Mindfulness is "paying attention in a particular way; on purpose, in the present moment, and non-judgmentally" (Kabat-Zinn, 2016). It is an inherent human ability that can be learned, and the mindfulness movement has been associated with better patient health outcomes (Soler et al., 2014). An essential component of mindfulness is the ability to observe intentionally and not to react but to respond based on the present experience (Goleman, 2013).
Nurses, not unlike the population at large, are tasked with multiple roles, responsibilities, and demands. Learning to be mindful allows one to focus on the present moment with a patient, while suspending other thoughts, feelings, and experiences. This ability comes with the practice of mindfulness, which empowers the caregiver to focus on the needs of the patient in order to provide safe, patient-centered, compassionate care (Quality and Safety Education for Nurses Institute, 2014). Nurse educators who incorporate mindfulness practice into their educational curricula encourage learners to develop focused practice that will allow them to respond to the complex nature of health care (Jeffries, 2014).
Faculty of an associate degree nursing program observed that students demonstrated lack of awareness of the patient environment and failed to acknowledge the patient and the patient's needs during simulations. On the basis of these findings, mindfulness was integrated into the curriculum beginning with senior-level students in spring 2014. The process started with an introduction to the concept of mindfulness and how its use affects the brain.
THE PRO STRATEGY
Students were taught the PRO strategy (Metta, n.d.), with PRO as the acronym for Pause, Relax, and Open. In order to direct focused care, first, one must stop or pause. To assist with relaxation, the students learn diaphragmatic breathing, a type of breathing that decreases stress hormones, resulting in relaxed openness. This openness to the patient environment enhances the ability of the student to assess patients more holistically.
With daily practice, the PRO strategy results in thickening of the prefrontal cortex, where emotions are managed. Increased emotional management results in greater self-awareness, self-management, relational empathy, and, ultimately, compassion. Compassion, or acting on the feeling of caring, is the goal of patient-focused care (Goleman, 2013). Practicing mindfulness will improve not only patient care but also care for the nurse as the caregiver.
Studies that evaluated the inherent ability to achieve mindfulness in subjects found an increase in physical and mental health and overall well-being (Soler et al., 2014). Faculty emphasized to students that, without open awareness, one enters the patient's room with the focus on one's need to perform tasks, instead of being open to the patient's needs.
Following this introduction to upper-level nursing students, mindfulness was introduced to lower-level students in the summer of 2014 and to new incoming students in the fall of 2014. Mindfulness is now fully integrated in all courses of the ADN curriculum.
MINDFULNESS WITH SIMULATION
In fall 2014, an increase in student enrollment meant increasing the number of students involved in each simulation scenario. In previous simulation scenarios, numerous types and numbers of roles were utilized: primary RN, secondary RN, medication RN, RN recorder, licensed practical nurse, and certified nursing assistant I and II. Faculty and student evaluations indicated that roles were too numerous, causing confusion and congestion in the simulation area. So, an observer role was created. Research has shown that observers learn as much as participants (Jeffries, 2014). Limited research has shown that the observer role can be used to extend student numbers (Hooper, Shaw, & Zamzam, 2015). The student observers were directed to focus on such concepts as safety, communication, and organization.
To further integrate the concept of mindfulness, a simulation faculty member changed the focus of the observer; a literature review indicated that this was not tried before. The student observer was positioned in the control room in front of a computer monitor that was fed by audio and video capabilities from the patient's bedside. Directions to the student observer included taking on the role of the patient, minus vocal capabilities, which were handled by the simulation faculty, and observing how the other simulation participants responded to the patient's needs. Documentation of the feelings and perceptions of the patient was encouraged so that the observer could share the patient perspective with the other participants during the debriefing.
The mindful student observers stayed intently focused on the patient during the simulation. One student was unable to sit still in the chair while in the control room. She explained, "I just cannot understand why they are doing that" and reported an intense desire to correct the actions of her peers. At the conclusion of the simulation scenario, a student observer commented, "That was an eye-opener," whereas another reported, "That was a great experience. I learned as much in there [control room] as I do out here [in simulation]." Others explained that they were able to notice more in the observer role than when participating in the simulation. A study of a high-fidelity patient simulation by Hober (2012) reported the same observer behavior.
During the debriefing, known as the most important component of simulation (Driefuerst, Horton-Deutsch, & Henao, 2014), the student reflections provided direct evidence of meaningful learning for both the observer and the other simulation participants. Comments by the observer, related to the patient's perspective, included the following: "You were talking over me, not to me," "I felt very alone," "I was fearful because you did not act like you knew what you were doing," and "You were so focused on what you were doing that you paid no attention to me."
Reflections that illustrated the use of a mindful approach included the following: "You looked at me and talked with me - not to me," "You used touch to ease my fears," and "You stayed with me and kept me calm." Comments by the other participants in the simulation included the following: "I was having difficulty focusing on the patient because I was so busy attending to my tasks," "We were so into what we were doing that we completely forgot that there was a patient in the bed," and "As a team we were very disorganized." The simulation faculty practiced a high level of facilitation as the students shared their feelings about the experience: what went well, what they would change if they could repeat the simulation, and what they would take away from this simulation to clinical practice.
GOING FORWARD
Continued integration of the concept and process of mindfulness in simulations is planned to enhance not only patient outcomes student outcomes as well. ADN faculty have developed a structured but observer rubric related to the mindful observer role.
Use of the Five Facet Mindfulness Questionnaire On-line (http://awakemind.org/quiz/php) with students at the beginning and end of the nursing program, in order to determine any significant changes related to the integration of mindfulness into the curriculum, is under review by the faculty. Another consideration is the identification of a method to track students' use of mindfulness techniques over time. An elective course on mindfulness is yet another method to provide more in-depth learning experiences for nursing students and students of other disciplines.
Mindfulness, although not a new concept, has gained increased interest, particularly in relation to the health benefits of its approach (Pickert, 2014). As faculty/student ratios are impacted by increasing nursing program enrollments, curricula that incorporate the mindful observer role may extend the simulation learning experience. The use of a mindful observer during simulations in our ADN program resulted in an effective learning strategy as reported by our nursing students.
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