paving the path to mindfulness: implementation of a
TRANSCRIPT
PAVING THE PATH TO MINDFULNESS: IMPLEMENTATION OF A PROGRAM TO
REDUCE STRESS AND BURNOUT IN INPATIENT PSYCHIATRIC NURSES
Kristin Elizabeth Rush
A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice in the School
of Nursing in the University of North Carolina.
Chapel Hill 2018
Approved by:
Grace Hubbard
Cheryl Giscombe
Robert Cameron
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© 2018 Kristin Elizabeth Rush
ALL RIGHTS RESERVED
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ABSTRACT
Kristin Elizabeth Rush: Paving the Path to Mindfulness: Implementation of a Program to Reduce Stress and Burnout in Inpatient Psychiatric Nurses
(Under the direction of Grace Hubbard)
Background: Inpatient psychiatric nurses experience high levels of stress and burnout
contributing to negative healthcare outcomes. Although evidence supports a high prevalence of
burnout, very few programs have been implemented to target prevention of stress and burnout in
psychiatric nurses.
Purpose: The purpose of project was to evaluate the helpfulness of a four-week
mindfulness program designed to reduce stress and burnout in psychiatric nurses working on
locked inpatient units.
Methods: This evaluation was formative in nature to assist in the development and
implementation of a four-week mindfulness program. The primary outcome measures were the
effectiveness of program content and the learning platform. A secondary outcome measure
assessed the barriers to and facilitators of the program. These outcomes were measured through
collection of quantitative data from an anonymous online survey and qualitative data obtained
through a focus group.
Results: Twenty-two psychiatric inpatient nurses enrolled in the program in a large
Southeastern hospital in the United States. Sixteen nurses completed the final survey with the
majority composition being female, working on day shift, and ranging from age 20 to 61+ years.
The majority of the participants either agreed or strongly agreed that the program content was
helpful (87.5%) and the learning platform was feasible (90.6%).
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Conclusion: The data suggests that the majority of the participants found this
mindfulness program worthwhile and useful. The information derived from this formative
evaluation provided guidance for continued development of the program with intent to make the
program available through the hospital intranet.
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To the psychiatric nurses devoted to improving the lives of patients through genuine care and compassion.
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ACKNOWLEDGEMENTS
I would like to express deep gratitude to Dr. Grace Hubbard for providing her guidance
on the development and execution of this project. Her contributions to this project are very much
appreciated and it was a true privilege to work together. I would also like to thank my committee
members, Dr. Cheryl Giscombe and Robert Cameron, who provided valuable feedback and
support throughout my research.
Additionally, I would like to thank my family and friends for their unwavering support
and understanding. Special thanks goes to my husband, John, who has unconditionally provided
me with love and encouragement through every twist and turn of my educational journey.
Finally, I would like to acknowledge my mother, Sherry, who has always believed in me and
lovingly made me into the person I am today.
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TABLE OF CONTENTS
LIST OF FIGURES .........................................................................................................................x
LIST OF ABBREVIATIONS ........................................................................................................ xi
CHAPTER 1: INTRODUCTION ....................................................................................................1
Background and Significance ..............................................................................................1
Problem Statement ...............................................................................................................1
Purpose Statement ................................................................................................................2
CHAPTER 2: REVIEW OF LITERATURE ...................................................................................3
Search Strategy ....................................................................................................................3
Background ..........................................................................................................................4
Effects of Stress and Burnout on Patient Safety ..................................................................5
Effects of Stress and Burnout on Nurses .............................................................................6
Effects of Stress and Burnout on Healthcare Systems .........................................................7
Mindfulness and Mindful Practice .......................................................................................7
Mindfulness Feasibility ......................................................................................................10
Mindfulness-Based Interventions ......................................................................................12
Program Evaluation ...........................................................................................................13
Limitations of Existing Research .......................................................................................14
CHAPTER 3: CONCEPTUAL MODEL.......................................................................................15
CHAPTER 4: PROJECT DESIGN ................................................................................................19
CHAPTER 5: METHODOLOGY .................................................................................................20
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Setting and Resources ........................................................................................................20
Study Participants ..............................................................................................................20
Key Stakeholders ...............................................................................................................20
Recruitment ........................................................................................................................21
Ethics and Human Subjects Permissions ...........................................................................21
Data Collection ..................................................................................................................21
Procedures for Project Implementation .............................................................................22
Program Module Overview................................................................................................23
Data Analysis .....................................................................................................................24
Barriers to Implementation and Sustainability ..................................................................25
Anticipated Resources and Budget ....................................................................................25
CHAPTER 6: RESULTS ...............................................................................................................26
Demographics ....................................................................................................................26
Helpfulness of Program Content and Learning Platform- Primary Outcomes ..................26
Barrier and Facilitators- Secondary Outcome....................................................................29
Website and Anecdotal Data ..............................................................................................29
CHAPTER 7: DISCUSSION .........................................................................................................31
Limitations .........................................................................................................................32
CHAPTER 8: RECOMMENDATIONS........................................................................................34
APPENDIX 1: LANGER’S MINDFULNESS-BASED MODULES ...........................................35
APPENDIX 2: WEEKLY TEMPLATE ........................................................................................36
APPENDIX 3: FLYER ..................................................................................................................37
APPENDIX 4: RECRUITMENT SCRIPT ......................................................................................3
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APPENDIX 5: INFORMATION SHEET .....................................................................................39
APPENDIX 6: QUALTRICS POST-EVALUATION SURVEY .................................................40
APPENDIX 7: BENNET’S HIERARCHY ...................................................................................43
APPENDIX 8: FOCUS GROUP QUESTIONS ............................................................................44
APPENDIX 9: AVERAGE TIME SPENT COMPLETING MODULES ....................................45
APPENDIX 10: TYPE OF DEVICE USED TO ACCESS WEBSITE .........................................46
REFERENCES ..............................................................................................................................47
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LIST OF FIGURES
Figure 1: Program Content Helpfulness ........................................................................................27
Figure 2: Learning Platform Feasibility .........................................................................................28
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LIST OF ABBREVIATIONS
IRB Institutional Review Board
KASA Knowledge, Skills, Attitudes, and Aspirations
LPN Licensed Practical Nurse
MBCT Mindfulness-Based Cognitive Therapy
MBI Mindfulness-Based Intervention
MBSR Mindfulness-Based Stress Reduction
PMH Psychiatric-Mental Health
RN Registered Nurse
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CHAPTER 1: INTRODUCTION
Background and Significance
Psychiatric-mental health (PMH) nurses are faced with unique challenges when providing
care for patients on locked psychiatric units. These challenges often lead to stress and burnout
with 21% to 67% of PMH nurses experiencing high levels of burnout (Morse, Salyers, Rollins,
Monroe-DeVita, & Pfahler, 2012). These high levels of stress and burnout may contribute to
negative outcomes for patients, nurses, and the healthcare system (Dreison, 2016; Hanrahan,
Aiken, McClaine, & Hanlon, 2010; Khamisa, Peltzer, & Oldenburg, 2013; Morse et al., 2012).
Stress and burnout in nurses can significantly impact nursing practice and the quality of
health care for patients. In addition, stress and burnout are associated with increased nursing
errors, higher patient mortality rates, and decreased patient satisfaction (Brady, O'Connor,
Burgermeister, & Hanson, 2012; McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Welp,
Meier, & Manser, 2015). The sustained effects of stress and burnout contribute to physical and
psychological symptoms such as depression in nurses who work in hospitals (Letvak, Ruhm, &
McCoy, 2012). As a result of these effects, the nurse’s ability to form a therapeutic relationship
with patients is decreased (Salyers, Flanagan, Firmin, & Rollins, 2015) potentially resulting in
increased risk for adverse patient outcomes, including violent behavior (Bowers, Brennan, Flood,
Lipang, & Oladapo, 2006; Salyers et al., 2015).
