JBI Database of Systematic Reviews & Implementation Reports 2015;13(10) 21 - 29

The effectiveness of mindfulness based programs in reducing

stress experienced by nurses in adult hospital settings: a
systematic review of quantitative evidence protocol
1,3
Elmarie Botha
1,3
Teri Gwin
2
Christina Purpora

1 School of Nursing, Samuel Merritt University, Oakland, USA

2 School of Nursing and Health Professions, University of San Francisco, San Francisco, USA
Downloaded from https://journals.lww.com/jbisrir by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 05/15/2021

3 UCSF Centre for Evidence-Based Patient and Family Care: an Affiliate Center of the Joanna
Briggs Institute

Corresponding author

Elmarie Botha

[email protected]

Review question/objective
The objective of this review is to identify the effectiveness of mindfulness based programs in reducing
stress experienced by nurses in adult hospitalized patient care settings.

Background
Nursing professionals face extraordinary stressors in the medical environment. Many of these stressors
have always been inherent to the profession: long work hours, dealing with pain, loss and emotional
1,2
suffering, caring for dying patients and providing support to families. Recently nurses have been
experiencing increased stress related to other factors such as staffing shortages, increasingly complex
patients, corporate financial constraints and the increased need for knowledge of ever-changing
3
technology. Stress affects high-level cognitive functions, specifically attention and memory, and this
increases the already high stakes for nurses. Nurses are required to cope with very difficult situations
4
that require accurate, timely decisions that affect human lives on a daily basis.

Lapses in attention increase the risk of serious consequences such as medication errors, failure to
4
recognize life-threatening signs and symptoms, and other essential patient safety issues. Research
has also shown that the stress inherent to health care occupations can lead to depression, reduced job
5
satisfaction, psychological distress and disruptions to personal relationships. These outcomes of stress
are factors that create scenarios for risk of patient harm.

There are three main effects of stress on nurses: burnout, depression and lateral violence. Burnout has
been defined as a syndrome of depersonalization, emotional exhaustion, and a sense of low personal
6
accomplishment, and the occurrence of burnout has been closely linked to perceived stress. Shimizu,
7
Mizoue, Mishima and Nagata state that nurses experience considerable job stress which has been a
8
major factor in the high rates of burnout that has been recorded among nurses. Zangaro and Soeken
share this opinion and state that work related stress is largely contributing to the current nursing
shortage. They report that work stress leads to a much higher turnover, especially during the first year
after graduation, lowering retention rates in general.

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JBI Database of Systematic Reviews & Implementation Reports 2015;13(10) 21 - 29

In a study conducted in Pennsylvania, researchers found that while 43% of the nurses who reported
high levels of burnout indicated their intent to leave their current position, only 11% of nurses who were
9
not burned out intended to leave in the following 12 months. In the same study patient-to-nurse ratios
were significantly associated with emotional exhaustion and burnout. An increase of one patient per
9
nurse assignment to a hospital’s staffing level increased burnout by 23%.

Depression can be defined as a mood disorder that causes a persistent feeling of sadness and loss of
10
interest. Wang found that high levels of work stress were associated with higher risk of mood and
anxiety disorders. In Canada one out of every 10 nurses have shown depressive symptoms; compared
11
to the average of 5.1% of the nurses’ counterparts who do not work in healthcare. High incidences of
12
depression and depressive symptoms were also reported in studies among Chinese nurses (38%)
13
and Taiwanese nurses (27.7%). In the Taiwanese study the occurrence of depression was
significantly and positively correlated to job stress experienced by the nurses (p<0.001).
11
In a multivariate logistic regression, Ohler, Kerr and Forbes also found that job stress was significantly
correlated to depression in nurses. The researchers reported that nurses who experienced a higher
degree of job stress were 80% more likely to have suffered a major depressive episode in the previous
year. A further finding in this study revealed that 75% of the participants also suffered from at least one
chronic disease revealing a strong association between depression and other major health issues.

A stressful working environment, such as a hospital, could potentially lead to lateral violence among
14
nurses. Lateral violence is a serious occupational health concern among nurses as evidenced by
extensive research and literature available on the topic. The impact of lateral violence has been well
15-22 23
studied and documented over the past three decades. Griffin and Clark state that lateral violence
is a form of bullying grounded in the theoretical framework of the oppression theory. The bullying
behaviors occur among members of an oppressed group as a result of feeling powerless and having a
15
perceived lack of control in their workplace. Griffin identified the ten most common forms of lateral
violence among nurses as “non-verbal innuendo, verbal affront, undermining activities, withholding
information, sabotage, infighting, scape-goating, backstabbing, failure to respect privacy, and broken
15(p258)
confidences”. Nurse-to-nurse lateral violence leads to negative workplace relationships and
disrupts team performance, creating an environment where poor patient outcomes, burnout and high
23
staff turnover rates are prevalent.
24
Work-related stressors have been indicated as a potential cause of lateral violence. According to the
Effort Reward Imbalance model (ERI) developed by Siegrist, work stress develops when an imbalance
25
exists between the effort individuals put into their jobs and the rewards they receive in return. The ERI
model has been widely used in occupational health settings based on its predictive power for adverse
health and well-being outcomes. The model claims that both high efforts with low rewards could lead to
26
negative emotions in the exposed employees. Vegchel, van Jonge, de Bosma & Schaufeli state that,
according to the ERI model, occupational rewards mostly consist of money, esteem and job security or
27
career opportunities. A survey conducted by Reineck & Furino indicated that registered nurses had a
very high regard for the intrinsic rewards of their profession but that they identified workplace
relationships and stress issues as some of the most important contributors to their frustration and
28
exhaustion. Hauge, Skogstad & Einarsen state that work-related stress further increases the potential
for lateral violence as it creates a negative environment for both the target and the perpetrator.

