The mindful nurse leader: Improving processes and outcomes; restoring joy to nursing

Pipe, Teri PhD, RN; FitzPatrick, Kate DNP, RN; Doucette, Jeffrey N. DNP, RN; Cotton, Amy MSN, RN; Arnow, Debra DNP, RN

doi: 10.1097/01.NUMA.0000491135.83601.3e
Feature: Executive Extra series, part 1

In this first installment of a three-part series on mindfulness, we describe a dynamic project aimed at elevating the importance of mindfulness, compassion, and presence as key competencies for professional nurses across the career span in all healthcare settings.

The first installment of this three-part series takes a look at how mindful practice can improve processes and outcomes, and restore joy to nursing.

Teri Pipe is the chief wellbeing officer and dean of the College of Nursing & Health Innovation at Arizona State University in Tempe, Ariz. Kate FitzPatrick is the chief nursing officer at the University of Vermont Medical Center and the associate dean for interprofessional practice, College of Nursing and Health Sciences, at the University of Vermont in Burlington, Vt. Jeffrey N. Doucette is the regional vice president of clinical services and chief nurse executive at Bon Secours Hampton Roads Health System in Suffolk, Va. Amy Cotton is the vice president of patient engagement and chief experience officer at Eastern Maine Healthcare Systems in Brewer, Maine. Debra Arnow is the vice president of patient care services and chief nursing officer at Children's Hospital & Medical Center in Omaha, Neb. All are Robert Wood Johnson executive nurse fellows.

The authors have disclosed no financial relationships related to this article.

Article Outline

Nurses are highly regarded by healthcare colleagues and patients/families for their knowledge and competence. A skilled and efficient clinical nurse can juggle answering call lights, administering medications, documenting care, admitting and discharging patients, and much more. But when a nurse is able to embrace an aware, focused, and present state that transcends the execution of tasks, he or she is practicing mindfulness. In the mindful space, seemingly small moments become profound experiences and intimate human connections exceed tasks.

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“In the Moment: Stories of Mindfulness in Nursing” was an action learning team project developed as part of the authors' Robert Wood Johnson Foundation Executive Nurse Fellowship experience. It was designed to increase understanding about the power of mindfulness in nursing practice by providing real-life examples of how nurses employ mindfulness and teaching mindfulness techniques to nurses at all stages of their career (including students) to build resiliency and foster their own health and wellness.

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What's mindfulness?

Mindfulness means intentionally paying attention to the present moment with a nonjudgmental attitude of acceptance and awareness. It sounds simple, right? Although easily taught, mindfulness is a challenging practice to maintain and strengthen, particularly when stressed and challenged. Compassion toward self and others is often a byproduct, if not an intentional effect, of mindfulness practice. As the participant becomes more accustomed to accepting the present moment as is, nonjudgmental acceptance begins to extend to the self and others. This type of acceptance isn't meant to negate ambition, goal-achievement, or productivity; rather, it builds a realistic picture of the present that can then be used to propel performance. In this sense, mindfulness, presence, and compassion are often interrelated.

Research has demonstrated the positive effects of mindfulness on sleep, anxiety, depression, pain management, and overall resilience.1 As attention is rooted more firmly in the present and less on the past and/or future, depression, rumination, and anxiety decrease.2 The resulting effect is energy that was once spent clinging to the past or worrying about the future can now be spent in the present. Some refer to this as learning to live by design rather than by default.

Cultivating present moment focus preserves energy for what can be acted upon. Additionally, mindfulness practices help the participant objectively observe automatic or habitual behaviors, coping patterns, thought processes, and stories, leading to a more deeply considered response. For nurses, this may mean being able to fully focus on patients and care requirements when at work and replenish themselves when away from work. The push and pull of work and life becomes less tense as mindfulness allows the participant to manage personal energy, which can lead to a feeling of less urgency or time sensitivity.

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The nursing need

Nurses are an integral part of today's dynamic healthcare delivery team, working in practice settings that are increasingly sensory rich, complex environments. Many professional nurses enter the workforce lacking the necessary skills to navigate repetitive critical incidents, death and dying, dynamic and changing teams, and, most important, the ability to focus on patients' and families' unique preferences. To date, most nursing curricula don't include ample focus on human connection skills that allow nurses to engage with patients in a meaningful, undistracted, unhurried manner while developing personal strategies for self-care and resilience. Likewise, healthcare work environments are seldom designed for reflective, mindful approaches to patient care and staff resilience.

In fact, stress in the healthcare workplace has generally been accepted as “just how things are”; some say being able to withstand ever-increasing stress is a “badge of honor.” Interruptions, distractions, competing priorities, time pressures, information overload, fatigue, stress, anxiety, feelings of sadness, and fear of missing out are often considered the normal experiences of living in the modern world. However, prolonged exposure to high levels of stress for extended, unremitting periods can lead to physical illnesses, such as cardiovascular disease and autoimmune conditions, depression, insomnia, and general malaise.1 These responses can contribute to nursing stress, burnout, and compassion fatigue, which may lead to compromised patient safety.3

The frenetic nature of the healthcare environment and high stakes outcomes combine to form a particularly important clinical challenge: paying mindful, laserlike, yet dynamic, attention to what's most important with focused presence and deep compassion. When this challenge is fully met, patients are safer and nurses are more engaged and less likely to suffer burnout and compassion fatigue.3 It's common knowledge in mindfulness work that when nurses pay close attention to patients, with intention and purpose, they're more likely to detect early warning signs of a change in condition. Likewise, nurses with a deeper awareness and focus are more likely to be stronger advocates for patients and colleagues.