Problem Statement
Although evidence supports a high prevalence of burnout, very few programs that target
or offer stress prevention and burnout in PMH nurses have been implemented (Morse et al.,
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2012). Mindfulness training offers promising benefits in reduction of stress and burnout in PMH
nurses who work in these settings (Aikens, 2014; Burton, Burgess, Dean, Koutsopoulou, &
Hugh-Jones, 2016; Kemper, Mo, & Khayat, 2015).
Purpose Statement
The purpose of this project is to develop and evaluate the helpfulness of a four-week
mindfulness program designed to reduce stress and burnout in PMH nurses working on locked
inpatient units.
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CHAPTER 2: REVIEW OF LITERATURE
Search Strategy
The review of literature includes available evidence regarding stress and burnout in PMH
nurses and the efficacy of mindfulness to address the problem. Although this literature review is
not meant to be exhaustive, PRISMA guidelines were used to direct and guide the literature
search (Liberati et al., 2009). Several databases were searched to find relevant articles addressing
the identified problem including CINAHL, Google Scholar, MEDLINE, PsycINFO, and
PubMed. Various combinations of key words were used to search for articles to include
“burnout, stress, psychiatric-mental health nurse, healthcare provider, mindfulness, mindfulness-
based intervention, MBSR, psychiatric, and safety.” Articles were sorted by relevancy and then
screened by title and abstract. The initial search was completed on October 3, 2016 with a date
limitation of articles published between the years of 2011 and 2016 which yielded 408 articles
after removal of duplicates. Subsequent searches used various combinations of key words
relevant to the literature review without a date limiter and the last search was completed on
November 17, 2016 and articles were screened by title and abstract. Published, peer-reviewed
articles were included if they were relevant to the review of background information,
investigation of the identified problem or the potential efficacy of mindfulness as an intervention.
Articles were excluded if written in a language other than English or the outcomes measured did
not include stress or burnout. After removal of duplicates in subsequent searches, a total of 59
articles were included in the review of literature.
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Background
The demands of professional nursing are inherently stressful regardless of setting. All
nurses provide care and support to patients and families who suffer physically and
psychologically to provide care and support (Smith, 2014). Nurses play a major role in
multidisciplinary healthcare teams, and they must balance their commitment as advocate for
patient needs with both personal values and workplace obligations or policies. The demands of
cost reduction in healthcare, patient acuity and complexity, increased workload and nursing
shortages also contribute to the work-related stress experienced by nurses (Dreison, 2016;
Khoury, 2015; Madathil, Heck, & Schuldberg, 2014). Nurses experience higher levels of stress-
related burnout compared to other colleagues in healthcare (Khamisa et al., 2013).
Burnout is defined as a psychological triad consisting of emotional exhaustion,
depersonalization and a diminished sense of personal accomplishment (Maslach, Jackson, &
Leiter, 1996; Maslach & Leiter, 2016). Emotional exhaustion or a feeling of being overextended
may lead to depersonalization in which one has a negative, cynical or detached attitude towards
patients (Maslach & Leiter, 2016; Maslach, Schaufeli, & Leiter, 2001). Stress can be defined as,
“…a negative emotional experience accompanied by predictable biochemical, physiological, and
behavioral changes that are directed toward adaptation either by manipulating the situation to
alter the stressor or by accommodating its effects” (Baum, 1990, p. 653). The acute stress
response functions to prepare the body to respond to a perceived environmental danger, but the
sustained effects of stress can contribute to physical and psychological problems such as anxiety,
insomnia, muscle pain, hypertension and a suppressed immune system (Baum & Posluszny,
1999).
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The occurrence of burnout is influenced by situational factors and individual factors.
Situational factors include characteristics of the job, occupation and organization; individual
factors include characteristics of demographic variables, personality and job attitudes (Bakker &
Costa, 2014; Maslach et al., 2001). Nurses who experience persistent stress and lack the ability
to effectively manage job demands have a greater propensity to develop burnout (Maslach &
Leiter, 1997). Leading situational factors that cause burnout and contribute to job demands
include workplace role dilemmas, stressful encounters, workloads and occupational pressure
(Bakker & Costa, 2014). Inadequate job resources, such as decreased social support, are
associated with higher levels of exhaustion and burnout. However accessible job resources,
including performance feedback or opportunities for development, may buffer the effects of
burnout (Gandi, Wai, Karick, & Dagona, 2011). Leadership styles of supervisors may protect
against (or contribute to) burnout and turnover of nurses (Madathil et al., 2014). Individual
factors, such as personality style and socioeconomic status may increase the predisposition to
burnout (Bakker & Costa, 2014). Personality characteristics including high self-efficacy,
optimism and self-esteem are better protected against development of burnout, whereas people
who have an external locus of control or avoidant coping styles have higher levels of burnout
(Bakker & Costa, 2014; Maslach et al., 2001). Additionally, individuals who are younger are
more likely to experience burnout at the beginning of their career since age is associated with
amount of work experience (Maslach et al., 2001).
Effects of Stress and Burnout on Patient Safety
The concern for patient safety remains in the forefront of healthcare years after the
Institute of Medicine (2000) report, To Err is Human. This report mandated significant changes
be made to reduce errors related to patient care. A study linking burnout and patient safety found
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that emotional exhaustion (one dimension of burnout) on intensive care units independently
predicted higher standardized mortality ratios (Welp et al., 2015). High levels of stress and
burnout have been shown to be related to nursing errors that are provoked by multiple
interruptions, stringent documentation requirements, habitual patterns of thinking, and decreased
ability to concentrate or focus (Brady et al., 2012; Hanrahan & Aiken, 2008). Perceived nursing
errors have also been attributed to heavy workloads, inexperience, lack of supervision and
communication problems (Karga, Kiekkas, Aretha, & Lemonidou, 2011). In addition to patient
safety, lower patient satisfaction scores are associated with high levels of nurse burnout
(McHugh et al., 2011). This combined evidence supporting an increase in nursing errors and
lower patient satisfaction indicate that nursing stress and burnout may contribute to a reduced
quality of care.
Effects of Stress and Burnout on Nurses
According to the American Nurses Association (2011) survey of nurses regarding the
health and safety of their work environments, the number one concern was the acute and chronic
effects of stress and overwork. The North American Nursing Diagnosis Association states the
inability to cope with stressors can result in difficulty in meeting role expectations, organizing
information, concentration, problem-solving, and communication patterns (Herdman, 2012).
Nurses can experience detachment as a result of burnout, which can negatively impact
the therapeutic relationship (Salyers et al., 2015). A compromised relationship with patients
places staff members at greater risk for aggressive and violent acts by patients (Bowers et al.,
2006; Whittington & Wykes, 1994). Compared to nurses on medical or surgical units, PMH
nurses report higher rates of verbal abuse, physical injuries and medication errors (Hanrahan &
Aiken, 2008).
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Effects of Stress and Burnout on Healthcare Systems
The concept of the Triple Aim, an approach to improving health system performance
through improved patient satisfaction, cost effective care, and optimal patient outcomes, has
spread across health care systems and become the framework of practice. However, the
widespread reports of burnout experienced by health care providers potentially compromises the
Triple Aim due to the negative influence of provider burnout on patient satisfaction and health
outcomes (Bodenheimer & Sinsky, 2014). This awareness has resulted in the recommendation
of a new dimension in which improvement of the work life of healthcare providers is the focus –
therefore, the Triple Aim has become the Quadruple Aim (Agency for Healthcare Research and
Quality, 2015).