Mindfulness based programs have proven to be a promising intervention in reducing stress experienced
29
by nurses. Mindfulness was originally defined by Jon Kabat-Zinn in 1979 as “paying attention on
purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment to

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30(p145)
moment”. The Mindfulness Based Stress Reduction (MBSR) program is an educationally based
program that focuses on training in the contemplative practice of mindfulness. It is an eight-week
program where participants meet weekly for two-and-a-half hours and join a one-day long retreat for six
5
hours. The program incorporates a combination of mindfulness meditation, body awareness and yoga
to help increase mindfulness in participants. The practice is meant to facilitate relaxation in the body and
calming of the mind by focusing on present-moment awareness. The program has proven to be
effective in reducing stress, improving quality of life and increasing self-compassion in healthcare
5
professionals.

Researchers have demonstrated that mindfulness interventions can effectively reduce stress, anxiety
31,32
and depression in both clinical and non-clinical populations. In a meta-analysis of seven studies
conducted with healthy participants from the general public, the reviewers reported a significant
33
reduction in stress when the treatment and control groups were compared. However, there have been
limited studies to date that focused specifically on the effectiveness of mindfulness programs to reduce
stress experienced by nurses.

In addition to stress reduction, mindfulness based interventions can also enhance nurses’ capacity for
30
focused attention and concentration by increasing present moment awareness. Mindfulness
techniques can be applied in everyday situations as well as stressful situations. According to
34
Kabat-Zinn, work-related stress influences people differently based on their viewpoint and their
interpretation of the situation. He states that individuals need to be able to see the whole picture, have
perspective on the connectivity of all things and not operate on automatic pilot to effectively cope with
stress. The goal of mindfulness meditation is to empower individuals to respond to situations
4
consciously rather than automatically.

Prior to the commencement of this systematic review, the Cochrane Library and JBI Database of
Systematic Reviews and Implementation Reports were searched. No previous systematic reviews on
the topic of reducing stress experienced by nurses through mindfulness programs were identified.
Hence, the objective of this systematic review is to evaluate the best research evidence available
pertaining to mindfulness-based programs and their effectiveness in reducing perceived stress among
nurses.

Keywords
burnout; depression; lateral violence; mindfulness; Mindfulness Based Stress Reduction (MBSR);
nurses; stress

Inclusion criteria
Types of participants

This review will consider studies that include Registered Nurses, regardless of their credentials or
specialty fields, who are currently employed in adult patient care settings. Studies involving nurses
employed in non-adult health service settings will be excluded.

Types of intervention(s)/phenomena of interest

This review will consider studies that evaluate any mindfulness based programs that originate from the
original Mindfulness-Based Stress Reduction Program developed by John Kabat Zinn.

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The intervention will be compared to standard care, which in most instances is no intervention. Studies
examining the effectiveness of mindful meditation alone without a concurrent structured mindfulness
based program will be excluded.

Types of outcomes

This review will consider studies pertaining to mindfulness based programs that include the following
outcome measure: perceived stress. Studies will be selected that measure stress experienced by
nurses as measured by a variety of perceived stress scales, including but not limited to, the Perceived
Stress Scale (PSS-14, PSS-10 and PSS-4) and the Depression and Anxiety Stress Scale (DASS-21).

Types of studies

This review will consider any experimental study design including randomized controlled trials,
non-randomized controlled trials, quasi-experimental, and before and after studies for inclusion.

Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy
will be utilized in this review. An initial limited search of PUBMED and CINAHL will be undertaken
followed by an analysis of the text words contained in the title and abstract, and of the index terms used
to describe the article. A second search using all identified keywords and index terms will then be
undertaken across all included databases. Thirdly, the reference list of all identified reports and articles
will be searched for additional studies. Studies published in English will be considered for inclusion in
this review. Studies published since 1979 will be considered for inclusion in this review as the first
mindfulness based stress reduction program was created in 1979 by John Kabat Zinn.

The databases to be searched include:

PUBMED
CINAHL
PsycINFO
Scopus
The search for unpublished studies will include:
Google Scholar
ProQuest Dissertation and Theses.

Initial keywords to be used will be:

Mindfulness; Nurses; Nursing; Stress; Stress reduction; Mindfulness based programs.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological quality
prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs
Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I).
Any disagreements that arise between the reviewers will be resolved through discussion, or with a third
reviewer.

Data extraction
Data will be extracted from papers included in the review using the standardized data extraction tool
from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions,
populations, study methods and outcomes of significance to the review question and specific
objectives. An attempt will be made to contact the authors of the primary studies for any missing
information or to clarify unclear data.

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Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All
results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data)
and weighted mean differences (for continuous data) and their 95% confidence intervals will be
calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square.
Where statistical pooling is not possible the findings will be presented in narrative form including tables
and figures to aid in data presentation where appropriate.

Conflicts of interest

The authors have no conflict of interest to declare.

Acknowledgements

We would like to acknowledge the following for their contribution and assistance during the
development of this protocol: Dr Michelle Hampton, Director of Doctorate of Nursing Practice, Samuel
Merritt University School of Nursing. Dr Pamela Minarik, Professor, Samuel Merritt University School of
Nursing.

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Appendix I: Appraisal instruments

MAStARI appraisal instrument

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Appendix II: Data extraction instruments

MAStARI data extraction instrument

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