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ABSTRACT
Background : Promotion and provision of individuals health is one of the bases for
development in societies. Students mental health is very important in each society. Students of
medical health sciences especially nursing students, are under various stresses in clinical
environment, in addition to the stress they experience in the theoretical education
environment. With regard to the importance of nursing students general health and
considered the various existing strategies to promote general health components, use of
complementary treatments is more considered because of their better public acceptance, low
costs, and fewer complications. One of the new strategies in this regard is Laughter Yoga. The
present study was conducted with an aim to define the effect of Laughter Yoga on stress level
among nursing students.
Material and Methods : This is quasi experimental study among final year nursing
students Bachelor in Nursing of Universiti Teknologi MARA (UiTM). The study aimed to examine
the effectiveness of laughter therapy in reducing stress among nursing student before final
exam with comparing the mean of stress between intervention and control group.The subjects
who fulfilled selection criteria had to complete the PSS ( Perceive Stress Scale ) to measure their
level of stress. Total fifty four Bachelor in Nursing final year students available during the time
of data collection constituted the study sample. In the study group, 27 students in intervention
group were held laughter yoga session and in the control group, no intervention was
conducted. Data was collected before and after the experimentation. Experimentation involves
administering laughter yoga therapy for 15-20 minutes daily during ten days.
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Result : The findings showed a significant difference in the mean score of PSS score
before and after laughter Yoga therapy intervention and control group of the study.
Conclusion : The findings showed that Laughter Yoga had a positive effect on students
level of stress and improved physical and mental disorders, lowered anxiety and depression and
promoted their social function. Therefore, laughter Yoga can be used as one of the effective
coping strategies on reducing students stress.


CHAPTER 1
CHAPTER 1
INTRODUCTION
Everyone has stress and we face it in our daily life. It is a natural phenomenon that
everyone experience in his or her life. How people cope with difficult or stressful circumstances
has been subject of a considerable amount of research over the past decade. Students,
workers, parents do so have stress in their particular areas. Student nurses would have being
facing interpersonal and environmental stress.
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What is Stress ?
Stress is an automatic physical response to any stimuli that requires you adjust to
change (Benson & Casey,2008)
Lazarus and Folkman(1984) define stress as a relationship between a person and
environment that is appraised by a person as a taxing or exceeding her or his resources or
endangering his or her well-being
Stress definition by Varcarolis, Benner-Carson and Shoemaker (2006) is a state which is
created by a change in environment that is perceived by challenging, threatening or damaging
to a person well-being
The Physical Response to Stress
A threat or perceived threat evokes the physical stress response. Symphatetic nervous
system is trigger by hypothalamus that will cause increase respiratory rate, heart rate ,blood
pressure and constricting peripheral blood vessel and bronchiols. Chemical message such as
cortisol,epinephrine and norephinepherine send by hyphothalamus into blood stream.
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Stress among nursing students
Continuous stress cause changes and imbalance of hormones in the body and have the
potential to affect health outcomes. Stress brings advantages and disadvantages to them. It is
depend on how nursing students going to look upon them and take over them. Stress can cause
