Although the practice of mindfulness has been in existence for thousands of years, it has become a progressively popular topic in the general population, health care, business, academia, and science over the past couple of decades (Goleman & Davidson, 2018; Lomas, 2016). According to Goleman and Davidson (2018), there were only a few peer-reviewed research articles on mindfulness in the 1970s, but in 2016 alone, there were 1,113 published in the English language. Advances in technology and a plethora of information have produced an unprecedented rate of societal change and uncertainty that have created a need for people to become more resilient to maintain their health and well-being. Fortunately, researchers have demonstrated that mindfulness-based interventions (MBIs) are positively associated with resilience and well-being (Greiser & Martini, 2018; White, 2013).
Health care's complex and dynamic environment has created the need for a healthy workplace that promotes attentive, aware professionals, which has only magnified during the COVID-19 pandemic related to fears about personal and family safety, inconsistent guidance for protection, longer hours, and moral injury (Dzau et al., 2020). Mindfulness can be taught and cultivated to enhance well-being and cognitive function (Holzel et al., 2011; Jankowski & Holas, 2014; Kabat-Zinn, 2018). If nursing professional development (NPD) practitioners are to tap into its potential, mindfulness, with a wide range of applications and effects, requires investigation of its constructs to understand its essence and mechanisms of action.
The purpose of this analysis is to provide an operational definition for mindfulness, applying the Walker and Avant (2019) model for concept analysis. A review of interprofessional research found in the Cumulative Index to Nursing and Allied Health Literature and PubMed, along with literature from mindfulness pioneers such as Jon Kabat-Zin, Daniel Goleman, and Chade-Meng Tan, informed this concept analysis. The analysis led to the creation of a model to guide healthcare providers and NPD practitioners in engaging mindfulness practices that will enhance their well-being, improve the effectiveness of continuing education, and foster the provision of high-quality care.
SIGNIFICANCE OF MINDFULNESS TO NURSING
Mindfulness, with its roots in Buddhist and other contemplative conventions, is a complex phenomenon that began over 2,500 years ago that was only introduced into Western society in 1910 without religious and cultural underpinnings (Baer, 2003; Kabat-Zinn, 2003; Lomas, 2016). Mindfulness is commonly described as a compassionate way of knowing and awareness in the present moment without judgment (Kabat-Zinn, 2003) or a process of drawing on "novel distinctions" with enhanced sensitivity to one's environment (Langer, 2000). Conceptually, it is much more than consciously paying attention and being aware (Brown & Ryan, 2003; Lomas, 2016; White, 2013), and there are many constructs attributed to this phenomenon in the literature. The variety of constructs and imprecise translation to the English language may be rooted in the term's ancient origins, which creates a need for analysis and clarification.
In nursing and health care, stress and burnout are epidemics. Dzau et al. (2020) warned that, unless clinicians and policymakers take action, the COVID-19 pandemic will drive a parallel health emergency of healthcare provider burnout and other behavioral health issues. Researchers have demonstrated that increasing mindfulness and resilience mitigates stress and burnout and improves the workplace environment, patient outcomes, and patient satisfaction (Gilmartin et al., 2017; van den Riet et al., 2018). Mindfulness has also been positively associated with well-being, empathy, and compassion (Gilmartin et al., 2017; van den Riet et al., 2018). When nurses practice awareness, mindful attention, self-regulation, and nonjudgment with open acceptance, they are more compassionate toward themselves and others while experiencing less anxiety and repetitive negative thoughts (Pipe et al., 2016; Park & Holtschneider, 2018). These benefits hold for NPD practitioners, as well. To develop professionals, a practitioner must be in the moment and aware of the learner's needs to generate an atmosphere that promotes understanding, integration, and retention. In this way, mindfulness leads to a compassionate, learner-centered experience that fosters thinking and reflection and, ultimately, practice change.
CONCEPT IDENTIFICATION
According to John Kabat-Zinn (2003), the word mindfulness was translated from the Sanskrit word dharma, which means lawfulness or "the way things are" and has been described as the "heart" of Eastern meditation. Whereas, Tim Lomas (2016) stated that mindfulness originates from a Pali word sati that means awareness. Both men, however, stated that heart and compassion must be considered when conceptualizing the word, as one must be open-hearted and compassionate in their perception of the present moment, thoughts, and emotions. When considering the dispositional view of expression, one must study all translations and applications to imagine the term in use (Baldwin, 2008).
Depending on the context, the term mindfulness is used differently. In psychology, mindfulness techniques such as dialectical behavioral therapy, acceptance and commitment therapy, relapse therapy, mindfulness-based cognitive therapy (MBCT), and mindfulness-based stress reduction have been used in the treatment of borderline personality disorders, behavioral disorders, relapse prevention for substance abuse, and depression, respectively (Baer, 2003; Johnson et al., 2015). Bishop et al. (2004) also stated that mindfulness is beneficial in decreasing rumination and repetitive negative thoughts, which has been associated with preventing depression relapse. Davis and Hayes (2011) reported that MBIs are useful in psychotherapy to regulate emotions and reactivity and improve affect.
