe (Craig, 2010, Church 2010) was used as an intervention

in the study. EFT involves the light manual tapping of traditional acupressure meridian points
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( acupoints) on the head, face, neck, chest and hands while verbally confronting the feared
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object or stressor and repeating a phrase of reassurance. Participants are asked to repeat the
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phrase, “even though I have this feeling of stress and anxiety, I deeply and completely
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accept myself” while simultaneously tapping the acupoints. After the initial round of

tapping accompanied by this phrase, the participants are instructed to shorten the phrase to
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„this feeling of anxiety, stress‟ or some other short phrase that focuses on the fear.

Participants are then encouraged to repeat rounds of this process until they note their anxiety to

be decreased.

MEASUREMENT TOOLS

Three instruments were used in this project, the State-Trait Anxiety Inventory, (STAI),

(Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983), the Perceived Stress Scale (PSS)

(Cohen, Kamarck, & Mermelstein, 1983) and a qualitative questionnaire developed by the

researcher. The STAI, is a 40 item self-report instrument that measures both state and trait
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anxiety using a four point likert scale. State anxiety is defined as a temporary condition of

anxiety while trait anxiety is a longstanding anxiety trait. Reliability has been established at .92

for state anxiety) and .90 for trait anxiety (Spielberger, et al. 1983). Cohen et al.(1983) developed

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a 14 item self-report, one dimensional tool for measuring perceived stress called the Perceived

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Stress Scale (PSS) which uses a 5 point likert scale and has an established reliability of

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0.84, 0.85, and 0.86 for three samples. The14 item instrument was revised to a 10 item

instrument with a reliability of 0.78 (Cohen & Williamson, 1988). The 10 item PSS was used for

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this project.
Basic demographic data including age, gender, marital status, race/cultural background,
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years of previous college, current course enrollment, previous experience with EFT, and current

involvement with other anxiety/stress reduction interventions were also collected

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The pilot began with an introductory session (week 0) followed by four follow up
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sessions, each a week apart. Three introductory sessions were offered in order to meet student
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scheduling needs. In the introductory session, the researcher provided participants with step by step
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instructions for the technique using the EFT technique as described in The Basic Recipe (Craig,

2010), a demonstration and the opportunity to practice. Participants were encouraged to practice the
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technique daily. During the first follow up session (week 1) and the second follow up session,

(week 2), participants met as a group. Multiple sessions were offered each week to meet student

schedules. During these sessions the technique was practiced and PSS, STAI instruments were

completed via Survey Monkey linked to a study website. No group session was held during week

3 and participants practiced the technique independently and were instructed to complete surveys

remotely. In the final group session (week 4) in addition to the PSS, STAI surveys, a qualitative

questionnaire was completed and a debriefing statement provided. A gift certificate for $20.00

was provided for participants who completed the study.

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DATA AND RESULTS

Through Survey Monkey, demographic and quantitative data was exported to the

Statistical Package for the Social Sciences, version 20 (SPSS) for data analysis. Four participant

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files were excluded from the data sample because of no EFT log or duplicative project ID

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numbers.

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Sample Demographics

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There were thirty nine (n=39) initial participants in the pilot study. One participant

dropped out before the second week of the study due to increased anxiety and desire to seek
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professional help. The remaining 38 participants continued in the pilot through its duration of

four weeks. A duplicate case was identified in the demographic data sample adjusting the final
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demographic data sample data to 37. The demographic sample consisted of 33 females and four

males with an average age of 34. Marital status reflected 37.8% married and 62% single. Most
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(62%) were employed, with 40.5% working 16-30 hours per week. Highest level of education
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varied, with the majority of the sample already having a baccalaureate degree ( 54%), 16.2%
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with a graduate degree, 8% with an associate degree, and 16.2% with previous college and no

degree. Only 5.4 % listed their highest level of education as a high school diploma or GED. The

majority of students were in the intermediate level of the nursing program (51.3%), with 37.8%

in the fundamental level, and 10.8% in the advanced level. Average GPA range was self-reported

and results were 3.5-4.0 (54%), 32.4% in the 3.0-3.5 range, 10.8% in the 2.5 to 3.0 range and

2.7% in the 2.0-2.5 range. A summary of the sample‟s demographic data is found in Table 1.
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Quantitative Analysis

A repeated measures, analysis of variance (RMANOVA) was performed comparing

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baseline, week 2 and week 4 for each of the quantitative instruments, PSS, STAI-state and STAI-

trait. Although data was collected at baseline and then weekly for 4 weeks, when data was

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examined and cleaned for missing cases, duplicate cases and verification that the same

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participants were represented in each repeated measure, some cases were present in the PSS

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data set for week 1 and 3 which were not present in week 1 and week 3 STAI data sets.

