Applied Nursing Research xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Research Briefs
A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences Janice K. Horner, MPH, CPHQ ⁎, 1, Brigit S. Piercy, BSN, MHA 2, Lois Eure 3,
Elizabeth K. Woodard, PhD, RN 4 WakeMed Health & Hospitals, Raleigh, NC 27610, USA
a r t i c l e
i n f o
Article history: Received 22 August 2013 Revised 16 January 2014 Accepted 16 January 2014 Available online xxxx Keywords: Mindfulness Nurse satisfaction Patient satisfaction Compassion satisfaction Burnout Stress Inpatient nursing
a b s t r a c t The purpose of the Mindful Nursing Pilot Study was to explore the impact of mindfulness training for nursing staff on levels of mindfulness, compassion satisfaction, burnout, and stress. In addition, the study attempted to determine the impact on patient satisfaction scores. The pilot was designed as a quasi-experimental research study; staff on one nursing unit participated in the 10-week mindfulness training program while another, similar nursing unit served as the control group. The intervention group showed improvement in levels of mindfulness, burnout, and stress as well as patient satisfaction while the control group remained largely the same. This pilot provides encouraging results that suggest that replication and further study of mindfulness in the workplace would be beneficial. © 2014 Elsevier Inc. All rights reserved.
1. Background Hospitals seeking to remain viable in the current reimbursement environment must develop a laser focus on cost control and the effective use of limited resources. Subsequently, direct caregivers have been expected to do more with less, even as the acuity of the inpatient population has increased. Caregivers struggle with the effects of their increasing workload, and report feeling overwhelmed and stressed (Anthony & Vidal, 2010; Penque, 2009). Preventable errors in patient care may result from front-line staff who are too rushed to stop, look and listen before they “touch” a patient (e.g., draw blood, give medications, take an x-ray, etc.). Such chronic stress can lead to burnout, compassion fatigue and a lack of engagement, potentially resulting in staff turnover which creates an additional cost to any organization (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Some healthcare organizations are turning to mindfulness as a key stress management tool (Praissman, 2008). Mindfulness can be
⁎ Corresponding author. Tel.: +1 919 810 7865. E-mail addresses: [email protected] (J.K. Horner), [email protected] (B.S. Piercy), [email protected] (L. Eure), [email protected] (E.K. Woodard). 1 At the time of the study, Janice Horner was affiliated with WakeMed Health & Hospitals. 2 Tel.: +1 919 350 8457; fax: +1 919 350 7839. 3 Tel.: +1 919 602 9917; fax: +1 919 350 6248. 4 Tel.: +1 919 350 1700x10124; fax: +1 919 350 8313.
defined as “paying attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment to moment” (Kabat-Zinn, 2003, p. 145). For example, nurses at one academic, community-based hospital who participated in an 8-week Mindfulness Based Stress Reduction (MBSR) program demonstrated significant reduction in scores on two of three subscales of the Maslach Burnout Inventory. In addition, they reported significant increases in levels of mindfulness, as measured by the Mindful Attention Awareness Scale (MAAS) (Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2005). In a similar study, nurses and nurse aides in a large, urban geriatric teaching hospital participated in a shortened version of the traditional MBSR program. The intervention group experienced significant improvements in burnout symptoms, relaxation and life satisfaction compared to the control group (Mackenzie, Poulin, & SeidmanCarlson, 2006). Finally, a study conducted at a large, non-profit tertiary care hospital to test the effects of the MBSR intervention on measures of mindfulness, empathy, self compassion, serenity, work satisfaction and burnout among registered nurses found statistically significant changes in all post-intervention (Penque, 2009).