them to become stressful, feel distress and emotional effected while on the other hand, stress
give them motivation and evoked them to be more upholding and persistence in the study in
order to reach the optimum target and active further success.
Academic stress among college students has been a topic of interest for many years.
College students are prone to stress due to the transitional nature of college life. For example ,
many college students move away from home for the first time , which can necessitate leaving
all previously learned support systems such as parents, siblings and high school friends. Nursing
students also face the same stressor among other course students but additional to it, clinical
practice also cause stressor to them.
Various of diversional therapy that use of them to reduce stress such as games, outings,
gardening, massage and aromatherapy, cooking, social, cultural and spiritual activities. Laughter
therapy is a practice involving prolonged voluntary laughter. Laughter yoga therapy is based on
the belief that voluntary laughter provides the same physiological benefits as spontaneous
laughter. It is done in groups with eye contact and playfulness between participants. Forced
laughter soon turns into real and contagious laughter.
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Definition of laughter
The physiological definition describes laughter as a successive rhythmic spasmodic
expiration with open glottis and vibration of the vocal folds or as a series of spasmodic and
party involuntary expiration with inarticulate vocalization . Laughter is an innate capability that
not only helps humankind express emotion, but has also shown promise as a promotive,
preventive and therapeutic measure to a wide array of medical ail- ments
Benefits of laughter
Laughter has shown different physiological and psychological benefit. Some of the
laughter benefits are (1) reduce stress, anxiety, tension and depression symptom; (2)elevates
mood, self esteem, hope, energy and vigor; (3)enhances memory, creative thinking and
problem solving; (4)improve interpersonal relationship, interaction and attraction ;(5)increase
friendliness, helpfulness; (6)promote physiological well being; (7)improves quality of life and
patient care; (8) intensifies and its contagious.(Mora-ripoll, 2011)
1.2Statement Problem
A study to assess the effectiveness of laughter exercise in reducing stress among
nursing students in selected nursing college or university.
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1.3.Objectives of the study.
General Objective
To examine the effectiveness of laughter therapy in reducing stress among nursing
student before final exam.
Specific objectives of the study are:-
1. To identify the prevalence of stress among nursing student (baseline) pre test
2.To compare mean of stress between intervention and control group,
3. To examine the effect of laughter yoga on mean score of stress in intervention group.
1.4.Operational Definition
Asses: It refers to the evaluation of stress level among nursing students who
participated in this study
Effectiveness:It refers to significant reduction level of stress after laughter yoga therapy
implemented for certain period among nursing students in selected nursing colleg
Laughter Therapy: In this study, laughter is demonstrated by researcher. It interspersed
with deep breathing exercise to bring physical and mental relaxation. Laughter drills is not
induced with any humor or jokes. Each session, it should not more than 20 minutes.
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Stress:It refers to the score obtained on psychological and emotional distress
experienced by students when demands exceed their personal and social resources.
1.5.Hypothesis
Null hypothesis
Ho There is no difference in level of stress score between intervention and control
group
Alternative hypothesis
Ha1 There is a difference in level of stress score between intervention and control
group.
Ha2 There is a reduction in level of stress score in intervention group after introducing
to laughter yoga.





