1. Heard, Pamela Lichtenberg PhD, RN
  2. Hartman, Sherry DrPH, RN
  3. Bushardt, Stephen C. DBA

Article Content

As suggested in the literature, nursing burnout has been a prominent concern for the profession. Because of the complexities of today's healthcare environment-from patient care and clerical duties to digital storage systems and digital documentation-the work responsibilities of a nurse are challenging and technically complex, making the daily work load very demanding.1 These responsibilities require a multidisciplinary approach to treatment with an extended knowledge base in mental health, pharmacology, pathophysiology, pulmonary function, and infectious diseases, as well as spiritual and social skills necessary to render the most comprehensive and state-of-the-art care. Working under these conditions day after day will increase stress and job dissatisfaction, and may cause burnout. These conditions contribute to turnover and/or suboptimal performance that can result in a costly and detrimental situation for any healthcare organization.

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Burnout is a condition in which people suffer from emotional exhaustion, experience a lack of personal accomplishment, and tend to depersonalize others.2 Some psychological and behavioral attributes of burnout are low self-esteem, apathy, alienation, callousness, psychosomatic complaints, anxiety, inability to concentrate, and depression.2-6 Research on interventions for burnout are limited, but the nursing literature is replete with studies on how to address the issue of burnout in nursing and reduce job dissatisfaction through better scheduling, improved training, improved job descriptions, and better selection of students by schools of nursing.1,7-12 Although these approaches hold promise, nursing dissatisfaction and burnout continue to plague the profession. We suggest an alternative approach that nurse managers should consider to address these issues in the nursing profession through the practice of "mindfulness."


It starts with a spark

The practice of mindfulness has its origin in Buddhism-it means to be aware of being aware.13 It's a skill that involves focusing on the present and is developed through meditation. Mindfulness is the state of being attentive to, and aware of, what's taking place in the present.14 Mindfulness has been shown to promote psychological well-being and decrease various maladies.13


Proponents of mindfulness believe that one should truly live each moment. To do this, one must be fully immersed in the here and now. Mindfulness requires open-mindedness and has been described as the continued creation of categories.15 This is referred to as deautomatization or the breakdown of old categories or stereotypes. One isn't limited by strict categorization, specifically if something's "good" or "bad," of his or her life or points of view. Accordingly, a mindful person is relaxed. He or she's fully immersed in the here and now and has no regrets about the past or worries about the future.15


Although mindfulness practice has origins in Buddhist/Asian contexts, Western conceptualizations in psychology have also emerged. Some Western conceptualizations of mindfulness aren't based on, but rather share similarities with, Buddhist/Asian contexts.16 Being active and interested in life is an indication of mindfulness and engagement in each activity enables openness to opportunities.11 As such, when one isn't focused or doesn't have a focused activity or responsibility, one is closed or mindless. Mindlessness is reliance on old categories or labels and differentiating these as either good or bad, whereas mindfulness involves an increased awareness of multiple perspectives in life.11,16 To be mindful, one must create new categories, become open to new information, and be aware of more than one perspective.16 Mindless people are preoccupied with outcome, whereas mindful people are focused on the "process" known as the here and now.


It's been suggested that burnout is the result of being hindered by old categories and mindsets.17 This affinity to old mindsets, being comfortable with "the way we always did it," is what some believe contributes to staff job dissatisfaction and burnout. This can be combated by creating a diversity of job tasks, which would increase employee flexibility and contribute to mindfulness at work. Mindful employees are oriented to the present. They don't worry about having less than someone else, nor do they worry about change, which is viewed as an opportunity that generates creativity and new energy.11 Mindfulness is an ongoing process that involves engagement in one's work.17


Feeding the fire

Within the psychological, educational, medical, and scientific communities, mindfulness has gained momentum in the past 10 years as an accepted and empirically proven method of stress reduction and increased well-being. Over 7,000 people in psychotherapy and healthcare have participated in mindfulness training, and numerous articles and research studies have been published. One author noted that there's an "explosion of interest in learning about the implications of mindfulness in clinical work."9 Mindfulness isn't a fad, but a clinically proven way to decrease stress and induce positive effects.9


Primarily attached to psychological research, mindfulness is defined in relation to well-being, self-interest, positive outlooks, calmness, and serenity; essentially physical, emotional, social, and spiritual health. It's a balance between internal and external awareness.18 In mindfulness training, one must learn to focus on the internal voice of his or her body, mind, and spirit without judgment and distraction.