2. Purpose The purpose of the Mindful Nursing Pilot Study was to explore the impact of mindfulness training for nursing staff on their levels of mindfulness, compassion satisfaction, burnout, and stress. In addition,
0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2014.01.003
Please cite this article as: Horner, J.K., et al., A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.003
2
J.K. Horner et al. / Applied Nursing Research xxx (2014) xxx–xxx
the study attempted to determine the impact on patient satisfaction scores. 3. Hypotheses We hypothesized that the unit who participated in a 10-week mindfulness training program would show significant improvement in satisfaction and mindfulness, measured via two sub-scales from the Professional Quality of Life (ProQOL) Scale Version 5© and the Mindful Attention Awareness Scale (MAAS), as compared to the control unit. In addition, we anticipated that patient satisfaction would increase on the intervention unit. 4. Methods 4.1. Design The pilot was designed as a quasi-experimental study; staff on one nursing unit volunteered to participate in a mindfulness training program while staff on a similar nursing unit served as the control group. Recruitment strategies included interest meetings to provide staff with an overview of the study and to introduce the concept of mindfulness. Unit management championed the study and offered to assist with covering patients to allow staff to attend the classes during their normal shifts. 4.2. Sample Medical–Surgical units providing intermediate intensity of care were selected for the study. Forty-three employees from the intervention unit participated in at least one of the ten classes; participants included staff nurses, nurse aides, and clinical secretaries as well as the unit manager and supervisor. While participation was entirely voluntary, individuals were asked to commit to practicing what was covered in the classes.
4.5. Analysis JMP® software was used to analyze the survey results. Changes across time in both the intervention and control groups were compared using a 2-tailed t-test and one-way ANOVA. 5. Results 5.1. Attendance Participants were primarily female registered nurses with tenure of 10 years or less on their nursing unit. About 60% of the 43 participants attended five or more classes. Variable work schedules and the immediacy of patient care prevented most staff from attending all ten classes; therefore, classes were videotaped so staff could view them at their convenience. Weekly emails were sent to the participants to encourage their mindfulness practice; visual reminders were posted around the unit and were changed every 2 weeks to match the concurrent session topic. 5.2. MAAS measure The MAAS scores represent the average level of mindfulness across all respondents on a scale of 1–6, with higher scores reflecting higher levels of mindfulness. Though not statistically significant, postintervention scores rose in the intervention group but remained the same in the control population (Table 1). 5.3. ProQOL measures The ProQOL assessment was scored based on two components: compassion satisfaction and burnout. For both measures the average score is 50. Higher scores on compassion satisfaction reflect greater professional satisfaction, whereas higher scores on burnout reflect feelings of not being effective in one's position. Interestingly, burnout scores improved on the intervention unit, but both scores improved on the control unit (Table 1). Neither of these results reached statistical significance.
4.3. Study measures 5.4. Individual and unit stress levels IRB approval was obtained, and surveys were distributed. The survey included questions from the two assessment tools noted above as well as self-reports of individual and unit stress levels. The MAAS has demonstrated high test–retest reliability, discriminant and convergent validity, known-groups validity, and criterion validity. Internal consistency levels (Cronbach's alphas) generally range from .80 to .90 (Brown & Ryan, 2003). Similarly, the ProQOL has demonstrated good construct validity and internal consistency levels above the standard of .70 (compassion satisfaction α = .88; burnout α = .75; compassion fatigue α = .81) (Stamm, 2010). Analysis focused on the MAAS scores and two sub-scales from the ProQOL Compassion Satisfaction and Burnout. Patient satisfaction was measured using results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. 4.4. Intervention The curriculum focused on three main practices: breathing as a primary mindfulness tool; developing awareness of thoughts and feelings; and tips on how to be fully present during patient interactions. Classes were held once a week on both day and night shifts for 10 weeks. To minimize disruption to patient care, classes lasted only 30 minutes. Each class included mindfulness education and practice, facilitated by nurses and others with mindfulness expertise.
We included two questions about individual and unit stress levels, both self-reported on a scale of 0 (not stressed at all) to 10 (extremely stressed). The intervention unit showed improvement on both, while
Table 1 Unadjusted means of outcome measures pre- and post-intervention. Outcome measure MAAS score Intervention groupa Control groupb Compassion Satisfaction score Intervention groupa Control groupb Burnout score Intervention groupa Control groupb Individual stress score Intervention groupa Control groupb Unit stress score Intervention groupa Control groupb a b c
Pretraining
Posttraining
t
df
p valuec
4.2 4.7
4.4 4.7
−0.90 0.25
75 65
0.37 0.81
53.20 53.77
52.93 54.25
0.30 −0.55
75 65
0.76 0.58
46.20 46.05
45.71 45.00
0.60 1.24
75 65
0.55 0.22
5.0 4.1
4.2 4.0
1.69 0.18
75 65
0.10 0.90
5.8 6.7
5.1 6.7
1.30 0.11
75 65
0.20 0.91
Pre-training N = 46, post-training N = 31. Pre-training N = 28, post-training N = 12. p values are for changes over time within each group.