Stress and burnout have been linked to nurse turnover rates which can cost healthcare
organizations a substantial amount (Oyeleye, Hanson, O'Connor, & Dunn, 2013). According to
the “National Healthcare Retention Survey,” by Nursing Solutions Inc. (2016), PMH nurses have
a higher turnover rate compared to other specialty nursing areas and demonstrated a 57.2%
turnover rate in 2014 and 2015. The estimated turnover cost associated with each bedside
registered nurse ranges from $22,000 to $64,000 (Nursing Solutions Inc., 2016; Oyeleye et al.,
2013). It is essential to address the mental health and well-being of PMH nurses as the workforce
continues to age and the nursing shortage becomes more critical (Oyeleye et al., 2013).
Mindfulness and Mindful Practice
An emerging topic in research involves the use of mindfulness, cultivated out of Buddhist
and other ancient traditions, to improve health outcomes and reduce burnout (Aikens, 2014;
Burton et al., 2016; Kemper et al., 2015). Several studies support the use of mindfulness to
address stress and burnout (Aikens, 2014; Burton et al., 2016; Cohen-Katz et al., 2005; Khoury,
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2015; Mackenzie, Poulin, & Seidman-Carlson, 2006; Shapiro, Astin, Bishop, & Cordova, 2005).
Mindfulness is also gaining popularity in many well-known companies who have created
workplace programs to increase mindfulness in their employees including, Google, Aetna,
General Mills, Intel, and Target (Schaufenbuel, 2015).
One definition of mindfulness made popular by Kabat-Zinn (2003) is the practice of
purposefully paying attention nonjudgmentally in the present moment. Similarly, Langer (1989)
defines mindfulness as a flexible state of mind in which one is anchored in the present moment
by engaging with novel ideas while paying attention to context and variability.
As mindfulness spreads across a variety of fields and continues to become more
mainstream it is important to discern the nuances of mindfulness. The Mindfulness-Based Stress
Reduction (MBSR) program, developed by Kabat-Zinn (2003), is heavily focused on meditation
to support mindfulness practice in which one attempts to become aware of thoughts, situations,
emotions, and every day experiences. Ellen Langer’s (1989) application of mindfulness is
somewhat different. This perspective allows one to register his or her thoughts and actions
immediately, mindfully processing the present moment. The term mindful indicates that one
approaches a situation taking note of change and is open to new ideas and perspectives (Langer,
2016). Langer (2014) supports the use of meditation, but believes that it is a tool to achieve a
post-meditative mindfulness.
Langer’s initial research used a geriatric population in a nursing home in Connecticut
(Langer, 1989; Langer & Rodin, 1976). Elders in this community were given mindful choices to
make about their daily life, for example how to arrange their furniture in their room. They were
also given the option to choose a small plant to take care of. This emphasis on freedom to make
decisions and personal responsibility proved to increase the resident’s alertness, participation and
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general sense of well-being. This study led Langer to question the true value of choice related to
health and cascaded her research about mindfulness.
Cultivating a mind-state to decrease stress and burnout can be achieved by a variety of
methods. Stress and burnout as described by Maslach et al. (2001) can be caused by a variety of
factors including individual and system factors (Bakker & Costa, 2014). The meta-analysis by
Dreison (2016) examined the effectiveness of burnout interventions in mental health providers
and found person-directed interventions more effective than organizational interventions,
supporting the use of an intervention to modify the individual rather than attempting to modify
the work environment. Attempting to eliminate stress in the work environment is not realistic
and therefore directs investigation to evidence-based research that focuses on individual
interventions such as mindfulness.
Randomized controlled studies using the intervention of mindfulness have demonstrated
an increase in mindful practice and decreased burnout among nurses (Cohen-Katz et al., 2005;
Mackenzie et al., 2006; Shapiro et al., 2005). Mindfulness can transform the response to a
stressor by shifting focus to awareness of one’s thoughts, feelings, and bodily sensations in the
present moment without self-criticism (Burton et al., 2016). The integration of mindfulness has
the potential to allow one to skillfully respond to negative stressors, leading to burnout, while
resisting the autopilot reaction conditioned by past experiences (Aikens, 2014; Shapiro et al.,
2005).
Aikens (2014) examined the efficacy of a mindfulness workplace program through use of
a randomized control study and produced a medium to large effect size on mindfulness,
perceived stress, resilience, vigor and work engagement. This seven-week program combined
instruction in various formats including live and virtual instruction that focused on different
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themes of mindfulness such as focus on breath or body scanning (Aikens, 2014). Khoury (2015)
evaluated the use of mindfulness in nonclinical populations in a meta-analysis of 2660
participants and found a small effect size on burnout and a large effect size on stress. A recent
meta-analysis evaluating the effectiveness of mindfulness based interventions reported a medium
effect size on stress among healthcare providers (Burton et al., 2016). A review of literature
specifically examining available evidence regarding mindfulness based stress reduction
programs on nurses identified 13 studies of which 6 included practicing registered nurses,
identifying the need for future research in this population (Smith, 2014).
A variety of evidence supports the efficacy of mindfulness in reducing the psychological
distress of those experiencing stress and burnout. Important consideration must be taken when
exploring the various perspectives of mindfulness. To avoid a one size fits all approach,
mindfulness-based interventions must be tailored and readily accessible to the population of
PMH nurses.
Mindfulness Feasibility
One of the most well-known mindfulness programs was developed by Jon Kabat-Zinn
from the University of Massachusetts Medical Center (Kabat-Zinn, 2003). The MBSR program
is designed as an eight-week program with weekly meetings for a two and one-half hours, in
addition to an all-day retreat for six hours (Khoury, 2015; Shapiro et al., 2005). Other forms of
therapy that have incorporated mindfulness include Mindfulness-Based Cognitive Therapy
(MBCT), Dialectical Behavior Therapy, and Acceptance and Commitment Therapy (Spijkerman,
Pots, & Bohlmeijer, 2016), with MBSR remaining the program with the most research (Burton
et al., 2016; Lamothe, Rondeau, Malboeuf-Hurtubise, Duval, & Sultan, 2016; Smith, 2014).
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MBSR delivered in an eight-week format is not feasible for many healthcare providers
whose work schedules may be restrictive and could result in a high attrition rate (Burton et al.,
2016). Furthermore, organizations place high demands by employees to effectively use their time
in patient care delivery. Research studying alternative formats and sites have found positive
outcomes. For example, a shortened MBSR program of four weeks demonstrated a statistically
significant increase (p<.05) in the measurement of mindfulness before (M=28.75, SD=9.6) and
two months after (M=36.25, SD=9.6) (Hallman, O'Connor, Hasenau, & Brady, 2014). Similarly,
Aikens (2014) study demonstrated that a shortened web-based mindfulness program can produce
comparable results to a traditionally delivered, eight-week, in-person MSBR program.
Adaptation of the traditional MBSR format promotes increased access to the intervention.