There's increasing awareness that creativity, productivity, and extended high energy aren't the result of prolonged engagement with stressful mental frameworks, but rather of a more balanced, caring approach to the management of personal energy and one's responses to the environment and situation. It's been shown that individuals and groups can be taught to process their responses to stressful conditions in productive ways that support well-being, resilience, and long-term health.2 That's why healthcare leaders recently added a fourth aim to the Institute for Healthcare Improvement's Triple Aim: restoring joy and satisfaction to healthcare employees.4 A resilient, compassionate, and present nursing workforce is critical to delivering healthcare value.

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The leadership need

Similar to clinical practice, leadership is both an art and a science, with healing, nurturing, and bringing about optimal states of being for individuals and/or organizations at its core. Leadership can be defined as behaviors and ways of being that inspire a positive, enduring impact on those whose lives are influenced by one's presence.5 No matter the breadth of influence, much of the healing potential of leadership is grounded in a deep sense of authenticity and integrity. Strong leaders are courageous and guided by what they believe is valuable, meaningful, and true. Excellent leaders follow their inner compass to inspire, coach, and guide others with compassion, clarity, and purpose.5,6 An authentic leader must cultivate an awareness of who he or she is as a person to convey a sincere sense of self. This is an ongoing, dynamic, navigational practice, grounding the leader in true vision, purpose, and the strength required for top performance.

Mindfulness enables self-awareness, reflection, and intentional growth of leadership capacities. To understand their personal strengths, weaknesses, and best contributions, mindful leaders create practices that encourage them to “check in” with their own humanity to better use their capabilities. Built on the foundation of knowing the self and then having the courage to present the genuine self to others, authentic presence is highly valued as a leadership skill. Mindfulness practices often result in a deeper sense of self-compassion and forgiveness that extends more naturally to colleagues.

Person-centered communication practices improve both clinical outcomes and patient safety in healthcare settings.7 However, organizational culture may be a barrier to person-centered communication and patient engagement.8 Organization-wide approaches are needed to implement person-centered care interventions such as mindfulness. Nurse leaders are positioned to create effective systems and process changes to facilitate mindful practice at all points across the healthcare continuum. There's growing evidence that hospital performance is improved when leaders create optimal nurse practice environments—an additional incentive to cultivate mindfulness and person-centeredness in our current Value-Based Purchasing climate.9

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Let's get visual

With “In the Moment: Stories of Mindfulness in Nursing,” we wanted to celebrate and inspire mindfulness, compassion, and presence in nursing. We wanted to remind nurses and nursing students about the aspect of care that drew them into the profession and provide encouragement with simple ways to rekindle that connection with their professional passion. As leaders in our organizations, each of the authors selected a nurse to speak personally about what mindfulness and compassion mean in clinical encounters with real patients, as well as for personal resilience.

Visual narrative is a strong method for conveying meaning and fostering human connection. We identified that there's power in having nurses explain through visual narrative the specific ways that mindfulness is incorporated into their practice and how it impacts their patients/families and themselves. Simply reading about mindfulness doesn't provide the depth of a visual narrative, which helps make emotional and human connections to what it means to be mindful.

For this reason, each of the five nurses was interviewed on videotape for 1 hour; the interviews were subsequently professionally edited down to segments of just a few minutes. Please access the videos at https://drive.google.com/file/d/0B4DSpdC0BRYEOUNETGpJQ0hod2M/view?usp=sharing. These video stories are meant to be shared and discussed. We hope they provide a meaningful platform for broader reflection on the power of mindfulness and presence, and our goal is to collect many more stories from nurses with diverse backgrounds, representing multiple settings across the career span.

The next article in this series will describe the team's process of designing the project and the impact of mindfulness on productivity and outcomes in nursing leadership.

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REFERENCES

1. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298(14):1685–1687.
2. Pipe TB, Bortz JJ, Dueck A, Pendergast D, Buchda V, Summers J. Nurse leader mindfulness meditation program for stress management: a randomized controlled trial. J Nurs Adm. 2009;39(3):130–137.
3. Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18(6):424–428.
4. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–576.
5. Pipe T, Bortz J. Mindful leadership as healing practice. Int J Human Caring. 2009;13(2):34–38.
6. Pipe TB. Illuminating the inner leadership journey by engaging intention and mindfulness as guided by caring theory. Nurs Adm Q. 2008;32(2):117–125.
7. Agency for Healthcare Research and Quality. Guide to patient and family engagement in hospital quality and safety. www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html.
8. Luxford K, Safran DG, Delbanco T. Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. Int J Qual Health Care. 2011;23(5):510–515.
9. Kavanagh KT, Cimiotti JP, Abusalem S, Coty MB. Moving healthcare quality forward with nursing-sensitive value-based purchasing. J Nurs Scholarsh. 2012;44(4):385–395.
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