Mindfulness-based stress reduction and MBCT have been beneficial in the medical treatment of fibromyalgia, psoriasis, chronic pain, hypertension, diabetes, and cancer in health care (Baer, 2003; Kabat-Zinn, 2003; Poulin et al., 2016). In addition, MBCT has helped decrease the utilization of healthcare services for high-frequency users of private practice and the emergency room (Kurdyak et al., 2014).
In information technology, mindfulness is associated with computer self-efficacy, personal innovation, and malleability (Thatcher et al., 2018). There is a thread in the literature that indicated the concepts of mindfulness in information technology differ from other ideas, including cognitive absorption, alertness to distinction, awareness of multiple perspectives, orientation, and curiosity (Langer, 2000; Thatcher et al., 2018). The benefits of MBIs in the literature are numerous; however, there has historically been a shortage of knowledge related to the mechanism of actions. Neuroscience is filling that gap.
Neuroplasticity refers to the brain's ability to change in both structure and function resulting from our repetitive thinking, attention, and behavior (Tan, 2012). Neuroscience has shown that MBIs are associated with decreased activity in the amygdala and thickening in the prefrontal cortex, which acts as a buffer for depressive symptoms and increases attention and sensory processing (Brefczynski-Lewis et al., 2007; Davis & Hayes, 2011). The decrease of the amygdala activity and the increase in the prefrontal cortex have also been associated with the enhanced ability to self-regulate emotions (Holzel et al., 2011; Jankowski & Holas, 2014).
Definitions
Defining mindfulness is not an easy task. Although maintaining awareness and attention are consistent threads, the literature contains varying constructs for what constitutes mindfulness. Chade-Meng Tan (2012) stated that mindfulness is simply a shift from "doing" to "being" and training your mind to move beyond the formal practice of awareness of breathing to real-time attention in everyday life. In the same vein, Jon Kabat-Zinn (2012) stated that mindfulness is not so much about getting to a destination, as it is about being fully aware of and present in the here and now.
Some of the most often cited definitions for mindfulness found in the literature are as follows:
1. "the practice of maintaining a non-judgmental state of heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis" (Merriam-Webster, n.d., Definition 2);
2. "the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment (Kabat-Zinn, 2003, p. 145);
3. "intentionally bringing one's attention to the internal and external experiences occurring in the present moment, and is often taught through a variety of meditation exercises" (Baer, 2003, p. 125);
4. "a transformative process where one develops an increasing ability to 'experience being present,' with 'acceptance,' 'attention,' and 'awareness'" (White, 2013, p. 282); and
5. "a process of regulating attention in order to bring a quality of nonelaborative awareness to current experience and a quality of relating to one's experience with an orientation of curiosity, experiential openness, and acceptance" (Bishop et al., 2004, p. 234).
A facet of mindfulness not captured in the above definitions is that it is intentional and takes practice and training over time to develop the skill for use in real-time, everyday life (Baer, 2003; Kabat-Zinn, 2003; Tan, 2012). In addition, mindfulness requires the ability to maintain focused attention, as well as recognize and identify one's thoughts and emotions-also known as meta-attention and metacognition. These two ways of thinking create the conditions for neuroplasticity to occur (Jankowski & Holas, 2014; Tan, 2012).
DEFINING ATTRIBUTES
Although the definition of mindfulness varies across professions, its meaning in nursing narrows; the defining attributes for mindfulness in nursing, as depicted in Figure 1, are attention, awareness, openness, and metacognition.
1. Attention-intentionally focus on the current experience using anchors such as breathing, bodily sensations, or other senses.
2. Awareness-purposefully being aware of internal and external stimuli as they arise in the present moment.
3. Openness-accepting all sensations, thoughts, emotions, and experiences as they occur without judgment, evaluation, or interpretation.
4. Metacognition-to acknowledge when the mind has wandered to thoughts, sensations, and emotions; identify them; and gently bring your attention back to the present, which creates the conditions for neurological changes (Tan, 2012).
Model Case
A nurse in an acute care inpatient unit is having a hectic day. She just received her second admission of the day after discharging two patients. When she notices that she is beginning to feel overwhelmed and her emotions are starting to get the best of her, she practices intentional breathing to self-regulate and bring her attention back to her patients (metacognition). During her initial assessment, she becomes aware that her patient's skin is slightly diaphoretic and cool to the touch. Although her patient states that he feels fine and it was hot in the emergency room, she obtains a finger-stick blood glucose. His blood glucose comes back at 60 ml/dl. She then treats his low blood sugar, and the recheck 20 minutes later is 96 mg/dl.