Please cite this article as: Horner, J.K., et al., A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.003
J.K. Horner et al. / Applied Nursing Research xxx (2014) xxx–xxx
the control group remained largely unchanged. The reduction in stress levels for the intervention unit approached significance (Table 1).
Patient satisfaction data were captured at three points: pre-study, during the study and immediately after. As noted in Table 2, patient satisfaction scores on the intervention unit increased by 32 points on “overall rating”; scores on “communication with nurses” increased by 17 points. 5.6. Qualitative data Throughout the 10 week program staff shared feedback about their experiences practicing mindfulness; post study evaluation indicated that the participants deemed the program a success (Table 3). 6. Discussion The results of this pilot study support the potential effectiveness of brief mindfulness training to reduce stress levels of nursing staff. Despite the small sample size both individual and unit measures of stress approached significance. An interesting finding was the difference in individual vs. unit stress levels. Specifically, on both units, participants rated their own stress level lower than that of the unit. This may indicate that individuals believed that their peers' stress levels were higher than their own, or that the overall environment on the unit was stressful. Based on the reduction in both stress measures on the intervention unit, it appears that participants believed that the mindfulness training helped reduce their own stress and collectively, the stress level on the unit. Participants noted this positive impact on stress reduction in their comments (Table 3). Our results are similar to those reported by Mackenzie et al. (2006) in a study we used as the primary model for our intervention. Although we did not find significant improvement in participants' scores on the MAAS and ProQOL measures, the results were in the hypothesized direction. Both the intervention and control units scored themselves relatively high on the mindfulness scale at baseline. Similarly, both units scored in the “average” range for burnout at baseline, indicating that burnout was not as great a problem as expected. It is possible that the intervention period was too short to see much change in these two measures, although other similar studies demonstrated significant improvement in mindfulness (Cohen-Katz et al., 2005; Penque, 2009) and burnout (Cohen-Katz et al., 2005; Mackenzie et al., 2006; Penque, 2009).
Table 2 Patient satisfaction scores.
Overall ratinga Communication with nursesb
Table 3 Qualitative responses from participants. Q: Do you believe there has been a fundamental shift in your ability to be more present and aware in your life as a result of participating in the mindful nursing pilot? Please explain.
5.5. Patient satisfaction measures
Overall ratinga Communication with nursesb
3
Pre-intervention
During intervention
Post-intervention
(April 2012)
(May–June 2012)
(July 2012)
56% 63%
69% 84%
88% 80%
Control (April 2012)
Control (May–June 2012)
Control (July 2012)
77% 78%
60% 72%
88% 84%
“Because of this class, it makes me realize that there are easy and practical ways to diminish [my] stress level with breathing exercises and getting more focused to what is going on.” “I am listening more without rushing to provide an answer or response.” “I like to breathe and pause and check in before dealing with certain patients.” “Being mindful and aware has given me control over my stress and emotions. I can find meaning and reward in everything I do.” “I think by being more aware of your surrounding it makes you more aware of your inner being. I think this class has helped me help others with their stress level, by being able to realize stress behaviors.”