Additionally, after data examination and cleaning week 1 and week 3 had a decreased sample
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size of N= 28 for STAI state and trait. To maintain the sample size at the N=30 minimum

recommendation for a pilot study (Melnyk & Cole 2011, Burns & Grove, as cited in White
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2012), data analysis was performed on baseline, week 2 and week 4 data which after
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cleaning had adequate sample size.

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RMANOVA assumes that the dependent variable is continuous, is approximately

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normally distributed, has sphericity, and has one independent variable. The sphericity
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assumption was met in the STAI-state results but violated in both the PSS and STAI-trait results.

To rectify this violation, an adjustment to degrees of freedom was made through Greenhouse-

Geisser correction and sphericity was met. A traditional alpha level of .05 was chosen as the

indicator of statistical significance.

Data analysis supported the hypothesis, nursing students will have reduced anxiety relative

to baseline as measured by the Perceived Stress Scale, the State-Trait Anxiety Inventory.

PSS results: Mauchly‟s test of sphericity, an important assumption for RMANOVA, was

violated (significance of the approximate Chi-square of 9.18 is .010, a significance level < 0.05)
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and so a Greenhouse-Geisser correction to degrees of freedom was applied. Greenhouse-Geisser

correction values demonstrated that the mean scores for PSS week comparisons were

significantly different (F (1.6, 47.2) =24.59, P<0.0005, partial eta squared .45).

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The Bonferroni pairwise comparison tests demonstrated that the mean difference of 3.16

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was significant (p=.05) from week 0 (baseline) to week 2; the mean difference of 2.52 was also

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significant week 2 to week 4 (p=.05) and the mean difference of 5.68 was significant from week

0 (baseline) to week 4. Descriptive statistics for the sample (n=31) demonstrated a decrease in

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PSS score mean from baseline of 23.87 (std. deviation 6.51) to 20.71 (std. deviation 6.17, in

week 2 and 18.19(std. deviation 6.86) in week 4 (p=.05). This represents a 23.8 % decrease in
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anxiety as measured by PSS. Descriptive statistics results are presented in Table 2. A profile plot

demonstrates the difference in means over the 4 week period in Figure1.

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STAI state results.

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Mauchly‟s test of sphericity for STAI state, with in subjects effect (P =.860) was not found
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to be statistically significant (p>.05) and the sphericity assumption was not violated. The
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observed F value was statistically significant, F (2, 58) =22.22, p<.001, partial eta squared
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=.434. Bonferroni pairwise comparison tests suggested that although there was a decrease in

anxiety from week 0 (baseline) to week 2 (mean difference 3.33) this change was not significant.

However, when comparing week 2 to week 4, a mean difference of 9.7 was found to be

significant (p=.05). Furthermore, when comparing week 0 (baseline) to week 4, the mean

difference of 13.03 was significant (p=.05).

Descriptive statistics for the sample (n=30) demonstrated a decrease in mean from baseline

of 38.13 (std. deviation 10.03) to 34.8 (std. deviation 10.78) in week 2 and 25.1 (std. deviation

7.42) in week 4 (p=.05). This represents a 34.2% decrease in anxiety as measured by STAI state.
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Descriptive statistics results are presented in Table 3. A profile plot demonstrates the difference

in means in Figure 2.

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STAI trait results. Mauchly‟s test of sphericity was found to be significant

(p=.009) and the sphericity assumption had been violated. With a correctional adjustment

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made to degrees of freedom through Greenhouse-Geisser, mean scores for anxiety were

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significantly different (F(1.56, 45.19) =20.48, p<0.0005). Bonferroni adjustments for

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multiple comparisons demonstrated a decrease in anxiety from week 0 (baseline) to week

2 (Mean difference 3.13) and this change was significant (p =.05). A comparison of week
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2 to week4 also demonstrated a decrease in trait anxiety (mean difference 4.4) and this

change was statistically significant (p=.05). The comparison of week 0 (baseline) to week
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4 also demonstrated a decrease in trait anxiety (mean difference 7.53) and this change
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was also significant (p= .05).