Practicing mindfulness allowed her to be open and pay attention in a dynamic situation and, therefore, catch a subtle change in her patient's condition (Pipe et al., 2016). She was able to pause, breathe, identify her emotions without judgment, recognize the space between stimuli and response, choose how to respond, and respond appropriately (Park & Holtschneider, 2018).
Contrary Case
One can refuse to acknowledge or pay attention to internal and external experiences such as environment, thought, emotion, and sensation (Brown & Ryan, 2003). A nurse was busy and overwhelmed after receiving two back-to-back admissions. She was becoming increasingly frustrated with her workload and could not concentrate. When she was assessing her patient, she noticed he was slightly diaphoretic. When he assured her that he felt fine and that it was just warm, she was relieved that she did not have to intervene and went on to admit her next patient.
An hour later, her patient was barely arousable. She called the rapid response team, and they arrived as she was obtaining a finger-stick blood sugar. His blood sugar was 25 mg/dl, which required intravenous dextrose and a transfer to critical care. The nurse spent the rest of the shift ruminating over her mistake and failure to rescue her patient sooner.
ANTECEDENTS AND CONSEQUENCES
Antecedents are the events that must occur or be present for the concept to ensue (Walker & Avant, 2019). The precursors for mindfulness are as follows:
* intention-one must have a reason to practice mindfulness, a purpose on purpose (Shapiro et al., 2006, Tan, 2012);
* motivation-for mindfulness to serve its full use and become part of everyday life, one must have the motivation to frequently practice both formally and informally (Baer, 2003; Kabat-Zinn, 2018; White, 2013); and
* an environment that supports and does not inhibit mindfulness practice.
Consequences are changes that happen as a direct result of the concept (Walker & Avant, 2019). Mindfulness has many benefits for healthcare providers that improve their mental and physical well-being and neurological functioning through neuroplasticity. As synthesized from the literature for this analysis, these consequences for healthcare providers translate into behaviors that enhance patient care (see Table 1).
Empirical Referents
How do we know if mindfulness is present? Empirical referents are determinants that the concept exists in the real world (Walker & Avant, 2019). The most frequently used tools to measure mindfulness in the literature were the Mindfulness Attention Awareness Scale, the Kentucky Inventory of Mindfulness Skills, the Five Facet Mindfulness Questionnaire, and the Freiburg Mindfulness Inventory (Baer et al., 2004, 2006; Brown & Ryan, 2003; Zeng et al., 2015). These tools have been built on each other; they measure the following constructs:
* The Mindfulness Attention Awareness Scale measures awareness and attention as a single item.
* The Kentucky Inventory of Mindfulness Skills scale measures observing, describing, acting with awareness, and accepting with judgment as four separate items.
* The Freiburg Mindfulness Inventory measures mindfulness.
* The Five Facet Mindfulness Questionnaire measures nonreactivity to inner experience, describing, observing, acting with awareness, and nonjudging of experience as five separate items.
Therefore, the common themes in the literature regarding these measurement tools indicate that mindfulness can be determined by quantifying awareness, attention/observing, acting without judgment/acceptance, and nonreactivity.
CONCLUSIONS AND RECOMMENDATIONS
Mindfulness presents an opportunity for healthcare professionals and NPD practitioners to enhance their self-care and well-being to become more compassionate and attentive to patients and learners. The COVID-19 pandemic has further intensified the need for all healthcare providers to practice self-care. For the NPD practitioner, this means identifying an intention or reason for cultivating mindfulness, developing a motivation to engage in MBIs, and creating an inviting environment for mindfulness and learning (see Figure 2). Through formal and informal mindfulness practices, the NPD practitioner can participate in learner-centered activities in which they are attentive to verbal and nonverbal cues of learner needs, aware of comprehension, open to input and other's perspectives, and cognizant of distinctions and patterns as they arise (Jankowski & Holas, 2014). In addition, the consequences of mindfulness for the NPD practitioner are enhanced well-being, the ability to be empathetic toward students to promote learning and practice change, and the development of positive mental habits, including self-regulation (Park & Holtschneider, 2018; Tan, 2012).
Harper and Maloney (2016) stated that NPD practitioners promote health and learning environments that influence practice and outcomes. To develop professionals, a practitioner must be in the moment and aware of generating an atmosphere that supports understanding, reflection, and retention to improve learning and the quality of care. A mindful NPD practitioner can use metacognitive thought processes to enhance interpersonal connections and create better learning environments that facilitate practice change and foster professional growth. Studies will be needed to test this model in practice. Still, this analysis lays the framework for the practical use of this construct in professional development as supported by the literature.
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