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CHAPTER 2
LITERATURE REVIEW
2.0 Introduction
This chapter explains regarding studies at have been done on laughter yoga, stress
factor and impact to students and effect of laughter yoga therapy. Literature reviews were
search using Scholar and PTAR database. Dates of publications were search from any date to
present. The key phrase used was laughter therapy to reduce stress. There were limited
number of studies addressing both stress and laughter therapy among nursing students and
none of the studies done in Malaysia. Among the studies only three studies relate nursing
students with laughter therapy while other only focusing on stress among nursing student and
coping strategies.
By understanding nursing students stressor and challenging during their students life is
essential in identifying the support they need in order to cope well and they able to study in
comfy environment. We believe that when students are able to cope with stress, it will
influence their self efficacy, development of a professional self-concept, autonomy perception
and also their learning process.

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2.1 Stress Among Nursing Student
According to Altiok ( 2013), nursing training is the most stressful event among nursing
student especially when being evaluated by their clinical instructor or tutor. In the research, 15
students were interviewed and the question is focused on for moments which are clinical
practice, theoretical training, social and personal life. According to students, they feel stress
because they are being supervised, worry that they will harm the patient and stress on
documenting patients data. Second year student is the most stressful year among other year.
Burnard et al.( 2008) in his study on stress among nursing in five different countries
(Albania, Brunei, the Czech Republic, Malta and Wales). Although each country, within this
study, has a unique culture, a cross-cultural comparison can be made in an attempt to better
under- stand stress in the student nursing population. The mean score for the total sample for
all the items on the stress scale was 52.3 (SD 17.1). The sample from Wales had the lowest
mean score and those in Brunei had the highest. Students in Brunei and Malta were more
stressed by the academic elements of the course than by the clinical elements. Whereas for
those students in the Czech Republic For students in Wales and in Albania Korce there were
no differences in stress experienced between the academic and clinical elements of the course.
The results indicated that there were no significant differences
A study by Fong, Hil, & Bs, (2009) Hong Kong baccalaureate nursing students' stress and
their coping strategies in clinical practice. Two hundred five nursing students completed a self-
administrative survey including demographics, Perceived Stress Scale, and Coping Behavior
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Inventory. Results showed that students perceived a moderate level of stress (M = 2.10, SD
=0.44). The most common stressor was lack of professional knowledge and skills. Among the
four types of coping strategies (transference, stay optimistic, problem solving, and avoidance),
transference was the most frequently used. Furthermore, senior students who perceived a
higher level of stress from taking care of patients were more likely to choose problem-solving
strategies. Senior students who had no religious belief and perceived a higher level of stress
from teachers and nursing staff were more likely to use avoidance strategies. The results
provided valuable information for clinical educators in identifying students' needs, facilitating
their learning in the clinical setting, and developing effective interventions to reduce stress.
A descriptive cross sectional study among Iranian first year nursing students on source
of stress and coping strategy to decrease stress identified that they are exposed on variety of
stressors. Since they are first year nursing students, most of them have problem in finding new
friends(76.2%) as interpersonal source of stress. They also identified the most frequent
academic stressor was increased class workload (66.9%).Therefore in this study , the
researcher suggested that student support system should be establish during first year and to
ensure students coping strategy improvement should be monitor throughout their study.
Coping strategy should be implement either by the counselor or their lecturer. (Seyed, Tafresi &
Hagani ,2007)
A study by Timmins & Kaliszer (2002) on causes of stress among nursing students by
distributing a questionnaire among 110 students . The results showed that there are five factors
that cause stress among them which are first factor is academic factor. Second and third factors
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are related to relationship among friends and lecturer , fourth factor is financial and fifth factor
is related to death of patient. The researcher suggested that educators should include adequate
support structures for clinical areas, preceptorship programmes and the availability of student
counseling programmes.

2.2 Effect of laughter therapy
A study among 109 elderly in Korea on effect of laughter on depression and cognitive
function showed that the mean score was decreased after laughter therapy . They concluded
that laughter therapy is considered to be useful, cost-effective and easily- accessible
intervention that has positive effects on depression, insomnia, and sleep quality in the elderly
(Ko & Youn, 2011).
A study was conducted by Kaur & Walia, (2008)in the National Institute of Nursing
Education PGIMER, Chandigarh with an objective to evaluate the effect of laughter therapy on
the stress level of nursing students. The study sample involved 42 nursing students, age
between 17 21 years. In this study, data was collected on pre-test and post-test, also included
a session of laughter therapy for 20 minutes daily for ten days in between of that test. After the
experimentation, the level of stress was decreased at statistically significant level following the
laughter therapy session. The level of stress was decreased from 23 to 18. Hence the positive
effect of experimentation (laughter therapy) on reducing the stress level was proved
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Kimata ( 2007 ) in his study of the effect of laughter in increasing breast milk production
among healthy mother who breast feeding her infants with atopic eczema. The result of the
study showed that laughter increased the levels of breast-milk melatonin in both mothers with
AE and healthy mothers, and feeding infants with increased levels of melatonin-containing milk
reduced allergic responses in infants. Thus, laughter of mothers may be helpful in the
treatment of infants with AE.
Study by Yazdani.et.al,( 2014) stated that laughter Yoga had a positive effect on
students general health and improved the signs of physical and sleep disorders, lowered
anxiety and depression, and promoted their social function. Therefore, laughter Yoga can be
used as one of the effective strategies on students general health.
According to Nagendra.et.al (2007), laughter yoga therapy has psychological,
physiological and immunological benefit. Blood pressure will be decrease and cortisol level will
be decrease which will decrease level of stress and less perception of stress as seen in
Perceived Stress Scale (PSS). In heart rate reduction showed no significant difference . This is
because heart will be decrease in longer period of laughter therapy. Apart of being therapeutic
and reducing stress, laughter yoga therapy has more application for normal healthy people as a
preventive measure for all physical and mental health problem.