Overall, the improvement in the study measures post-intervention are supported by similar studies with nursing staff in the hospital setting (Cohen-Katz et al., 2005; Mackenzie et al., 2006; Penque, 2009). These studies had success with staff attending classes off shift, i.e., staff attended classes before or after their shift or on their days off. Our study offered on-the-job mindfulness training in an attempt to reduce barriers to participation. In retrospect however, this may have prevented full participation due to competing patient care demands and valued time off. 7. Limitations The results of this pilot are encouraging in light of several limitations encountered by the research team. The electronic survey was distributed to all staff pre- and post-intervention, regardless of their intention to participate in the training. This was done for two reasons: to increase the sample size and to see if the training would have an impact on the entire unit, even in the absence of full staff participation. However, many of the staff did not complete the survey and thus, the sample size was smaller than we desired. The modest sample size limits generalizability and reduces statistical power. Another limitation of this study included variability in session attendance. Unit staff work 12 hour shifts creating extended days off; consequently no employee was able to attend every session. In addition, the natural but unpredictable ebb and flow of patient care always took priority over mindfulness classes. Finally, some participants were curious about the content, but not ready to make the commitment to daily practice. 8. Implications for practice Hospitals may find it beneficial to incorporate mindfulness training to reduce stress levels among nursing staff. In addition, the results of this pilot suggest that further study of the impact of mindfulness practices on staff and patient satisfaction, and burnout is warranted. One recommendation is for hospitals to standardize the tools used to measure such key indicators. In studies previously cited, each research team used a different tool to measure mindfulness. Our research team measured burnout through the ProQOL, whereas most studies used the more common Maslach Burnout Inventory. Replication with an emphasis on incorporating common measurement tools as well as removing the logistical challenges associated with offering training during the work shift is recommended. Acknowledgments
a
Percent of patients responding 9 or 10 on a 10 point scale where 10 is the “best hospital possible”. b Percent of patients responding “always” to nurse communication bundle.
Support was received from the WakeMed Foundation. The authors would like to acknowledge the following individuals who contributed
Please cite this article as: Horner, J.K., et al., A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.003
4
J.K. Horner et al. / Applied Nursing Research xxx (2014) xxx–xxx
to this study: Lorraine Penry, RN; Elena Schertz, RN; Sheila Veeder, RN; Pauline Stillman, RN; Crystal Drake, RN and Bill Bass. References Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, 1287–1293. Anthony, M. K., & Vidal, K. (2010). Mindful communication: A novel approach to improving delegation and increasing patient safety. Online Journal of Issues in Nursing, 15(2), 2. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848.
Cohen-Katz, J., Wiley, S. D., Capuano, T., Baker, D. M., & Shapiro, S. (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout, part II. Holistic Nursing Practice, 19(1), 26–35. Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156. Mackenzie, C. S., Poulin, P. A., & Seidman-Carlson, R. (2006). A brief mindfulness-based stress reduction intervention for nurses and nurse aides. Applied Nursing Research, 19, 105–109. Penque, S. (2009). Mindfulness based stress reduction effects on registered nurses. Doctoral Dissertation. University of Minnesota (Retrieved September 29, 2011 http://purl.umn.edu/58728). Praissman, S. (2008). Mindfulness-based stress reduction: A literature review and clinician’s guide. Journal of the American Academy of Nurse Practitioners, 20(4), 212–216. Stamm, B. H. (2010). The concise ProQOL manual (2nd ed.) (Pocatello, ID: ProQOL.org).
Please cite this article as: Horner, J.K., et al., A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.003
Contents lists available at ScienceDirect
Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Research Briefs
A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences Janice K. Horner, MPH, CPHQ ⁎, 1, Brigit S. Piercy, BSN, MHA 2, Lois Eure 3,
Elizabeth K. Woodard, PhD, RN 4 WakeMed Health & Hospitals, Raleigh, NC 27610, USA
a r t i c l e
i n f o
Article history: Received 22 August 2013 Revised 16 January 2014 Accepted 16 January 2014 Available online xxxx Keywords: Mindfulness Nurse satisfaction Patient satisfaction Compassion satisfaction Burnout Stress Inpatient nursing
a b s t r a c t The purpose of the Mindful Nursing Pilot Study was to explore the impact of mindfulness training for nursing staff on levels of mindfulness, compassion satisfaction, burnout, and stress. In addition, the study attempted to determine the impact on patient satisfaction scores. The pilot was designed as a quasi-experimental research study; staff on one nursing unit participated in the 10-week mindfulness training program while another, similar nursing unit served as the control group. The intervention group showed improvement in levels of mindfulness, burnout, and stress as well as patient satisfaction while the control group remained largely the same. This pilot provides encouraging results that suggest that replication and further study of mindfulness in the workplace would be beneficial. © 2014 Elsevier Inc. All rights reserved.
