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Mindfulness-Based Stress Reduction for Health Care Staff

Expanding Holistic Nursing Paradigms to the Whole System

Hazlett-Stevens, Holly PhD

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doi: 10.1097/HNP.0000000000000404
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Abstract

INTRODUCTION

Mindfulness-based stress reduction (MBSR) is a widely accepted practice for teaching mindfulness meditation to medical patients suffering from the stress of chronic pain and illness. Health care providers also have discovered the benefits of MBSR for themselves, reducing their own occupational and personal stress. Mindful medical providers may be better able to listen attentively to patient concerns and to respond with greater patience and compassion, both improving the quality of care and saving patients from the additional burden of feeling misunderstood or disregarded by medical staff. In addition, staff who may not provide direct care often interact with patients within the larger health care system as well, addressing patient billing, health insurance, and scheduling needs. Although many staff might benefit from mindfulness training programs within the health care setting and such direct benefits could indirectly improve patient encounters, the original intensive MBSR curriculum is likely too demanding to implement for staff within the busy workplace. For these reasons, the MBSR curriculum was adapted into 6 weekly 75-minute training sessions held during staff members' lunch break. Preliminary feedback received from staff participants was highly favorable, suggesting that this abbreviated protocol may be feasible and acceptable to implement within the health care workplace setting.

MINDFULNESS-BASED STRESS REDUCTION IN MEDICAL SETTINGS

Jon Kabat-Zinn developed MBSR in 1979 at the University of Massachusetts (UMass) Medical School for medical patients suffering from the stress of chronic pain and illness. This 8-week intensive course teaches mindfulness meditation and mindful movement practices over 25 to 30 hours of class instruction. Early research from the original UMass stress reduction clinic documented clinical benefits of MBSR for patients with chronic pain.1,2 Dozens of randomized controlled trials conducted since have documented the efficacy of MBSR for a wide variety of medical conditions, and a number of systematic reviews and meta-analyses now support this intervention approach.3–6 As mind-body medicine treatment approaches became widely adopted in medical settings across the United States, MBSR was implemented in hundreds of medical settings worldwide for the management of many medical conditions. In addition, recent research has established the efficacy of MBSR to reduce negative emotions and to promote health and well-being among community samples,7,8 and meta-analysis of studies conducted among healthy adults supports this practice as well.9

As Kabat-Zinn10 developed and implemented MBSR, he identified a common source of patient stress that was not directly related to their medical conditions: many patients reported feeling disregarded, not heard, or dismissed by health care staff during the course of diagnosis and treatment of their medical conditions. MBSR therefore provided patients not only a means of coping with the stress of physical pain and illness, but also for coping with distress following difficult interpersonal interactions with health care providers and staff—many of whom were likely struggling with occupational or personal stressors of their own. As MBSR became popular within the UMass Medical School, physicians, nurses, and other health care staff began to attend MBSR classes themselves to reduce their own stress and to optimize their own health and well-being.11 A growing body of research has shown that MBSR reduced stress and burnout among various groups of health care providers, including physicians, nurses, social workers, physical therapists, psychologists, medical students, and psychotherapists in training.12 Indeed, a recent meta-analysis of 38 randomized controlled trials concluded that mindfulness training reduced anxiety, depression, psychological distress, and stress among health care professionals.13 In addition to preserving health care staff's availability to continue providing services, mindfulness staff training may improve the quality of provider-patient interactions and directly improve the quality of care provided to patients.14 One systematic review of MBSR research conducted with health care professionals specifically examined such emotional competencies and found evidence that MBSR might improve provider empathy.15 Therefore, implementation of MBSR and mindfulness training programs for health care staff themselves may improve the quality of care delivered in medical settings.

DEVELOPMENT OF THE CURRENT TRAINING PROGRAM

Although mindfulness training programs have been studied among medical students, nurses, and other health care providers, such programs tend to be time-intensive and therefore difficult to implement. Program curricula may require considerable abbreviation and adaptation if the mindfulness training is to be offered to health care employees during the course of the workday within the health care setting. Furthermore, inclusion of staff who do not provide direct medical services yet regularly interact with patients may support larger system integration of holistic nursing values into the entire health care setting as a whole. The abbreviated MBSR training program described later was developed with these issues in mind and was provided to a group of medical clinic staff including not only nurses, but also staff who worked with low-income patients to address medical billing concerns and to provide patient support in accessing medical insurance.