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Summary of the literature












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CHAPTER 3
METHODOLOGY
3.1 STUDY PROFILE
This study was conducted at Faculty of Science, University Technology MARA, (UiTM)
Shah Alam. All the final year nursing students Bachelor in nursing in Faculty of Science (UiTM)
were invited asked to complete questionnaires. The study was conducted in March 2014 which
was about four months before the examination period so as to minimize the extra stress
symptoms. All students who participated in the study were informed about the objectives of
study and information about the instruments was explained by well trained researchers. The
participation was entirely on voluntary basis. All students were guaranteed the confidentiality.
The study was approved by Faculty of Sciences as well as University (UiTM) Research and
Ethical Committee.

3.1.1 Research Design
Research design planned for the study is quantitative quasi-experimental time series
design (two group pre test and post test) which include manipulation, control and no
randomization. A pre test is use to determine the stress level of participants before the laughter
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yoga while post test is used to compare changes in participant stress level. The control group
characteristics is the same like experiment group but intervention is not injected.



3.1.2 Method of Data Collection
The population of study would consist of students who are studying Bachelor of Nursing
in Faculty of Science in UITM Puncak Alam. They were invited asked to complete
questionnaires. The subject were given Subject Information Sheet and explained about the
study. The participation was on voluntary basis. Those who signed and informed consent and
fulfilled the selection criteria were enrolled in this study. We use a convenient sampling method
for 60 students only at UITM PuncakAlam.
The subjects were given a form to gather their data related to socio-demography and they
have to complete three sets of questionnaires:
i. PSS (Perceived Stress Scale)

Perceived Stress Scale are developed by S. Cohen, T. Kamarck& R. Mermelstein year
1983. This validated and reliable self-reported questionnaire had beenused in various clinical
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settings, cultures and populations and was translated in Malay by ASEAN Journal of Psychiatry,
Vol. 15 (1), January - June 2014: 8-13.The PSS-10 can be used to determine whether
appraised stress is an etiological factor in behavioural disorders or disease. Items of the PSS
were designed to tap how unpredictable, uncontrollable, and overloaded respondents find
their lives. PSS-10 has been found to provide better predictions for psychological symptoms,
physical symptoms and utilization of health services than other similar instruments.
The PSS was originally developed as a 14 item instrument, designed to measure the
degree to which situations in ones life are appraised as stressful. A shorter 10 item version of
the original PSS, was developed and allows assessment of perceived stress without any loss of
psychometric quality. The questions in the PSS ask about thoughts and feelings during the last
month. In each question the respondent is asked how often they felt a certain way. The PSS-10
is an economical scale that can be administered in only a few minutes and is easy to score.
The PSS-10 scores are obtained by reversing the scores on the four positively stated
items, e.g. 0=4, 1=3, 2=2, 3=1 and 4=0 and then sum across all 10 items. Items 4, 5, 7and 8 are
the positively stated items. The higher the PSS score, the more likely it is that the individual will
perceive that environmental demands exceed their ability to cope.
3.2 SELECTION CRITERIA
3.2.1 Inclusion criteria
1.Student who are willing to participate in the study
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2.Student who had training of laughter yoga before
3.Female nursing student
3.2.2 Exclusion criteria
1.Student who is not available during laughter yoga therapy session
2.Student who did not have stress
3.Student who have chronic disease such as cardiac problem, hypertension and epilepsy.

3.3 SAMPLING PROCEDURE

In this research study, laughter therapy will be our intervention group while no
interventionwill be as control group. A pre test is use to determine the stress level of
participants before the laughter yoga as a baseline data while post test was used to compare
changes in participant stress level. Characteristics are the same among both group.