Reasons for attrition in previous studies with healthcare providers include work-related
pressures and a shifting work schedule (Burton et al., 2016). Additionally, one study reported
that initial engagement in the program was low due to inability to express to participants the
value and benefit of participating (Bazarko, Cate, Azocar, & Kreitzer, 2013). In order to combat
high attrition and lack of engagement, the meta-analysis by Burton et al. (2016) reported that
some studies incentivized participants by offering a gift of low monetary value, education
credits, or payment for work time. Based on the previous studies, findings suggest that it may be
helpful to identify key champions at the implementation site to educate candidates. These
champions will positively influence the desire to participate as others will want to emulate
engaging behavior. The use of familiar employees from within the department and face-to-face
enrollment strategies produces more favorable response rates (Khamisa, Peltzer, Ilic, &
Oldenburg, 2014). Additional measures to promote engagement include utilization of nursing
management in the recruitment and data collection process to increase response rates (Khamisa
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et al., 2014). Addressing these issues upfront will enable better resolution of the larger issue
which is the degree of participant burden (Newington & Metcalfe, 2014).
Mindfulness-Based Interventions
Although many studies evaluating Mindfulness-Based Interventions (MBI)s do not report
all details regarding intervention, patterns of study characteristics can still be examined. Many
studies use varied lengths of MBSR producing positive results, but this makes it difficult to
determine what the minimal effective dose of the intervention should be (Burton et al., 2016;
Lamothe et al., 2016; Smith, 2014). Burton et al. (2016) examined nine research studies in their
meta-analysis of MBI’s and found a medium effect size on stress in healthcare providers. The
length of intervention ranged from 1 day to 10 weeks and included varying study designs of pre-
post intervention, quasi-experimental, and randomized control designs. Interventions included
mindfulness instruction (8 studies), meditation (6 studies), breathing exercises (3 studies),
yoga/stretching (4 studies), group discussion (4 studies), and homework (3 studies). All
participants were self-selected which may increase motivation and engagement of participants
contributing to positive effects of interventions (Burton et al., 2016).
Lamothe et al. (2016) investigated 39 studies in a systematic review of MBSR
interventions on healthcare providers. They found that MBSR decreased perceived stress in 95%
of the studies, decreased burnout in 53% of the studies, and increased mindfulness in 82% of the
studies. The length of intervention ranged from 1 week to 12 weeks. The majority of the
interventions were based on traditional MBSR but adapted to differing lengths and delivery
methods such as telephonic format (Lamothe et al., 2016).
One important meta-analysis to note examined the effectiveness of MBI delivered via
online platforms to clinical and non-clinical adult populations (Spijkerman et al., 2016). Methods
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of delivery included a smartphone application, a virtual online classroom and most commonly
web page documentation. Although findings demonstrated a small effect size on mindfulness, the
number of exposures to the intervention increased the effect size of mindfulness (Spijkerman et
al., 2016). The moderate effect size demonstrated in this meta-analysis for stress is comparable
to the traditionally delivered MBSR or MBCT meta-analysis by Gotink et al. (2015).
Overall these results offer promising outcomes for the use of MBI to decrease symptoms
of stress and burnout. The adaptions to broaden the range of delivery methods were
demonstrated to be effective and the use of internet platforms may appeal to a broader
population. Furthermore, evidence suggests that shortened mindfulness programs instead of a
traditional 8-week program produces comparable positive outcomes—deceasing the burden of
time commitment.
Program Evaluation
Program evaluation is defined as “the systematic collection of information about the
activities, characteristics, and outcomes of programs to make judgments about that program,
improve program effectiveness, and/or inform decisions about future program development”
(Centers for Disease Control and Prevention, 2012, p. 4). Types of programs include
interventions, policies, and specific projects. The goal of the program is to improve the health of
a population by evaluating what interventions or approach is best to address the problem.
Program evaluation may be guided by theory during development, but it is not intended to prove
or disprove the value of the guiding theory (Lowe & Cook, 2012). Further, the evaluation of
programs does not have to include randomized trials to be credible or of value. Program
evaluations are utilized to gain valuable lessons-learned allowing for continued development and
support of that program (Lowe & Cook, 2012).
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Limitations of Existing Research
There is a large body of evidence supporting prevalence of stress and burnout among
various healthcare workers, but most research regarding PMH nurses have been conducted
outside the United States limiting generalizability (Hanrahan et al., 2010; Madathil et al., 2014).
Further, evidence supports that research regarding interventions to reduce stress and burnout in
PMH nurses is significantly lacking (Morse et al., 2012). Inconsistency in research design and
methodology make it difficult to generalize results to other populations in healthcare (Khoury,
2015). An additional challenge is the absence of detail in reporting of interventions, which makes
it difficult to analyze what components of the intervention have the biggest impact (Burton et al.,
2016). The gap in knowledge regarding PMH nurse stress and burnout along with various
mindfulness interventions to ameliorate the problem calls for further investigation.
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CHAPTER 3: CONCEPTUAL MODEL
Ellen Langer, a social psychologist and professor at Harvard University, developed her
theory of mindfulness over several decades through application of the theory to various social
issues that include: prejudice, diversity, adoption and the art of aging (Demick, 2000; Kawakami,
White, & Langer, 2000; Langer, 2009; Langer & Moldoveanu, 2000a, 2000b). Langer’s (1989)
definition of mindfulness is a flexible state of mind in which one is anchored in the present
moment by engaging with novel ideas, while paying attention to context and variability. Langer’s
(1989) explanatory theory of mindfulness has a substantial base of research supporting the use of
her theory to increase mindful behavior (Carson & Langer, 2006; Langer, 1989). Langer’s
approach offers increased flexibility, and therefore feasibility, for application in settings with
restrictive work schedules like healthcare. Langer’s theory of mindfulness is quite simple,
noticing new things allows you to engage in the present moment increasing attention and
awareness (Langer, 1989).
Langer’s (1989) theory of mindfulness evolved by initially examining the concept of
mindlessness. This concept evolved from Langer’s experience dealing with a family member
who was in a health crisis. The healthcare providers quickly diagnosed the medical problem,
relying on previous experience without considering different interpretations of the chief
complaint. These preconceived categories may have interfered with their ability to break free
from habitual decision-making that resulted in the misdiagnosis of what was actually a brain
tumor later found during autopsy (Langer, 1989). This alarming personal experience motivated
Langer to conceptualize mindless behavior, “in the sense that attention is not paid precisely to
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those substantive elements that are relevant for the successful resolution of the situation”
(Langer, Blank, & Chanowitz, 1978, p. 636). In other words, mindlessness occurs when an
individual is “cognitively committed” to a rigid mindset based on previously categorized
experiences (Carson & Langer, 2006).
Langer’s mindfulness framework includes the central tenets: novelty seeking,
engagement, novelty producing and flexibility (Langer, 1989). Haigh, Moore, Kashdan, and
Fresco (2011) describe novelty seeking as the tendency to draw new and different distinctions
about one’s environment with an open and inquisitive approach. Open-minded awareness of
one’s environment is also associated with engagement so that one is able to notice relevant or
novel details which promote one to be focused in the present moment. Novelty producing allows
the individual to generate new categories, rather than relying on preconceived notions from past
experiences, in order to learn more about the environment. Finally, a flexible awareness
encourages one to welcome multiple perspectives and allows freedom to shift perspective based
on context (Haigh et al., 2011). In other words, the application of Langer’s tenets to a stressful
situation in which thinking and behavior have a tendency to become increasingly rigid, offers a
feasible approach to refocus on mindfulness, and allowing new and different perspectives for
conceptualizing one’s situation.