1. Background Hospitals seeking to remain viable in the current reimbursement environment must develop a laser focus on cost control and the effective use of limited resources. Subsequently, direct caregivers have been expected to do more with less, even as the acuity of the inpatient population has increased. Caregivers struggle with the effects of their increasing workload, and report feeling overwhelmed and stressed (Anthony & Vidal, 2010; Penque, 2009). Preventable errors in patient care may result from front-line staff who are too rushed to stop, look and listen before they “touch” a patient (e.g., draw blood, give medications, take an x-ray, etc.). Such chronic stress can lead to burnout, compassion fatigue and a lack of engagement, potentially resulting in staff turnover which creates an additional cost to any organization (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Some healthcare organizations are turning to mindfulness as a key stress management tool (Praissman, 2008). Mindfulness can be
⁎ Corresponding author. Tel.: +1 919 810 7865. E-mail addresses: [email protected] (J.K. Horner), [email protected] (B.S. Piercy), [email protected] (L. Eure), [email protected] (E.K. Woodard). 1 At the time of the study, Janice Horner was affiliated with WakeMed Health & Hospitals. 2 Tel.: +1 919 350 8457; fax: +1 919 350 7839. 3 Tel.: +1 919 602 9917; fax: +1 919 350 6248. 4 Tel.: +1 919 350 1700x10124; fax: +1 919 350 8313.
defined as “paying attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment to moment” (Kabat-Zinn, 2003, p. 145). For example, nurses at one academic, community-based hospital who participated in an 8-week Mindfulness Based Stress Reduction (MBSR) program demonstrated significant reduction in scores on two of three subscales of the Maslach Burnout Inventory. In addition, they reported significant increases in levels of mindfulness, as measured by the Mindful Attention Awareness Scale (MAAS) (Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2005). In a similar study, nurses and nurse aides in a large, urban geriatric teaching hospital participated in a shortened version of the traditional MBSR program. The intervention group experienced significant improvements in burnout symptoms, relaxation and life satisfaction compared to the control group (Mackenzie, Poulin, & SeidmanCarlson, 2006). Finally, a study conducted at a large, non-profit tertiary care hospital to test the effects of the MBSR intervention on measures of mindfulness, empathy, self compassion, serenity, work satisfaction and burnout among registered nurses found statistically significant changes in all post-intervention (Penque, 2009).
2. Purpose The purpose of the Mindful Nursing Pilot Study was to explore the impact of mindfulness training for nursing staff on their levels of mindfulness, compassion satisfaction, burnout, and stress. In addition,
0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2014.01.003
Please cite this article as: Horner, J.K., et al., A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.003
2
J.K. Horner et al. / Applied Nursing Research xxx (2014) xxx–xxx
the study attempted to determine the impact on patient satisfaction scores. 3. Hypotheses We hypothesized that the unit who participated in a 10-week mindfulness training program would show significant improvement in satisfaction and mindfulness, measured via two sub-scales from the Professional Quality of Life (ProQOL) Scale Version 5© and the Mindful Attention Awareness Scale (MAAS), as compared to the control unit. In addition, we anticipated that patient satisfaction would increase on the intervention unit. 4. Methods 4.1. Design The pilot was designed as a quasi-experimental study; staff on one nursing unit volunteered to participate in a mindfulness training program while staff on a similar nursing unit served as the control group. Recruitment strategies included interest meetings to provide staff with an overview of the study and to introduce the concept of mindfulness. Unit management championed the study and offered to assist with covering patients to allow staff to attend the classes during their normal shifts. 4.2. Sample Medical–Surgical units providing intermediate intensity of care were selected for the study. Forty-three employees from the intervention unit participated in at least one of the ten classes; participants included staff nurses, nurse aides, and clinical secretaries as well as the unit manager and supervisor. While participation was entirely voluntary, individuals were asked to commit to practicing what was covered in the classes.