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The flow chart is stated in appendix 1







3.4 VALIDITY AND RELIABILITY OF THE STUDY
The Perceived Stress Scale (PSS) assesses the degree to which the participants appraised
their lives as being stressful during the past month. This provides a more subjective assessment
of stress than the life events score. Internal consistency is high 0.78 to 0.91 and test- retest
reliability coefficients ranging from 0.55 to 0.85 [8].(Al-Dubai, Barua, Ganasegeran, AJadoo, &
Rampal, 2014). The sample of the questionnaire is in appendix 2
CONTROL
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3.5 PILOT STUDY
The researcher conducted a pilot study from 11/2/2014 until 18/3/2014 with 20
participants which are 10 for intervention and 10 for control. The objectives of the pilot study
were to test the research instruments validity and pre preparation before proceed with actual
study. During 4 weeks pilot study, the researcher only had 20 participants, this is due to
restriction of inclusion criteria. An initial inclusion criterion was nursing students in Bachelor of
nursing at Uitm Puncak Alam that sit at semester six while they are break between class and
not had much time to do the session.
Chi Square and t-test was used to examine for homogeneity of demographic data such
as age, gender and PSS score. Comparison baseline PSS score mean score between intervention
group and control group independent t-test was used to compare the both result while paired
t-test was used to compare the PSS score mean score in intervention group and control group.
Total participants in this study was 20 nursing students.
The mean ages of intervention group and control group were 18.8 and 19.1 years. Male
in intervention group was 0(0.0%) and control group was 3(15.0%) while female in intervention
group was 10(50.0%) and control group was 7(35.0%) and p value was 0.13. This result showed
that demographic data was homogeneous due to p value is more than 0.05. By performed this
pilot study and the result showed that the researcher can proceed with actual study evidence
by the p value result was less than 0.05.
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During the pilot study, the researcher was able to establish good rapport with the
participants and get their cooperation in performing laughter therapy session. There was no
other major problem arising during the pilot study. Most of the nursing student in the control
group were complaining same or moderate in stress during the session and for the intervention
group most of the nursing students was satisfied and they are showed less or no any stress
compared with control group. Overall all the participants was satisfied with the session that has
been done on them and the problem during this study was their time between class so short
about half an hour to one hour and we should follow their schedule.


3.6 ETHICAL APPROVAL
Ethical approval was given by University Technology Mara Research Committee.
3.7 DATA ANALYSIS
The data of this study was analysed using Statistical package for Social Studies (SPSS)
18.0, which is able to generate epidemiological statistics.
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3.8 PROPOSED OUTCOME
At the end of the research, we are expect that people can change minds towards laugh
as in Malaysian society, laugh is not good. A student can perform their own laughter as stress
reliever. Moreover, we are hope multiple stress relievers including laughter yoga should be
introduce in their curriculum activities in university.
3.9 PROBLEMS AND LIMITATIONS
The problems and limitations that we will discover during conducting this research are
due to the length of the study, a significant number of respondents available in the preliminary
testing maybe unavailable or unwilling to participate in the final stage of testing. Our
methodology could have also included surveying or interviewing individuals involved with the
participants. For example, family, friends, significant others could been part of the study. A
focus group would allow us to conduct a group interview of participants to evaluate their
attitudes, negatives or positive and to identify a recommendations for the therapy provided to
them. This study also have a problem due to limited time to do because not enough time
between arrangement of study and working time.



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CHAPTER 4
RESULT

DATA ANALYSIS

This chapter explained the result of the data collected. Demographic data such as age
and gender was examined independent t-test. Independent t-test was used to examine the
effectiveness of Laughter therapy to students. Chi square was used to compare the
effectiveness of laughter therapy between intervention group with control group.

4.1 SCREENING AND CLEANING THE DATA

The total participants in this study were 54 and 8 main variables. Provided data already
screened and cleaned, no error in entered data detected. According to Coakes & Steed (2007),
data screening and transformation techniques are useful in making sure that data have been
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entered correctly and that the distributions of variables that are to be used in analysis are
normal. Descriptive statistic will use for data cleaning. Box plot helps to identify outliers.