An example of how Langer has applied mindfulness to reduce stress can be examined in
her study with 60 surgical patients’ about to undergo a major surgery. Langer explains, that “...it
is rarely events themselves that cause stress, but rather the views people take of them and the
attention they give to those views” (Langer, Janis, & Wolfer, 1975, p. 158). Individuals who
were presented with the coping strategy of considering multiple perspectives demonstrated lower
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anxiety, a higher ability to cope and requested pain relievers and sedatives less frequently
compared to the control group.
Following this theory, interventions to increase mindfulness must encourage the participant
to identify new ideas to increase engagement in the present moment. This can be done by simply
identifying five new things about an object or person, which in turn makes it easier to pay
attention or adjust focus to what is being noticed. For example, patients often experience varying
levels of emotions throughout the day which can go unnoticed if the focus is solely on the task at
hand. Taking the time to notice five new things about how a patient might appear different from
the last interaction can help identify escalating behavior or a change in mood and challenge
habitual thinking. The mindful interaction with the patient makes the therapist appear more
charismatic and authentic, producing genuine communication in which the patient feels cared for
(Carson & Langer, 2006; Langer, 1989). An example of how mindfulness can lead to a positive
outcome is the mistake made by a company called 3M when they were trying to make glue. The
glue failed to adhere which could be viewed as a mistake or failure, but instead the company
engineers began to problem solve what could be done with a glue that does not completely
adhere. Noticing how the product was different from their intention, they were able to creatively
problem solve leading to the successful invention of Post-it notes (Langer, 1989).
A limitation of this theory may be its lack of explicit interventions to impact mindfulness.
Brown, Ryan, and Creswell (2007) suggest that Langer’s theory is more of a cognitive style in
which you examine perceptual inputs from the external environment and subsequently suggest
that one should also be receptive to internal reality. To address both internal and external
realities, an intervention such as body scanning might be used. This technique guides the
participant to focus on individual parts of his/her body starting at the head and then moving
18
down the body in a non-judgmental way. The body scan allows one to experience sensation of
different parts of the body, alternating between a wide and narrow focus of attention without
trying to change anything (Sauer-Zavala, Walsh, Eisenlohr-Moul, & Lykins, 2013).
Langer’s approach to MBI lends itself well to the context of inpatient psychiatric units. Her
lack of specific protocols allows flexibility and adaptability to a wide array of situations. In a
sense, Langer gives the end-user the tools to cultivate an environment that encourages creativity
and growth in the skillful application of mindfulness. Enhancing present awareness through
mindful practice can allow PMH nurses on inpatient units to tune into the milieu, quickly
attending to subtle changes in patient behavior or mood, cultivating a safe environment.
19
CHAPTER 4: PROJECT DESIGN
This Doctor of Nursing Practice scholarly project was a formative program evaluation of
a four-week mindfulness program that addressed stress and burnout. The formative evaluation
design was chosen as being the most useful during the development and implementation of a
new program. This type of evaluation facilitates determination of feasibility and provides
feedback for future improvements (Taylor-Powell, Jones, & Henert, 2003). A logic model was
used as a graphic depiction to conceptualize preliminary planning and the process of
implementation. The logic model served to articulate understanding of the current situation, the
changes desired through the program effort, the activities planned to promote the change, the
resources needed for the initiative, and external factors that might influence outcomes (Appendix
1). In addition, Bennett’s Hierarchy was utilized to guide overall program evaluation, with an
emphasis on linkage of program outcomes to evaluation questions (Bennett, 1976; Radhakrishna
& Relado, 2009). Program outcomes included the extent to which (1) the program increased
awareness of Ellen Langer’s tenets of mindfulness, (2) modules feasibly delivered content, and
(3) knowledge gained from the program was demonstrated through integration of mindfulness
practice in the work site. Outcome measures included participant evaluation of content
helpfulness of each of the four modules, ease of use with the learning platform, and discussion of
barriers to and facilitators of the program. These outcomes were measured through collection of
quantitative data from a post-evaluation survey and qualitative data obtained through a focus
group.
20
CHAPTER 5: METHODOLOGY
The four-week mindfulness program included online content with specific mindfulness
practice strategies supported by Ellen Langer’s (Langer, 1989) four central tenets of mindfulness
(novelty seeking, engagement, novelty producing and flexibility). A new module was developed
by the Project Lead and made available to participants for each of the four weeks through Google
Sites with access from any desktop or smart device. Each module was designed to have an
approximate duration of thirty minutes with a progressively building lesson plan (Appendix 2).
Setting and Resources
The setting for this project was three locked psychiatric units with 53 behavioral health
beds located in a large hospital in the Southeastern United States. The inpatient behavioral health
department serves child, adolescent, and adult patients who may be admitted under voluntary or
involuntary status. There were approximately 59 nurses (RN-49; LPN-10) staffing the units.
Other behavioral health staff included certified nursing assistants, social workers, recreational
therapists, physician assistants, nurse practitioners and psychiatrists.
Study Participants
Targeted study participants were licensed practical nurses (LPN) or registered nurses
(RN) working in a part-time or full-time capacity, who agreed to participate in the program, and
complete the data collection information process.
Key Stakeholders
Identification of champions at the implementation site facilitated organizational and
participant buy-in. A key stakeholder and champion was the nurse manager who supported the
21
need for additional resources to nursing staff experiencing stress and burnout. A second
champion was the corporate nurse scientist who served as a liaison between the hospital research
council and assisted in obtaining IRB approval. Additionally, a strong nurse leader on the unit
served as a champion to help with enrollment and buy-in from participants.
Recruitment
Participants were recruited from the pool of nurses assigned to these three units using
flyers on the unit, face-to-face interaction, and work email communication (See Appendices 3 &
4). The participants were provided with an information sheet to serve as consent to participate
(See Appendix 5). The nurse manager served as the onsite champion and strongly supported buy-
in from all leadership to encourage participant enrollment in the program.
Ethics and Human Subjects Permissions
Approval for this program evaluation was received from the Institutional Review Boards
(IRB) at Novant Health and the University of North Carolina at Chapel Hill.
Data Collection
Quantitative and qualitative data were collected. Quantitative data was obtained through
Qualtrics (2017), an online anonymous survey to collect data related to demographic profiles of
the participants, adherence to module instruction, content of the program, and evaluation of the
program’s helpfulness (See Appendix 6). Participants were asked to rate various aspects of the
modules to assess the impact of the program based on outcomes identified using Bennett’s
Hierarchy (Bennett, 1976) (See Appendix 7). Application of Bennett’s Hierarchy is discussed
further in the Program Module Overview section.
Qualitative data was collected using a focus group. The focus group was designed to
elicit information regarding barriers to and facilitators of the program, promote recognition of
22
common themes about participants’ experiences and develop of recommendations for
improvements (See Appendix 8).
Procedures for Project Implementation
Project implementation spanned a period of four weeks consisting of weekly lesson plans
designed to engage and immerse participants in mindfulness. Each module focused on different
aspects of Ellen Langer’s central tenets of mindfulness and provided a skill for participants to
practice during that week. The weekly template for instruction consisted of an overview of the
consequences of stress and burnout, Langer’s four tenets of mindfulness, using mindfulness in
everyday life, and integration of mindfulness into the workplace setting. The online modules
were delivered electronically via Google Sites. The modules provided suggestions for self-
reminders to practice mindfulness such as a smart phone application that could be downloaded at
no cost. Although initial email communication to recruit participants were sent through work
email, participants were given the option to provide a personal email address if they choose to
participate due to the lack of access to work email at home. Participants email addresses were
stored on a locked password protected laptop only accessible by the Project Lead. The
participants were emailed the website address and information sheet which described the
program purpose, procedures, confidentiality and what the participant should expect if they
chose to voluntarily participate (Appendix 5). Each week the participants were sent an email to
indicate availability of a new module and the website address for easy access. During week five,
participants were emailed an anonymous link to the post-evaluation survey and information
regarding the date, time and location of the focus group.