This training program was delivered to staff within a large nonprofit community medical clinic that provides comprehensive health care to low-income individuals. Clinic administrators had become concerned about the high levels of stress experienced by all clinic employees who worked with patients—not only nursing staff and others who provided medical care, but also staff who helped patients secure insurance coverage or other funding for their medical care. Familiar with the published benefits of MBSR, clinic administrators approached the author, an MBSR instructor and researcher, to develop and provide MBSR training to a pilot group of clinic staff. Two practical restrictions for the training program were identified: (1) staff would not be asked to attend the training outside their normal workday hours, and (2) to provide the training to all staff at once, the training could not take place when their office was open to patients. As a result, the training was scheduled to take place during 6 weekly 75-minute staff lunch breaks, with the understanding that employees would have the opportunity to eat their lunch during the training sessions. The instructor arranged for the 75-minute lunch periods with clinic administrators beforehand to accommodate the MBSR training program.

After an initial 75-minute presentation modeled after the standard introductory MBSR orientation, 5 clinic staff members elected to attend the 6-week abbreviated MBSR training program. The purpose of this report is to describe how the original MBSR curriculum was adapted to meet clinic staff needs and describe preliminary staff feedback suggesting high levels of staff satisfaction and acceptability of this mindfulness training program. Results from this initial pilot group are reported following an institutional review board human subjects determination review that allowed for the publication of staff feedback. The reader is referred to Kabat-Zinn10 for descriptions of each MBSR practice and activity mentioned next.

PROGRAM IMPLEMENTATION

Session 1 curriculum

The first training session began with introductions and an overview, followed by an opening meditation inviting staff members to reflect on their intentions for participation. After a silent 15-minute lunch eating meditation, staff members were guided through a brief awareness of breathing sitting meditation and the MBSR body scan meditation. After discussion of experience with these practices, staff members were given CD recordings of guided practice instructions and asked to complete the 9 dots exercise, to practice the body scan and a brief awareness of breathing meditation each day, to eat one meal mindfully, and to practice bringing mindfulness to daily activities.

Session 2 curriculum

The second training session began with awareness of breath and body scan meditation practices, followed by a brief mindful movement-guided practice. Staff members practiced mindfulness of the body while standing and while engaging a few simple hatha yoga body movements. After the silent 15-minute lunch and subsequent discussion of staff members' meditation practice, the instructor introduced the acronym STOP (S = Stop; T = Take a breath; O = Observe; P = Proceed) as a means of bringing mindfulness into daily life. She also invited discussion of experience with the 9 dots exercise and the role of perception in stress. In addition to repeating the previous week's practice schedule and trying the STOP informal practice, staff members were asked to complete the pleasant events calendar.

Session 3 curriculum

The third training session began with formal sitting meditation practice, as the instructor guided staff members through awareness of breath, whole body breathing, and mindfulness of body sensations meditation instructions. Mindful movement practice with additional hatha yoga poses immediately followed. After the silent lunch and group discussion of practice experiences, staff members shared their discoveries from completing the pleasant events calendar. Staff members continued with guided body scan practice and sitting meditation home practice over the next week, while continuing to work with the STOP practice and bringing mindfulness to additional routine daily activities. They were also asked to complete the unpleasant events calendar over the week.

Session 4 curriculum

The fourth training session began with formal practice of the full MBSR sitting meditation sequence: awareness of breath, body sensations, sounds, mind states/thoughts and emotions, and opening into “choiceless awareness,” in which staff members anchored the focus of attention in the present moment itself while observing various types of mental phenomena passing by without becoming caught up in them (eg, sensory experiences, interoceptive body sensations, sounds, and thoughts). After a brief self-guided stretching mindful movement practice, staff members ate their lunch in silence. After group discussion of the practice, staff members described their experiences with unpleasant events and the instructor presented information on the nature of stress reactivity and the possibility of responding to stressful events with mindfulness. Home practice included the guided sitting meditation recording, continued practice of STOP and mindfulness in routine activities, and bringing mindfulness to times of stress reactivity in the course of daily life. Staff members also were given the difficult communications calendar to complete.