4.2 SAMPLE DESCRIPTION
The total observed participants in this study was 54, which both arm was 27 in
intervention group and 27 in control group. After enrolled in this study, randomization and
allocation of assignment was by the researcher. The participant flow chart based on CONSORT
statement shows the enrollment of participant in this study (Figure 4.1).









Excluded (n= 5)
Not meeting inclusion criteria (n= 0 )
Declined to participate (n= 5)
Other reasons (n=0 )
randomized (n=54)
control intervention
Enrollment
Assessed for eligibility
(n=54)
Allocation
Allocated to intervention (n=27)
Received laughter therapy (n=27)
Allocated to no intervention (n=27)
No receive any laughter therapy
(n=27)
Follow-up
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4.3 CHECK FOR HOMOGENOUS OF THE STUDY GROUP
Inferential statistic was used to check for homogeneity. Chi square test was used to test
the baseline homogeneity of categorical variables. Independent t test was for continuous data.
The demographic and spss score enrolled in this study are presented in table 4.1.

Characteristic INTERVENTION CONTROL stat.(df) p-value
n (%) or Mean SD
Age (year) 21.90.26 22.20.64 -2.21(52)
a
0.O31
Gender

Male
2(7.4%) 2(7.4%) 0.00 (1) 1
Female
25(92.6%) 25(92.6%) 0.00 (1) 1

Demographic data of participants
Table 4.1 presenting the demographic data of total participant in this study. Total
participant in this study was 54 nursing students. The mean ages of intervention group and
After 5 days
level of stress=decrease


After 5 days
level of stress=same/increase
Analysis
Analysed (n=27)
Excluded from analysis (give
reason) (n=0)
Analysed (n=27)
Excluded from analysis (give
reason) (n=0)
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control group were 21.9 and 22.2 years. Men in intervention and control group comprised the
same which are 2(7.4%) while female was 25(92.6%) in intervention and control group and p
value was 0.031.

4.4 TESTING OF HYPOTHESIS
Table 4.2 will provide result for objective one.
Table 4. 2. Baseline PSS SCORE in both intervention and control group.

INTERVENTION CONTROL t(df) p
PSS SCORE meanSD
BASELINE 22.41.59 21.41.44 2.408(52) 0.20
POST 13.53.79 22.41.33 -11.47(52) 0.000
a
Independent t-test
This continuous data had been tested using independent t-test. In order to use parametric test,
the data has been tested using test of normality and Shapiro Wilk showed p value more than
0.005 that is 0.024. Prevalence of stress among participants was 100%. Intervention group has
been classified into moderate was 2 (18.2%), severe 25(58.1%) whereas control group has been
classified into moderate 9(81.8%), severe 18(41.9%).
After introducing intervention, result showed that intervention group has been
classified into normal 12(44%) and moderate 15(55.6%) and control group 100% fall into severe
category.

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POST TEST
This continuous data had been tested using independent t-test. In order to use parametric test,
the data has been tested using test of normality and Shapiro Wilk showed p value more than
0.005 that is 0.041. On the fifth days after laughter Yoga therapy introduced and implemented
questionnaire on post PSS score were given to the students. The result of post intervention was
presented in the table 4.2. The stress level was significantly reduced in intervention group
compared to pre test of intervention group. Intervention group showed 27 participants or 50%
and in control group there was no significant difference in pre and post PSS score. Through the
result, in intervention group, the post PSS score reduce drastically compared to baseline PSS
score with p value less than 0.005. About 27(50%) of participants of intervention group showed
reduction of intervention group from baseline PSS score and post PSS score.