23
Program Module Overview
The content outline for this program (Appendix 2) was developed based on the basic
tenets of mindfulness by Ellen Langer. Each week was designed for the participant to practice a
skill that would enhance understanding of that week’s content. Week one presented participants
with the consequences associated with emotional, mental, and physical forms of stress and
burnout. The participants were also introduced to Ellen Langer’s four central tenets of
mindfulness through an engaging 22-minute video. The first concept for participants to practice
and apply was demonstrated through a hypothetical scenario in which highlighted the importance
of considering multiple perspectives. Participants were then asked to practice brainstorming at
least two different ways to interpret a stressful situation. Week two focused in greater detail on
the two tenets of novelty seeking and engagement. The concept of mindlessness, leading to
autopilot decision-making, was covered and explained the strategies of novelty seeking and
engagement as a solution behavior. Three strategies for implementation of novelty seeking and
engagement were provided - a rainbow walk noticing different colors, a walk in which different
sounds are noticed, and a brief body scanning exercise. All skills were designed to help the
participants practice making small shifts in their attention to become engaged with new details of
the environment. The third week discussed the tenets of novelty producing and flexibility to
assist participants with learning the concept of creating new categories of information while
welcoming multiple perspectives. Participants practiced strategies to transform the way they view
stress - changing bad stress to enhancing stress. The fourth and final week discussed integration
of mindfulness into the workplace. Provided with an example of how companies encourage
innovation, participants were introduced to strategies for integration of creativity in the
workplace. Key components of mindfulness were applied to a workplace scenario of a stressful
24
nursing assignment. Other examples for practice included making a mundane routine new in
small ways and noticing five new things about a patient encounter.
The logic model (Appendix 1) served as a graphic depiction which allowed the Project
Leader to consider input, activities and participation to develop the program modules. These
three components comprise the first steps in process evaluation of Bennet’s Hierarchy to
examine the ultimate impact of the program (See Appendix 7). Conceptualization of the logic
model guided the development of the four modules and determination of actual participants.
Additionally, the logic model allowed planning for short-term, intermediate and long-term
outcomes related to the Project. Both the logic model and Bennet’s Hierarchy were used to create
and plan the survey questions that were used to measure primary outcomes. Nine statements (11-
19) were designed to gather information regarding the primary outcome of content helpfulness.
These statements focused on knowledge, skills, attitudes, and aspirations (KASA) of the
participants related to mindfulness and Ellen Langer’s four tenets of mindfulness. Six statements
(20-25) were designed to collect data about the primary outcome of learning platform
helpfulness and the participant’s perceptions regarding ease of using the program.
Data Analysis
Quantitative and qualitative data were analyzed for evaluation of primary and secondary
outcomes. Quantitative data gathered from the Qualtrics survey to assess the primary outcomes
of program content and learning platform feasibility and usability were analyzed. Descriptive
statistics were used for analysis of demographics and program outcome data. Examples of
demographic data collected include: age, gender, number of years licensed as a nurse, number of
years employed in the psychiatric-mental health field, and job characteristics including full-time
25
or part-time status (Appendix 6). Tables and graphs were developed from the results to display
patterns in the data.
Qualitative analysis of data from the focus group examined the secondary outcome,
identification of barriers to and facilitators for the program format and content. These data were
reviewed for the presence of themes addressing the ease of use of the program.
Barriers to Implementation and Sustainability
It was anticipated two key barriers were participant engagement and demanding
healthcare productivity requirements. Participation in this program evaluation occurred through
self-selection and was not mandated. The Project Lead utilized key champions consisting of the
nurse manager and a strong nurse leader to promote the program. The learning platform and self-
paced module format were designed to increase potential for sustainability with a long-term goal
of inclusion in the hospital-based education program and the hospital’s intranet for on-going staff
development.
Anticipated Resources and Budget
Resources that were considered included staff time, the materials in the modules,
technology related to Google Sites, and computer or phone access.
26
CHAPTER 6: RESULTS
Demographics
Twenty-two nurses consented to participate in the program evaluation. Sixteen of the 22
nurses completed the post-implementation Qualtrics survey. Of these 16 nurses, 15 completed all
four modules. The nurse participants ranged in age from 20 to 61+ years old. The majority of the
sample was female (87.5%) and worked primarily on day shift (81.25%). There was no
representation from nightshift. Further, the majority (87.5%) of participants worked full time
(36-40 hours/week) and had 15 or less years of experience as a nurse in the psychiatric-mental
health field.
Helpfulness of Program Content and Learning Platform - Primary Outcomes
Statements 11-19 on the Qualtrics Survey asked participants to rate (strongly disagree-
strongly agree) whether the program content was helpful for increasing curiosity, paying
attention to small details, using multiple perspectives, and engaging in mindfulness practice.
Responses strongly supported content helpfulness with outcomes of strongly agree (32%) and
agree (55%) (See Figure 1). Statements 20-25 asked participants to rate (strongly agree-strongly
disagree) the ease of use of Google Sites, multimedia, type of information to promote
understanding, and clarity of modules. Questions about the learning platform feasibility
demonstrated similar strong results: strongly agree (49%) and agree (42%) (See Figure 2). A
total of 91% of the participants agreed they had aspirations for behavior change and desired to
integrate mindfulness into the workplace setting and everyday life (statements 15 and 16).
27
Participants indicated they practiced mindfulness approximately four days a week during and
after the program.
Figure 1: Program Content Helpfulness
* The degree to which each participant agreed with statements related to helpfulness of the program content.
0 2 4 6 8 10 12
1= Strongly Disagree
2= Disagree
3= Nuetral
4= Agree
5= Strongly Agree
Program Content Helpfulness
I feel that mindfulness can help meeffectively manage stress and burnout.
I have a better understanding of howmindfulness can reduce stress andburnout.
I am able to successfully utilizeinterventions to practice mindfulness.
I plan to use at least one mindfulnessstrategy in the workplace setting.
I plan to use mindfulness in myeveryday life.
I feel more open to consideringmultiple perspectives.
I feel more open to considering newways of doing things.
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Figure 2: Learning Platform Feasibility
* The degree to which each participant agreed with statements related to the feasibility of the learning platform.
The modules were designed to require approximately 30 minutes or less each week. The
majority of the participants indicated they spent between 10 and 30 minutes on average
completing each module (See Appendix 9). Five participants downloaded and used one of the
smartphone applications that would send “be mindful” reminders at various times. Eighty-six
percent of the participants responded “agree” or “strongly agree” to a positive change in attitude,
because of working with Langer’s tenets of mindfulness (statements 11-14). Twelve participants
thought mindfulness could assist with management of stress and burnout (statement 19). Finally,
0 2 4 6 8 10 12
1= Strongly Disagree
2=Disagree
3= Neutral
4= Agree
5= Strongly Agree
Learning Platform Feasibility
Google sites was easy to access andnavigate.
The amount of multimedia (audio,video, animation) used in the modulesadded value to the effectiveness ofthe program.
I would recommend these modules topeers in the workplace.
The program modules were clear andeasy to follow.
The activities helped me gain a clearerunderstanding of mindfulness.
This program was useful in meetingmy needs for information about waysto use mindfulness to reduce stressand burnout.
29
91% of the participants agreed the program increased their knowledge and use of mindfulness to
decrease stress and burnout and felt capable of practicing mindfulness interventions (statements
17 and 18).