4.5. Analysis JMP® software was used to analyze the survey results. Changes across time in both the intervention and control groups were compared using a 2-tailed t-test and one-way ANOVA. 5. Results 5.1. Attendance Participants were primarily female registered nurses with tenure of 10 years or less on their nursing unit. About 60% of the 43 participants attended five or more classes. Variable work schedules and the immediacy of patient care prevented most staff from attending all ten classes; therefore, classes were videotaped so staff could view them at their convenience. Weekly emails were sent to the participants to encourage their mindfulness practice; visual reminders were posted around the unit and were changed every 2 weeks to match the concurrent session topic. 5.2. MAAS measure The MAAS scores represent the average level of mindfulness across all respondents on a scale of 1–6, with higher scores reflecting higher levels of mindfulness. Though not statistically significant, postintervention scores rose in the intervention group but remained the same in the control population (Table 1). 5.3. ProQOL measures The ProQOL assessment was scored based on two components: compassion satisfaction and burnout. For both measures the average score is 50. Higher scores on compassion satisfaction reflect greater professional satisfaction, whereas higher scores on burnout reflect feelings of not being effective in one's position. Interestingly, burnout scores improved on the intervention unit, but both scores improved on the control unit (Table 1). Neither of these results reached statistical significance.
4.3. Study measures 5.4. Individual and unit stress levels IRB approval was obtained, and surveys were distributed. The survey included questions from the two assessment tools noted above as well as self-reports of individual and unit stress levels. The MAAS has demonstrated high test–retest reliability, discriminant and convergent validity, known-groups validity, and criterion validity. Internal consistency levels (Cronbach's alphas) generally range from .80 to .90 (Brown & Ryan, 2003). Similarly, the ProQOL has demonstrated good construct validity and internal consistency levels above the standard of .70 (compassion satisfaction α = .88; burnout α = .75; compassion fatigue α = .81) (Stamm, 2010). Analysis focused on the MAAS scores and two sub-scales from the ProQOL Compassion Satisfaction and Burnout. Patient satisfaction was measured using results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. 4.4. Intervention The curriculum focused on three main practices: breathing as a primary mindfulness tool; developing awareness of thoughts and feelings; and tips on how to be fully present during patient interactions. Classes were held once a week on both day and night shifts for 10 weeks. To minimize disruption to patient care, classes lasted only 30 minutes. Each class included mindfulness education and practice, facilitated by nurses and others with mindfulness expertise.
We included two questions about individual and unit stress levels, both self-reported on a scale of 0 (not stressed at all) to 10 (extremely stressed). The intervention unit showed improvement on both, while
Table 1 Unadjusted means of outcome measures pre- and post-intervention. Outcome measure MAAS score Intervention groupa Control groupb Compassion Satisfaction score Intervention groupa Control groupb Burnout score Intervention groupa Control groupb Individual stress score Intervention groupa Control groupb Unit stress score Intervention groupa Control groupb a b c
Pretraining
Posttraining
t
df
p valuec
4.2 4.7
4.4 4.7
−0.90 0.25
75 65
0.37 0.81
53.20 53.77
52.93 54.25
0.30 −0.55
75 65
0.76 0.58
46.20 46.05
45.71 45.00
0.60 1.24
75 65
0.55 0.22
5.0 4.1
4.2 4.0
1.69 0.18
75 65
0.10 0.90
5.8 6.7
5.1 6.7
1.30 0.11
75 65
0.20 0.91
Pre-training N = 46, post-training N = 31. Pre-training N = 28, post-training N = 12. p values are for changes over time within each group.
Please cite this article as: Horner, J.K., et al., A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.003
J.K. Horner et al. / Applied Nursing Research xxx (2014) xxx–xxx
the control group remained largely unchanged. The reduction in stress levels for the intervention unit approached significance (Table 1).