In this study, an independent sample t-test was conducted to compare the mean in baseline
PSS score and after five days (post). The PSS score for equality of variences with p value of 0.20
which is more than 0.05 can assume that the level of stress are relatively decrease. The result
showed there is no significant difference in baseline PSS score for intervention group (M=22.4,
SD=1.59) and control group (M=21.4, SD=1.44) with p value of 0.20. Result for post PSS score
also showed there was difference for intervention group (M=13.5, SD=3.79) and control group
(M=22.4, SD=1.33) with p value 0.000. This is showed a good result means level of stress
participants that receive laughter therapy are reduced.


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SUMMARY
In this chapter, the results of the data collected have been described. Researcher found
no correlation between baseline characteristics and group assignment. The two groups did not
differ significantly with regard to risk factors that could contribute to development of stress,
suggesting that the sample was homogeneous. Baseline for PSS score was appeared similar in
both groups which mean both group has same level of stress condition. After five days of
introducing laughter therapy with intervention group, post PSS score data revealed there was a
significant difference between both groups. Result showed that intervention group able to
reduced their stress level compared to control group. In chapter five, the discussion of the
result as well as strength and weakness of the study, limitation and recommendations for
future research will be addressed.





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CHAPTER 5
DISCUSSION & CONCLUSION

Introduction
In chapter five, major finding of the study was discussed followed by examination of the
data addressing the research question. In addition, the strengths and weakness of the study
was explored. Finally, recommendation and the conclusion was made for the purpose of
nursing practice, organization, and future research.
5.1 Overview of the study
The study was design to evaluate the efficacy of the five days application of Laughter
Therapy session in reducing level of stress among nursing students, which is as simple, quick
and alternative method. Every person experience different forms of stress throughout the life.
It is more likely to be the reflection of interpersonal problems than the physical noxious stimuli
for change and growth. Many studies have shown the negative effects of stress on the health.
To get relief from stress, numbers of interventions were carried out. Among these, laughter is
considered as the best one as it needs no talent. Review of literature has shown the positive
impact of laughter in improving the health status. As nursing students are the part of this world,
they are not screened from the shadow of stress. The findings showed that laughter therapy
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had a positive effect on students level of stress and improved the signs of physical and mental
disorders, lowered anxiety and depression and promoted their social function. Therefore,
laughter therapy can be used as one of the effective strategies on students stress.
5.2 Baseline characteristics of the participants
The sample population of this study was composed of nursing students with same
batch, from both gender and same ages. The study groups were homogenous with respect
these characteristics, so influence of these aspects can be generalized for all the sample.
5.3 Stress reduction after laughter therapy
In our study, intervention study who received five days laughter yoga therapy show
significance reduction of stress with p value less than 0.000 compare to control group. The null
hypothesis of the study was rejected because there is significance difference between their
stress level before and after laughter yoga therapy. This finding is the similar to Kaurs study on
Effect of laughter therapy on level of stress: A study among nursing students. In the study,
they found out that when laughter yoga is injected among intervention group, it shown positive
effects on reducing the stress level of subjects 32,df 41, p <0.05) Mean stress score was
decreased from 112at statistically significant level (tcal32,df 41, p <0.05) Mean stress score was
decreased from 112 to 103 after the laughter therapy at statistically significant level (tcal32,df
41, p <0.05) Mean stress score was decreased from 112 to 103 after the laughter therapy.
Another study by Nagendra.et.al., (2007) among IT professional in Bangalore India also showed
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that after 7 session of laughter yoga, PSS result showed significance difference between the
groups (independent t test ) p<0.01. There was also significance difference within laughter
yoga group p<(paired t test).
Focusing on psychological distress, interestingly, we found the prevalence of clinical
depression was low (5.5%). This prevalence was lower than depressive symptoms (12.9%)
among medical students in Sweden (Dahlin et. al. 2005). The prevalence was also lesser than
study by Tjia et. al (2005) who found that prevalence of moderate depression was 15% and
severe was 2% by Beck Depression Index (BDI) 13 item. Regarding the level of stress before
experimentation (laughter therapy) twelve (28.6%) subjects experienced mild stress, twenty
three (54.7%) experienced moderate level of stress. The number of subjects experienced
moderate level of stress was reduced to 18(42.8%) from 23(54.7%) after the experimentation.
Although same number of subjects experienced severe level of stress before and after the
laughter therapy. It inferred that laughter therapy has positive effect in reducing the level of
stress of study subjects. (Kaur,Walia, 2008).
5.4 Recommendation
5.4.1 Recommendation for future research
The main finding of this research supported the previous research of the effectiveness
of laughter therapy yoga therapy to reduce stress. For future study, more lengthy day with
longer intervention period , more participants with longer follow up period is needed to more
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fully examine the effects of laughter therapy. Since Malaysian culture is belief that excess
laughter will make us easier to forget , participants should do laughter therapy from their deep
inside. This should be assess more. Laughter yoga therapy does not does not specify on how
many days we can obtain the results because 20 minutes therapy also gave a good result so
more study same time frame should be done. Our study focus on perform laughter yoga
therapy before final exam. In study by Timmins & Kaliszer (2002) stated that nursing student
have more stress during their clinical practice so our recommendation is study on laughter
therapy should be done during their clinical practice
5.5 Implication of the study
The implication of this study are it can give idea to students on more coping strategis to
reduce their stress level during their study. It is because laughter yoga therapy can be done
alone or grouping with limited area. Laughter yoga therapy also can be implemented in their
curriculum in university.
5.6 Strength of the study
The strength of this study is in participants allocation is homogenus which will decrease
bias. The students also can apply laughter therapy well because they were teach and instruct by
professional laughter yoga therapy leader.
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5.7 Limitation of the study
During our research, we face a difficulty in managing our time and students time due to
our workplace workload and students schedule time. Hopefully, future research we can
manage it properly.
5.8 Conclusion
Laughter yoga therapy is one of the stress reduction technique which will give better
result in reducing stress in students. Laughter yoga therapy does not need high cost to
perform it. Although laughter yoga therapy still need proper technique, but once they learn it,
they can perform it alone.