Barriers and Facilitators - Secondary Outcome
The goal of the focus group was to gather information related to barriers to and
facilitators of the program. Two of the sixteen nurse participants attended the 30-minute focus
group. This group occurred the first week after implementation of the four-week module
implementation. The discussion did not reveal any barriers to participation in the program. A
valuable suggestion was offered to combine all the practice skills into one printed document for
easy reference. Major facilitators of the program identified by the focus group participants
included the brief length of the modules, reminder emails, easy use of Google Sites, and
increased accessibility from multiple types of devices. One of the participants described
practicing the mindfulness skills either early in the morning or later in the evening when
everything was quiet and there were fewer distractions.
Website and Anecdotal Data
Based on Google Analytics for the Paving the Path to Mindfulness Website, there were
380 “page views” during implementation. Thirteen minutes was the average duration of
engagement with the website during a single session. Participants used hand-held smart devices
to access the website approximately 53% of the time (See Appendix 10).
Information was also recorded by the Project Leader through informal communication
with the nurses during various work shifts and through email communication. Two nurses
communicated that they would have liked the website to offer some type of confirmation when
they completed the module. Approximately five-to-six nurses commented how much they
30
enjoyed the engaging videos and expert speakers that presented the content. While at work, the
Project Leader overheard a fellow nurse’s phone play a sound alert and she indicated the
mindfulness mobile application was the cause of the sound. Another nurse commented she had
always thought of “stress as the enemy…and will now think of stress in a different way.”
31
CHAPTER 7: DISCUSSION
The data suggests that most participants found the content and learning platform of the
program to be helpful and useful. Further, the majority expressed a desire to integrate
mindfulness into their practice and believed that mindfulness could assist with management of
stress and burnout. Overall, the participants agreed that the program increased their knowledge
and capability to practice mindfulness. Most of the nurses who chose to participate in this
program had 15 years or less of psychiatric nursing experience and would recommend the
modules to other peers in the workplace. This is a valuable outcome of the mindfulness program
as the literature supports individuals were more likely to experience burnout earlier in their
career (Maslach et al., 2001).
The number of page views indicates participants frequently engaged with the website
during implementation. Although the focus group did not yield information related to barriers to
participation in the program, based on the Project Leader’s knowledge of the implementation
site, possible barriers can be suggested. Many of the nurse-participants were either working or
on vacation at the time of the focus group, which limited participation. The units participating in
this program experienced significant transitions contributing to increased workplace demands.
For example, during the first week of recruitment, one of the nursing units was closed for
construction and all patients were transferred to a newly constructed larger unit. This space was
also unfamiliar to nursing staff. Prior to, during, and after implementation, several new
employees were hired and the units experienced significant leadership change; changes in a short
period of time that potentially created barriers to the engagement of the nurse-participants and
32
the degree of success of the program. Situational factors of this type are reflected in the
literature as contributors to the development of stress and burnout (Bakker & Costa, 2014) and
can be mediated with management-level support (Khamisa et al., 2014). This was exemplified
by the leadership on the units involved with this innovation.
The literature highlighted work-related demands and a shifting work schedule as reasons
for attrition in previous healthcare studies (Burton et al., 2016). This was considered in the
program design related to distribution of information to the participants while respecting the
limited flexibility in shift work schedules. The short duration of modules and easy access to the
program were efforts to address barriers to participation, and they were identified by focus group
participants as facilitators of the program. Learning platform accessibility is imperative to
promote increased number of exposures to an online mindfulness intervention (Spijkerman et al.,
2016) and this was accomplished by desktop, mobile phone and tablet access. Quantitative and
qualitative data gathered from this program evaluation support participants’ favorable perception
of platform accessibility permitting increased exposure to the modules. This was evidenced by
the high number of webpage views. The information derived from this formative evaluation will
provide guidance for continued development of the program and plans for the next
implementation period. The intent is to make the program available through the hospital intranet.
Limitations
A potential limitation is the formative nature of the program. Currently there is no
published evidence known to the writer describing such a program. The small number of
participants in the focus group limited range of potential feedback that might have yielded
additional barriers and/or strengths of the program. The program evaluation was not designed to
analyze individual nurse factors to the response of stress and burnout. Individual responses could
33
provide additional data for a project of this type. The abbreviated nature of the program might be
considered a limitation. However, the literature supports shorter programs are ideal to reduce the
burden of time commitment. Additional implementations of this mindfulness program will
provide data for future program development with possible utility for other units in the hospital.
34
CHAPTER 8: RECCOMENDATIONS
Expanding this program to other nurses will provide the opportunity to further refine the
program. To ensure maximum participation in the focus group it would be advantageous to
consider offering a virtual focus group or other modalities for feedback from participants. Many
of the participants commented about the ability to access the program on any smart phone
device. This is key to ensuring participant engagement for future programs. Inclusion of night
shift and nurses working off-shifts is important as stress and burnout may be experienced
differently from the participants in this program evaluation. New graduate nurses might also
benefit from this program as they enter their nursing career and begin to develop self-care skills.
Creation of a system change to increase staff satisfaction and work-life balance requires
healthcare organizations to support all levels of leadership, as indicated by the Quadruple Aim
(Agency for Healthcare Research and Quality, 2015). It is recommended that further assessment
of this program occur overtime to link consistent implementation of the program with a change
in individual nurse factors of stress and burnout such as rates of physical injuries, nursing call
outs, and medication errors. The implementation and evaluation of this program offers a
promising beginning journey to provide nursing staff with alternative ways to manage stress and
burnout.
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APPENDIX 1: LANGER’S MINDFULNESS-BASED MODULES
Program: Mindfulness Modules Goal: Increase mindfulness
INPUTS ACTIVITIES OUTCOMES
What we invest What we do Why this project: short-
term results
Why this project:
intermediate results
Why this project: long-term results
• Time • Materials –
modules • Technology
– Google based website
• Equipment - computer
• Educate • Develop
curriculum • Facilitate
access to information
• Conduct focus group
• Program evaluation survey
Learning
• Increase awareness of Langer’s tenets of mindfulness
• Knowledge gained from the program is demonstrated through integration of mindfulness in the work site
• Knowledge about impact of stress and burnout on health and quality of life
• New skills for mindfulness practice
• Motivation to engage in new behaviors
• Change in attitude
Action
• Willingness to practice new behaviors
• Integrate feedback from program evaluation and develop recommendations for future improvements
• Program repeated annually as part of required training
• Program added to hospital intranet
Conditions
• Successful program could influence attitudes about work, improve work environment, decrease callouts
Who we reach
• Nurses on psychiatric inpatient units
• Supervisors
Assumptions • Stress and burnout can be reduced through mindful
practice
External Factors • Understaffing, frequent
staff callouts • Limited time to complete,
not mandatory
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APPENDIX 2: WEEKLY TEMPLATE
Week 1
Key Topics:
• Discussion of key objectives of the program • Overview of stress and burnout consequences • Introduction to Langer’s approach to mindfulness vs. mindlessness, website and reminder
cues o Langer’s theory of mindfulness, central components, video of Ellen Langer
discussing mindfulness o Skill practice for considering multiple perspectives
Week 2
Key Topics:
• Novelty Seeking- ways to prevent mindlessness • Engagement- noticing details or changes in the environment • Using mindfulness in everyday life
o The rainbow walk- go for a walk and look for something red, orange, yellow, green, blue, indigo and violet (ROYGBIV)
o Counting sounds walk- go for a walk and count how many sounds you hear (ie: cars, animals, people, wind, footsteps on leaves etc.)