Patient satisfaction data were captured at three points: pre-study, during the study and immediately after. As noted in Table 2, patient satisfaction scores on the intervention unit increased by 32 points on “overall rating”; scores on “communication with nurses” increased by 17 points. 5.6. Qualitative data Throughout the 10 week program staff shared feedback about their experiences practicing mindfulness; post study evaluation indicated that the participants deemed the program a success (Table 3). 6. Discussion The results of this pilot study support the potential effectiveness of brief mindfulness training to reduce stress levels of nursing staff. Despite the small sample size both individual and unit measures of stress approached significance. An interesting finding was the difference in individual vs. unit stress levels. Specifically, on both units, participants rated their own stress level lower than that of the unit. This may indicate that individuals believed that their peers' stress levels were higher than their own, or that the overall environment on the unit was stressful. Based on the reduction in both stress measures on the intervention unit, it appears that participants believed that the mindfulness training helped reduce their own stress and collectively, the stress level on the unit. Participants noted this positive impact on stress reduction in their comments (Table 3). Our results are similar to those reported by Mackenzie et al. (2006) in a study we used as the primary model for our intervention. Although we did not find significant improvement in participants' scores on the MAAS and ProQOL measures, the results were in the hypothesized direction. Both the intervention and control units scored themselves relatively high on the mindfulness scale at baseline. Similarly, both units scored in the “average” range for burnout at baseline, indicating that burnout was not as great a problem as expected. It is possible that the intervention period was too short to see much change in these two measures, although other similar studies demonstrated significant improvement in mindfulness (Cohen-Katz et al., 2005; Penque, 2009) and burnout (Cohen-Katz et al., 2005; Mackenzie et al., 2006; Penque, 2009).
Table 2 Patient satisfaction scores.
Overall ratinga Communication with nursesb
Table 3 Qualitative responses from participants. Q: Do you believe there has been a fundamental shift in your ability to be more present and aware in your life as a result of participating in the mindful nursing pilot? Please explain.
5.5. Patient satisfaction measures
Overall ratinga Communication with nursesb
3
Pre-intervention
During intervention
Post-intervention
(April 2012)
(May–June 2012)
(July 2012)
56% 63%
69% 84%
88% 80%
Control (April 2012)
Control (May–June 2012)
Control (July 2012)
77% 78%
60% 72%
88% 84%
“Because of this class, it makes me realize that there are easy and practical ways to diminish [my] stress level with breathing exercises and getting more focused to what is going on.” “I am listening more without rushing to provide an answer or response.” “I like to breathe and pause and check in before dealing with certain patients.” “Being mindful and aware has given me control over my stress and emotions. I can find meaning and reward in everything I do.” “I think by being more aware of your surrounding it makes you more aware of your inner being. I think this class has helped me help others with their stress level, by being able to realize stress behaviors.”
Overall, the improvement in the study measures post-intervention are supported by similar studies with nursing staff in the hospital setting (Cohen-Katz et al., 2005; Mackenzie et al., 2006; Penque, 2009). These studies had success with staff attending classes off shift, i.e., staff attended classes before or after their shift or on their days off. Our study offered on-the-job mindfulness training in an attempt to reduce barriers to participation. In retrospect however, this may have prevented full participation due to competing patient care demands and valued time off. 7. Limitations The results of this pilot are encouraging in light of several limitations encountered by the research team. The electronic survey was distributed to all staff pre- and post-intervention, regardless of their intention to participate in the training. This was done for two reasons: to increase the sample size and to see if the training would have an impact on the entire unit, even in the absence of full staff participation. However, many of the staff did not complete the survey and thus, the sample size was smaller than we desired. The modest sample size limits generalizability and reduces statistical power. Another limitation of this study included variability in session attendance. Unit staff work 12 hour shifts creating extended days off; consequently no employee was able to attend every session. In addition, the natural but unpredictable ebb and flow of patient care always took priority over mindfulness classes. Finally, some participants were curious about the content, but not ready to make the commitment to daily practice. 8. Implications for practice Hospitals may find it beneficial to incorporate mindfulness training to reduce stress levels among nursing staff. In addition, the results of this pilot suggest that further study of the impact of mindfulness practices on staff and patient satisfaction, and burnout is warranted. One recommendation is for hospitals to standardize the tools used to measure such key indicators. In studies previously cited, each research team used a different tool to measure mindfulness. Our research team measured burnout through the ProQOL, whereas most studies used the more common Maslach Burnout Inventory. Replication with an emphasis on incorporating common measurement tools as well as removing the logistical challenges associated with offering training during the work shift is recommended. Acknowledgments
a
Percent of patients responding 9 or 10 on a 10 point scale where 10 is the “best hospital possible”. b Percent of patients responding “always” to nurse communication bundle.
Support was received from the WakeMed Foundation. The authors would like to acknowledge the following individuals who contributed
Please cite this article as: Horner, J.K., et al., A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.003
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Please cite this article as: Horner, J.K., et al., A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.003