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ACKNOWLEDGMENTS



The researchers of this study would like to thank the research center of the Faculty of Health
Science and supervisor Mrs. Sharifah Shafinaz Binti Sharif Abdullah and the nursing students in
Uitm Puncak Alam who participated in this research.
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REFERENCES
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Altiok, H. . (2013). The Stress Sources of Nursing Students *. Educational Sciences:Theory &
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Burnard, P., Edwards, D., Bennett, K., Thaibah, H., Tothova, V., Baldacchino, D., Mytevelli,
J. (2008). A comparative , longitudinal study of stress in student nurses in five countries:
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URSING S TUDENTS S TRESS AND T HEIR C OPING S TRATEGIES IN. Journal of
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Kaur, L., & Walia, I. (2008). Effect of laughter therapy on level of stress: A study among nursing
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Kimata, H. (2007). Laughter elevates the levels of breast-milk melatonin. Journal of
Psychosomatic Research, 62, 699702. doi:10.1016/j.jpsychores.2006.12.007
Ko, H., & Youn, C. (2011). Effects of laughter therapy on depression , cognition and sleep
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Mora-ripoll, R. (2011). Potential health benefits of simulated laughter: A narrative review of the
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Nagendra, H. R., M.S, D. C., & Et.al. (2007). The Efficacy of Laughter yoga To Overcome
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Research, 19(1), 3640.

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APPENDIX 1















Recruitment of Subjects: UITM nursing students that are
ready to participate in the laughter yoga therapy and control group
Screening Process:
Step 1- Informed consent
Step 2- Look for inclusion/ Exclusion Criteria
Step 3-Enrolment for the study



Basal Level Assessment: Demographic Data Collection, Pre PSS
Questionnaires for level of stress
Laughter yoga therapy:27 subject
received 5 days laughter yoga
therapy.
Control: 27 subjects receive no
intervention.
After 5 sessions : Intervention end. Post assessment for both groups.

Data Analysis: by SPSS quasi experimental (laughter and control group)
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APPENDIX 2
PSS Questionnaire