Week 3
Key Topics:
• Novelty Producing: process stimuli to create new categories or information • Flexibility: consider multiple perspectives & use environment as feedback • Rethinking Thinking Video
Week 4
Key Topics:
• Using mindfulness in the workplace setting- creative solutions to challenges o Example: 3M Post-It Notes
• Participants will practice noticing five new things o After returning to an interaction with a patient, notice five new things about how
that patient appears
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APPENDIX 3: FLYER
PAVING THE PATH TO MINDFULNESS We want your participation! The purpose of this program is to evaluate a four-week program
designed to help reduce stress and burnout in psychiatric-mental
health nurses through the use of mindfulness. To participate you
must be a registered nurse or licensed practical nurse and work
in a part-time or full-time capacity.
ONLINE MODUES FOR NURSES
DECREASE STRESS AND BURNOUT
INCREASE MINDFULNESS
INFLUENCE PROGRAM
EVOLVEMENT
HAVE QUESTIONS? CONTACT THE
PROJECT LEAD!
PROJECT LEAD: Kristin Rush, BSN
704-281-3186 [email protected]
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APPENDIX 4: RECRUITMENT SCRIPT
I invite you to partake in the opportunity to experience and evaluate a four-week program designed to help reduce stress and burnout in psychiatric-mental health nurses through the use of mindfulness. To be eligible to participate you must be either a registered nurse or licensed practical nurse and work in a part-time or full-time capacity. This program consists of four online modules designed to equip you with skills related to mindfulness that you can use in your everyday life and in the workplace. Each module takes approximately 30 minutes to complete and will be available via Google Sites so that you can access the information from anywhere—including desktops and smartphone devices. After completion of the four modules, you will be asked to participate in a brief anonymous survey (less than 15 minutes to complete) and attend a focus group (less than 30 minutes) to provide feedback about barriers to and facilitators of the program.
39
APPENDIX 5: INFORMATION SHEET
You are being asked to participate in a research study being conducted by Kristin Rush. Purpose: To evaluate the effectiveness of a four-week mindfulness program designed to help reduce stress and burnout in PMH nurses working on locked inpatient units. Procedure: You will participate in the evaluation of a mindfulness program consisting of four modules that take approximately 30 minutes each to complete. After completing the modules, you will be asked to complete one survey that will take less than 15 minutes to complete. The survey asks questions regarding your experience of the program. You will also be asked to participate in a focus group that will take less than 30 minutes to discuss barriers and facilitators of the program. Voluntary participation: Participation in the research study is voluntary. Should you choose to participate in this research study, you have the right to withdraw at any time without consequence. Additionally, you have the right to refuse to answer any questions for any reason, without consequence. Risks and benefits: The researchers conducting this study have determined that participation in this study poses minimal risk to participants. If you, as an employee, experience any type of distress from participating in this study, please speak with either researchers, your nurse manager, or contact the Employee Assistance Program at Novant Health at 1-800-828-2778. The benefits associated with this research are possible improved employee satisfaction, retention rate, job performance, patient care and patient satisfaction. If you have any questions or want more information regarding the research and study, you may contact the researcher at [email protected]. If you have concerns about your rights or treatment, or the risks and benefits related to this study, you may contact the Presbyterian Healthcare IRB at 704-384-8898 and the Novant Health nurse scientist (Gloria Walters) at [email protected]. Confidentiality: Your participation and responses to the survey questions will be anonymous and confidential. Please do not disclose identifying information on the surveys. The surveys are electronic and will be submitted to an electronic database. Data collected through the focus group will be anonymous and used only for identifying common themes. Consent to Participate: Please retain a copy of this consent form for your records. By completing this survey and attending the focus group, you are voluntarily consenting to participate in this portion of the research study. If you do not wish to participate in this study, please disregard this email.
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APPENDIX 6: QUALTRICS POST-EVALUATOIN SURVEY
1) How many modules did you complete? a. None b. One c. Two d. Three e. Four
2) Did you utilize a phone application with reminder cues to help you remember to practice mindfulness techniques?
a. Yes b. No
3) What was the average amount of time you spent each week completing the modules? a. Less than 10 minutes b. 10-20 minutes c. 21-30 minutes d. 31-40 minutes e. Greater than 40 minutes
4) What is the average amount of days per week you practiced mindfulness during and after the program?
a. One b. Two c. Three d. Four e. Five f. Six g. Seven
5) What is your age? a. 20-30 years b. 31-40 years c. 41-50 years d. 51-60 years e. 61+ years
6) What is your gender? a. Male b. Female c. Other
7) What shift do you primarily work? a. 7a-3p b. 7a-7p c. 3p-11p d. 7p-7a e. 11p-7a f. Other
8) How many hours per week do you USUALLY work at your job? a. 21-30 hours b. 31-40 hours
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c. 41-50 hours d. 51-60 hours e. 61+ hours
9) How many years have you worked as a RN or LPN? a. 0-5 years b. 6-10 years c. 11-15 years d. 16-20 years e. 21-25 years f. 26-35 years g. 35+ years
10) How many years have you worked in the field of psychiatric-mental health? a. 0-5 years b. 6-10 years c. 11-15 years d. 16-20 years e. 21-25 years f. 26-35 years g. 35+ years
As a result of participating in this program, please indicate the degree to which you agree with each statement: Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree (Likert Scale 1-5)
11. I feel a curiosity to learn new things in situations.
12. I feel an increased ability to pay attention to small details in the environment.
13. I feel more open to considering new ways of doing things.
14. I feel more open to considering multiple perspectives.
15. I plan to use mindfulness in my everyday life.
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
42
16. I plan to use at lead one mindfulness strategy in the workplace setting.
17. I am able to successfully utilize interventions to practice mindfulness.
18. I have a better understanding of how mindfulness can reduce stress and burnout.
19. I feel that mindfulness can help me effectively manage stress and burnout.
Please indicated the degree to which you agree with each statement: Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree (Likert Scale 1-5)
20. This program was useful in meeting my needs for information about ways to use mindfulness to reduce stress and burnout.
21. The activities helped me gain a clearer understanding of mindfulness.
22. The program modules were clear and easy to follow.
23. I would recommend these modules to peers in the workplace.
24. The amount of multimedia (audio, video, animation) used in the modules added value to
the effectiveness of the program.
25. Google sites was easy to access and navigate.
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
1= Strongly Disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree
43
APPENDIX 7: BENNETT’S HIERARCHY
End Results: Social, economic, environmental conditions (SEEC)--ultimate effect of the program
Practice Change: Practices adopted as a result of participation in program
KASA Change: Change in knowledge, skills, attitude, and aspirations
Reactions: Particpant reactions to involvement in the program
Participation: Types and number of persons involved
Activities: Program activties--meetings, newsletters etc.
Input: Resouces allocated to program--time, funds etc.
44
APPENDIX 8: FOCUS GROUP QUESTIONS
1. What were the best things about the modules? 2. What could have been done differently that would have improved the modules? 3. What were the biggest barriers to participation? 4. What additional topics in the area of mindfulness would be helpful in future modules?
45
APPENDIX 9: AVERAGE TIME SPENT COMPLETING MODULES
6%
38%
31%
25%
0%
Average Time Spent Completing Modules
Less than 10 minutes 10-20 minutes 21-30 minutes 31-40 minutes Greater than 40 minutes
46
APPENDIX 10: TYPE OF DEVICE USED TO ACCESS WEBSITE
47
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