Mindfulness is multifaceted, with four skills that can be practiced: mindful observation, acting with awareness, accepting without judgment, and mindful description-all which form the definition to observe without judgment.19


The practice of mindfulness is found in religious and secular practices, and it's also prescribed in cognitive/behavioral therapy.20 Mindfulness meditation is a conscious individual discipline of intentional self-regulation, also known as vipassana or insight meditation.21 In mindfulness-based meditation (MBM), the mind is considered separate from the brain. The brain can be measured, visualized, and touched, but the mind is formless and has no boundaries.22 The mind often wanders and worries and if someone is worried about a future event, he or she may have anxious thoughts. With MBM, the mind lets the anxious thought pass but doesn't judge the thought as negative or positive. After the thought has passed, the mind focuses back on the present.23


Mindfulness meditation is also called mindfulness-based stress reduction (MBSR). MBSR was developed by Jon Kabat-Zinn in 1979 and is comprised of an 8- to 10-week course on mindfulness training for a group of no more than 30 participants. The group is instructed to meet weekly for 2 to 2.5 hours to learn meditation techniques and mindfulness skills. A trained practitioner guides the group in weekly meditation exercises, which include sitting meditation, body scanning, and hatha yoga. The later part of the group session is reserved for reflection or introspection. Members are free to discuss various stressors during the week, as well as progress on homework assignments. Group members are expected to practice mindfulness meditation, with the help of a relaxation tape or CD, for at least 45 minutes per day when not in class. The group is also asked to keep a journal to record process or regression. At or about the sixth week of training, the group participates in a day-long seminar with intensive meditation training.15


Burning bright

Research in the area of mindfulness originally dealt with physical ailments. The initial use of mindfulness in the physical realm was to decrease or prevent chronic pain.24 It has also been used for treatment of many other physical and emotional maladies. Mindfulness has been linked to increased satisfaction with life; decreased stress levels; relief of or decrease in chronic pain, anxiety, depression, or substance abuse; and relief of pain from cancer. Studies have shown that mindfulness often serves as an adjunct to traditional care.13,25-29 Based on this evidence, the practice of mindfulness may also prove beneficial to nurses who are suffering from burnout.


The literature review revealed a resurgence of studies exploring burnout. Subsequently, there has been an increased interest in various interventions to ameliorate burnout, one being mindfulness meditation and practice. There have been studies examining burnout and mindfulness among nursing students and nursing faculty, as well as others employed in "helping" professions, but few involving practicing nurses.


The first known study including practicing nurses and the effects of MBSR on the nurses' stress and levels of burnout showed no significant differences in the wait-list control group and the treatment group in preintervention mindful awareness; however, there were significant within-group differences between both pre- and postinterventions.30,31 Similarly, there were no preintervention differences between groups on the burnout inventory, but significant differences were found in the emotional exhaustion and personal accomplishment scales of the burnout inventory postintervention. The depersonalization scores indicated a trend toward significance between the groups after MBSR. Participants were supplied with evaluation forms and interviews were conducted. Overall, the participants were very pleased with the program and found it to be beneficial to them in their practice and personal lives.30,31


Another study investigated the effects of MBSR on stress, mood, health, endocrine function, and immunity in individuals with HIV.32 The researchers reported that natural killer cell activity increased significantly in the intervention group compared with the control group postintervention. The researchers noted that although the indication that MBSR positively affects the immune response in HIV patients is promising, further studies are needed with larger randomized samples to determine the validity of the findings.