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Descriptive statistics for the sample (n=30) demonstrated a decrease in mean from
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baseline of 37.87 to 34.73 in week 2 and 30.33 in week 4 (p=.05). Overall, this represents
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19.9% decrease in anxiety when comparing baseline to week 4. Descriptive statistics

results are presented in Table 4. A profile plot demonstrates the difference in means in

Figure 3.

Qualitative results.

Qualitative data, as measured by the self-report of nursing students in a six item

questionnaire developed by the researcher, reported a perceived reduction in anxiety and stress.

Questions covered the following themes: ease of technique, changes in mood or feelings,

immediate reduction in stress, changes in anxiety or stress after 4 weeks, changes in mood after 4
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weeks, and other feelings or experiences with EFT. Response rate was 100% on all six

questions. A text analysis was performed through SurveyMonkey on qualitative data to identify

frequently used words and phrases. In addition, qualitative data was manually reviewed for

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individual comments, and repeated themes were identified and categorized.

For the question, “Did you experience any changes in mood or feelings immediately after

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using the technique” a text analysis revealed that 87% of the students felt calmer, more relaxed

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after using EFT. For the question, “Did you experience any changes in mood or feelings

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immediately after using the technique” a text analysis revealed that 87% of the students felt

calmer, more relaxed after using EFT. Comments included:

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“I felt a decrease in moods of tension and anxiety, and an increased feeling of

control over the present situation I was in.”, “I was not as anxious and it
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transferred to not being in a bad mood.” and “EFT did calm me down when I
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used it 15-30 minutes before a test.”

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In addition to the feelings of increased calm and relaxed, 17% reported that the technique

helped them sleep:

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“This technique worked especially well when I woke up during the night (which

happens rarely, but is annoying.). I would do EFT and go right back to sleep.”,

“Yes. I felt calm, sleepy, and relaxed. Most of the time, when I use EFT at night, I

fall right asleep afterwards.”

For the question, “Did you experience any reduction in anxiety or stress immediately

after using EFT? If so how did you experience the change (decreased heart rate, less agitation,

etc.)?”, most participants (82%) described an immediate calming, relaxing or less tension:

“I feel a sense of calm and relaxation after using the technique as many times as

it took to take my mind off of the stress and anxiety.”, “Right away. It was very
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effective in reducing my stress in minutes.” and “Yes, I was almost always

instantly calmer after 1 or 2 rounds of doing it.”

Many participants (51%) also reported a decrease in somatic symptoms:

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“Yes, decreased heart rate and decreased "tightening" or weight in the pit of my

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stomach.”, “Yes. Less pressure in my chest.” and “I could feel this relief with the

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reduction of tension in my jaw, my heart rate would decrease, and I could feel the

tension leave my shoulders and neck.”

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For this same question some (10%) also reported an increased feeling of control:

“More in control, breathing slowed.”, “Yes, I felt calmer and more in control of
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the current situation immediately after doing EFT.” and “I felt that using EFT

gave me a perceived feeling of control and security.”

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For the question, “After the four weeks of using EFT, did you experience any overall
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change in mood or feeling?” 38% reported that their mood had not changed but they did find
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EFT to be an effective tool for decreasing anxiety:

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“Not really. I feel it worked better for me as an acute therapeutic tool.”, “Not

particularly, I felt the technique worked to temporarily relieve stress; I don't think
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I experienced an overall change in mood.” and “I still experience worries and

nervousness however EFT has provided a way to relieve those feelings, at least

temporarily and provides a way to better control and manage those feelings.”

In contrast, 33% reported that EFT might have impacted their mood:

“I believe that my mood has improved since beginning EFT.”, “Yes, I felt

happier. I feel that I am an easier going person.” and “I changed to more of a

positive mood/feeling while using EFT”. Some 20% of the participants were not

sure: “My overall mood has not been drastically changed, although I would say
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that my overall attitude has improved greatly and I am more successful at being

positive on a daily basis since practicing EFT.”, “It is really hard to say because

I have so many other things going on right now. I have had some personal issues

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this past month and I have a final coming up.” and “I feel great, but I don't know

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if that is because of EFT.”

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In the next inquiry, “After four weeks of using EFT did you experience any overall change

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in feelings of anxiety or stress? If so, how did you experience the change (decreased heart rate,

less agitation, etc.), 56% of participants admitted to experiencing less stress and anxiety after
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four weeks of using the technique. Comments included:

“I would say overall I am somewhat less anxious and stressed because things
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don't seem to make me upset quite as easily or quickly.”, “Slightly. I feel calmer.”
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and “Levels of anxiety have gone down to a more tolerable rate.”