Session 5 curriculum

The fifth training session included formal sitting meditation practice ending with lovingkindness meditation instructions. Staff members also received formal walking meditation instructions. After the silent lunch and group discussion of practice, review of the difficult communications calendar led to further discussion about the nature of stress reactivity and the possibility of skillful responding with awareness. Staff members were invited to practice mindfulness formally on their own without the recordings over the next week while continuing to bring mindfulness into routine activities. Staff members also practiced bringing mindfulness to stressful situations with STOP and to practice deliberate responding whenever possible. Staff members also were invited to notice what they chose to take into their systems over the next week, including food and drink as well as media, sensory input, and encounters with other people.

Session 6 curriculum

The final session began with the changing seats exercise, followed by a silent sitting meditation practice in which staff members chose the meditation object of focus for themselves. After the silent lunch period, the instructor provided information about further mindfulness resources. The session ended with discussion of staff members' experience with the training program. Staff members also described ways in which they intended to continue their mindfulness practice, including daily use of the STOP practice, regular periods of awareness of breathing meditation, and use of the CD recordings at home.

STAFF MEMBER FEEDBACK PROVIDED

All 5 staff members who began the mindfulness training program completed the training. At the final training session, staff provided anonymous written feedback about the program individually. All staff members also verbally described their training program experience with the instructor during the final group session.

QUALITATIVE REPORT DESCRIPTIONS

All staff members conveyed a very favorable impression of the program, reporting that they benefitted from attending the training and expressing gratitude that they could attend the training during their workday. As examples, one staff member noted approaching situations in which she does not have control more skillfully; another staff member noted responding to stressful situations much more calmly; a third staff member mentioned how greater awareness in her personal life allowed her to see things from a different perspective and to enjoy life more. One staff member also mentioned that participating in the group format was especially valuable, often revealing that others had shared experiences or feelings and providing peer social support.

QUANTITATIVE ITEM RATINGS

At the end of the program, 3 of the 5 staff members also completed ratings of the mindfulness program on a 0- to 10-point scale and answered more specific questions about their practice. All 3 staff members reported ratings of 8, 9, or 10 on each of the following questions: (1) How helpful was this stress reduction class for you? (2) Has this stress reduction class reduced your overall level of stress? (3) Have you noticed improvement in the ways you handle stressful events in your life? (4) Has this stress reduction class improved your overall quality of life and/or enjoyment of life? See the Table for specific item ratings from each of these 3 participants.

TABLE. - Individual Participant Ratings for Each Question Asked at the End of the Mindfulness-Based Stress Reduction Program
Participant How Helpful? (0-10) Reduced Overall Level of Stress? (0-10) Improvement in Handling Stress? (0-10) Improved Quality/Enjoyment of Life? (0-10)
#1 10 8 9 9
#2 10 10 10 10
#3 10 8 8 9

Awareness of breathing was identified as the formal meditation practiced most often. Two staff members reported practicing 3 to 5 times per week and 1 reported practicing 1 to 2 times per week. All 3 staff members endorsed frequent daily informal mindfulness practice, including mindfulness of everyday activities, the STOP acronym, and awareness of pleasant or unpleasant activities, difficult communications, and stress reactivity.

CONCLUSIONS

Preliminary feedback from this pilot program suggested that MBSR might be adapted to meet the practical needs of health care staff while reducing stress and improving their quality of life. Holistic models of health that view the patient as a whole person might be expanded even further to address the health and well-being of the staff that serve them. This broader approach views the entire medical delivery system as a whole system with potential outcomes of optimal functioning and resilience. Clinic administrators and nurse managers responsible for creating a healthy work environment for all staff might incorporate accessible mindfulness training programs to improve staff welfare while possibly improving patient engagement with staff. Abbreviated forms of MBSR, when provided as staff training opportunities within the health care setting workplace, may enhance the health and well-being of all staff, not only those staff providing direct medical services. Thus, mindfulness training may improve interactions patients have with staff members meeting their administrative needs as well as with staff caring for their medical needs. Research examining the implementation and effectiveness of such abbreviated mindfulness training programs for nursing and other health care system staff is needed to inform future efforts.

REFERENCES

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Keywords:

health care staff; MBSR; meditation; mindfulness

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