Other researchers examined the use of meditation and its effect on cortical thickness.33 The hypothesis tested was that between-group differences would be found in brain regions associated with attention and sensory processing, indicating evidence of cortical plasticity. The researchers used magnetic resonance imaging to assess cortical thickness and reported that meditation was associated with increased thickness. Between-group prefrontal cortical differences were greater in older subjects. These findings may indicate that meditation slows age-related thinning of the frontal cortex. The authors concluded that meditation may be associated with structural changes in the brain and that it may also affect age-related deficits in brain functioning.


One study investigated mindfulness and its effect on stress and empathy in nursing students.34 The results indicated that participation in the program significantly reduced anxiety, increased self-confidence, decreased stress, and decreased the propensity to be affected by others' negative emotions. Suggestions for further research included integrating a mindfulness program into the nursing curricula and practicing mindfulness throughout matriculation. The authors also reported that assessing and measuring students' stress and empathy levels upon graduation from the nursing program would provide valuable longitudinal data about the role of mindfulness in stress resilience, exam-taking habits, and job retention.


Mindfulness practice has also been postulated to have a positive effect on immune and brain function. This idea was tested by measuring brain activity before and after an 8-week long mindfulness program and at a 4-week follow-up, as well as measuring antibodies present after administering an influenza vaccine.35 The researchers reported that participants in the treatment group had increased antibody titers after the flu vaccine when compared with the control group. The treatment group also had greater brain scan changes than those of the control group. These changes included greater activity in left-sided anterior activation and positive affect. The authors concluded that the findings support the use of MBSR for the reduction of stress and positive changes in brain and immune function.


Twenty-one individuals with chronic pain were examined in a longitudinal study to determine if an 8-week long MBSR program would have any effect on pain symptoms.36 There was an overall reduction of psychological distress and symptoms of pain in the treatment sample following intervention and at the 3-month follow-up. Quality of life and general well-being also increased after the intervention and remained consistent at the follow-up. The authors concluded that mindfulness is a cost-effective way to decrease stress and increase well-being and quality of life.


A meta-analysis of MBSR studies was conducted to determine if evidence of improved health was present.37 Studies included in this analysis were published before December 2002. The authors identified 64 studies on MBSR during the time frame indicated, but only 20 of them met the inclusion criteria. Ten of the 20 studies included were controlled studies and five of these involved studies with patients. The authors further noted that only three of the 10 controlled studies appeared in peer-reviewed published papers. The meta-analysis revealed empirical evidence that MBSR may help individuals with clinical and nonclinical problems.


Researchers in Connecticut conducted a study to determine if completion of an MBSR program would result in an increase in healthcare utilization in an inner city community health center.38 There was a significant decrease in the number of chronic care complaints and visits from preintervention to postintervention. It was concluded that a MBSR program may be beneficial in containing healthcare costs, decreasing the number of patient visits, and decreasing the severity of complaints presented at the community health center in Connecticut.


There are very few mindfulness studies focused on nurses; however, a pilot study was conducted in 2006 to examine the effects of MBSR on stress in nurses and nurse aides.39 Participants in the intervention or treatment group received a modified version of Kabat-Zinn's MBSR training, consisting of 4 weeks of mindfulness intervention training as opposed to the typical 8-week training.13 Posttest results revealed that the intervention group had significantly lower burnout scores and higher life satisfaction and relaxation scores when compared with those of the wait-list control group. The authors contend that mindfulness and nursing theory are a good fit and the results of their study indicate that mindfulness training has the potential to serve nurses by aiding in the alleviation of stress and burnout.


Passing the torch

A review of the literature on mindfulness, while lacking in nursing-specific studies, supports the use of the technique for reducing burnout and increasing job satisfaction. Although the literature review provides strong support for the use of mindfulness, a word of caution is appropriate because many of the studies used small sample sizes and samples of convenience. In addition, different approaches to teaching mindfulness were used depending on the particular study. Additional research is needed comparing the effectiveness of the different instruction approaches.


Burnout continues to be a significant occupational hazard in the nursing profession. Current changes in the healthcare profession are likely to exacerbate these issues in the future as practitioners are required to "do more with less." Further studies need to be done to determine the effectiveness of mindfulness in practicing nurses. Mindfulness may be the necessary approach to help combat nursing burnout, affording considerable promise for the future of the nursing profession.




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