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A large number of respondents (43%) also reported that they were better able to cope after 4
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weeks:

“I feel more empowered to tackle my stress level and confident that going
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forward I will use the tool to keep my stress levels at a more comfortable level.”,

“I felt like I still had stress but it was better controlled using EFT.” and “EFT

enabled me to experience a temporary relief of stress and anxiety.”

Some participants (12%) reported no change in stress and anxiety over the four weeks:

“I don't believe so. My heart rate and breathing become increased when I get

anxious.”, “No change. I do not wrestle with anxiety very much.” and “I don‟t

think overall but I was able to use EFT to reduce my stress in immediate

situations”.
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For the question, “Are there any other feelings or experiences you would like to comment on

regarding your practice of EFT?” 82 % of participants provided positive comments about their

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experience with the technique; some of these include:

“I would say it's definitely worthwhile to have in „your tool bag‟ as a way to

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lessen anxiety as it's quick & easy to incorporate into one's daily routine.” and “I

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feel much more able to manage my anxiety. Even though I still feel anxious at

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times, I calm down more quickly.”
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DISCUSSION

Both qualitative and quantitative statistical analysis supported the pilot hypotheses, that
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nursing students participating in EFT would have reduced anxiety relative to baseline as
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measured by the Perceived Stress Scale, the State-Trait Anxiety Inventory, and a qualitative
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survey. The qualitative data provided participant feedback rich in expression of improved
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feelings of calm, relaxation, and diminished agitation and tension. Notably some participants
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also identified a decrease in negative somatic symptoms, as well as an improved ability to fall

asleep. Most participants also described that the technique provided them with a feeling of

control over stress and anxiety, another tool for stress management and coping.

For PSS data, the reduction in self-reported stress was statistically significant with a

mean difference baseline to week 4. PSS data supported claims in the literature that the stress

experienced by nursing students is greater than that reported by the female population in general

(Baldwin, 1999; Beck et al., 1997; Rhead, 1995). This is strongly reflected in PSS results where

baseline PSS measurement of stress in this sample was considerably higher than Cohen and

Williamson‟s (1988) reported PSS normative means for women (mean 13.7, std. deviation 6.6).
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The elevated perceived stress reported by nursing students in this sample may reflect a

greater perception of stressful events, the need for better coping strategies, and perhaps

personality attributes that are particular to those who chose the nursing profession.

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Conversely to PSS, STAI state results for baseline anxiety were just below Spielberger et

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al. (1983) normative values for females (mean 38.76, std. deviation 11.95) and did not reflect the

claim in the literature that the stress experienced by nursing students is greater than members of

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the general female population. Most importantly and similar to PSS results, for STAI state data,

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reduction in anxiety when comparing baseline to week 4 was also statistically significant. STAI

trait results for baseline anxiety are also just below Spielberger‟s (1983) normative values for
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females (mean 40.40, std. deviation 10.15). Similar to PSS and STAI state results, the reduction

in STAI trait scores baseline compared to week 4 was also considerable. This result is surprising
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and differs with expectations and results in the literature, since trait anxiety is reflective of one‟s
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personality trait for anxiety and expected to be stable over time. This may reflect that although
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the explanation to students completing the STAI trait tool was to comment regarding their
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usual or longstanding level of anxiety, students may have been commenting on their current
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level or state of anxiety.

Although the exact mechanism behind EFT has not been identified, Church (2010)

suggests that tapping of meridian points while focusing on the fear or negative emotion decreases

the associated feelings of anxiety. Repeating of a statement of self-acceptance, may contribute to

changing ones thinking or appraisal of the fear. Lane (2009) proposed that acupressure tapping

might produce, “a biochemical relaxation response that counter conditions anxiety producing

stimuli and traumatic memories” (p. 11). Both of these explanations support Galbraith and
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Brown‟s (2011) suggestion that cognitive reappraisal and relaxation play a key role in effective

stress management techniques.

The literature suggests that EFT has been shown to significantly decrease anxiety, and

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feelings of distress in a variety of populations and settings. These settings and conditions

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included veterans, phobic individuals, athletes, individuals diagnosed with fibromyalgia and

others. Both qualitatively and quantitatively, the results of this pilot study support that EFT may

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also decrease the feelings of stress and anxiety experienced by nursing students as well as offer

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them a means for coping or give them some measure of control over existing anxiety.

The study did have a number of limitations, one of which is its small sample size (n=39)
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which limits the ability to apply study results to the general population. There was also potential

for selection bias due to convenience sampling. This selection or sampling bias, inherent to
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convenience sampling, was accepted in this study with the knowledge that it also decreased the

ability to apply the study results to the general population. In addition, the nature of nursing
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being a profession dominated by females, persons of male gender were diminished from the
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sample. This again represents a selection bias and limits the ability to generalize study results
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across genders. Attention bias may also have been a limiting factor since participants were aware

of their involvement, and the study hypothesis. As a result of this bias, participants may have

given a more favorable response when responding to the instruments. Participants were all

familiar with the researcher as a current or former instructor. This could potentially influence

participants providing a more favorable response to instrument questions. However, the 98%

study retention rate suggests that the efficacy of the EFT was instrumental in keeping

participants engaged.
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CONCLUSIONS AND IMPLICATIONS FOR NURSING

EFT can be another tool for successful stress management and anxiety relief in nursing

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students. Beyond efficacy, the simplicity and immediacy of EFT make it especially attractive.

The technique can be taught quickly and then practiced by the individual with no need for

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frequent therapist intervention or the associated costs. Even more important, therapeutic effects

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have been reported to occur quickly, perhaps even instantaneously after performing the

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technique. Stress reduction and the resulting feelings of well-being and self-efficacy promote

psychological health and hardiness. The psychologically hardy individual is better able to cope
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and endure the certain stressors of academics and later, the professional environment. Improved

academic and professional retention is critical in nursing and in healthcare.

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With the predictions for an unprecedented nursing shortage looming in the next ten years,
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attracting and retaining competent candidates for nursing is imperative. Furthermore, to succeed
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in today‟s healthcare environment, the nurse must be resilient. Arming students with effective
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coping techniques increases their chances for successful health maintenance and professional
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longevity as they move from academics to practice.

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Church, D. (2010). The EFT Mini-Manual. Fulton, CA: Energy Psychology Press. Retrieved
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Church, D., Geronilla, L., & Dinter, I. (2009). Psychological symptom change in veterans after

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Gibbons, C., Dempster, M., & Moutray, M. (2008), Stress and eustress in nursing students.

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Table 1 Demographic data

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Marital GPA Employment Program Highest
Gender status Level education
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33 F 37.8% 3.5-4.0 62% employed 37.8% F 54% bachelors
4M married 54% 51.3% I 8% associate
62% single 3.0-3.5 40.35% @16-30 10.8%A 16.2% graduate
32.4% hrs/wk 16.2% prev.
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2.5-3.0 college
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10.8% 5.4% HS/GED

2.0-2.5
2.7%
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Table 2
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Descriptive Statistics PSS Baseline, week 2 and week 4, p=.05

Standard
PSS score Mean Deviation N
Baseline 23.87 6.51 31

Week 2 20.71 6.17 31

Week 4 18.19 6.86 31

.
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Figure 1. Estimated marginal means of PSS from baseline through week 4, (p=.05).
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Table 3

Descriptive Statistics STAI State, Baseline, week 2 and week 4, p=.05

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STAI state Standard
score Mean Deviation N

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Baseline 38.13 10.03 30

Week 2 34.8 10.78 30

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Week 4 25.1 7.42 30

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Figure 2. Estimated marginal means of STAI state, from baseline through week 4, (p=.05).
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Table 4

Descriptive Statistics STAI Trait, Baseline, week 2 and week 4, p=.05

STAI

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trait Standard
score Mean Deviation N
Baseline 37.87 11.69 30

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Week 2 34.73 10.67 30

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Week 4 30.33 8.12 30

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Figure 3. Estimated marginal means of trait, from baseline through week 4, (p=.05).
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HIGHLIGHTS

Nursing students experience considerable stress and anxiety in their education.

Emotional Freedom Technique (EFT) has been shown to decrease perceived anxiety in many

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groups.

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A mixed methods design was used including both a qualitative questionnaire to capture

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participants subjective experience and a quantitative pretest-posttest design used to determine

the efficacy of EFT in decreasing anxiety in a convenience sample of associate degree nursing

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students.

Three (3) instruments were used for measurement, the State Trait Anxiety Inventory (STAI), the
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Perceived Stress Scale (PSS) and a qualitative questionnaire.

Decreases in anxiety that were statistically significant (p=.05) were identified on the STAI and
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PSS; participants reported feeling calmer and more relaxed after using the technique.
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EFT may be an effective tool in this group as well as other healthcare professionals.
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