The Effects of Mindfulness Therapy on PICU Nurses’ Self-Reported Levels of

Job Satisfaction, Retention, Burnout and Compassion Fatigue

Chester Wheeler

College of Central Florida 

 Abstract

The demands of being a pediatric intensive care unit nurse have been associated with high stress levels and increased incidences of burnout, compassion fatigue, secondary traumatic stress, job dissatisfaction, and high attrition rates. Many healthcare organizations lack programs directed at promoting self-care behaviors for PICU nurses. Mindfulness therapy is a complementary alternative therapy that uses mediation and awareness of one’s self and situation to positively cope with life’s stressors. The purpose of this study will evaluate the effectiveness of an eight week long mindfulness therapy training program. Following a quasi-experiment nonequivalent control group pretest-posttest design, approximately 40 nurses will be purposively selected from two pediatric intensive care unit (PICU) settings in two different metropolitan hospitals to serve in either the intervention group or comparison group. After obtaining IRB approval, facility ethics committee approval, and signed informed consent forms from participants, five pre-test questionnaires to assess levels of burnout, compassion fatigue, emotional labor, job satisfaction, retention, and mindfulness will be completed. Instruments to be used will include a demographic/behavioral instrument, the Maslach Burnout Inventory, the Professional Quality of Life Scale, a Retention Survey, and the Five-Facet Mindfulness Questionnaire. Multiple linear regression analysis will be used to determine significant relationships between variables. Reliability-Corrected Analysis of covariance (ANCOVA) will be utilized to reduce the effects of the initial differences between the comparison and intervention group. It is hypothesized, that the intervention group will show significant increase in self reported job satisfaction and retention and a decrease in burnout and compassion fatigue.

 

 

Using Mindfulness Therapy to Promote Job Retention and Decrease Burnout 

Nursing is stressful career.  From long shifts at understaffed facilities, to critically ill patients and lack of resources, nurses endure a great amount of physical, mental, and emotional stress. Specialty nurses, such as pediatric intensive care unit (PICU) nurses, can experience a higher degree of stress than their medical-surgical nurse cohorts due to the presence of higher patient acuity, the need to be more vigilant with clinical care, and the demand for higher critical thinking and problem solving skills in the present moment (Ebb, 2009; Davis, Lind, & Celeste, 2013; Hinderer, et al., 2014; Khamisa, et al., 2015).

PICU nurses care for critically ill children that require highly specialized care while anxious and grief-stricken parents need simultaneous comforting, education, and genuine presence from the nurse. The emotional labor of these duties can contribute to symptoms of burnout (BO), compassion fatigue (CF), and attrition rates (Stewart& Terry, 2014; Cricco-Lizza, 2014; Vargas, et al., 2014). 

 

Problem

            Nursing is founded on the beneficence of caring for others, but who cares for the nurses?  Daily, PICU nurses provide specialized care to high acuity patients. These nurses experience the tragedies of children suffering and dying as well as the miracles of saving a precious life. Being exposed to every conceivable emotional response from grief-stricken parents and the stressors associated with this type of intensive work is emotionally laborious and can lead to symptoms of BO, CF or ultimately a nurse leaving his or her position. Hostile work environments, lack of staffing, and perceived lack of support further compound stressors contributing to nurse attrition rates (Hinderer,et al., 2014; Shoni, Bonnie, & Celeste, 2013).

Healthcare organizations frequently overlook the need for nurse-dedicated programs that teach self-care behaviors to help nurses cope with the most emotionally and physically laborious stressors associated with PICU nursing. Exploring self-care promotion programs’ efficacy in mitigating the occurrence of BO and CF in PICU nurses is invaluable to the holistic well being of both nurse and patient alike.

 

Purpose

            The purpose of this study is to evaluate the effectiveness of a 8 week long mindfulness therapy program on PICU nurses’ self-reported levels of burnout, compassion fatigue, job satisfaction, retention, and mindfulness.

 

Hypothesis

             The eight week long mindfulness therapy training program will be effective at increasing self-reported job satisfaction, retention, and mindfulness, while reducing levels of burnout and compassion fatigue?

 

Significance to Nursing

In the current era of widespread nursing shortages and higher productivity demands with fewer resources, developing positive coping mechanisms and strategies for managing stressful work environments is invaluable in facilitating nurses in retaining their positions, increasing their job satisfaction, and decreasing the occurrence of burnout and compassion fatigue.  This study will contribute to the understanding of how mindfulness therapy can contribute to promoting positive coping mechanisms in PICU nurses and serve as an example of possible institutional instruction on addressing this phenomenon.

 

Study Framework

Pamela Reed’s Self-Transcendence Theory (1991) was developed through deductive reformulation of non nursing lifespan theories drawing heavily from Roger’s conceptual system of unitary beings. The theory was originally intended for mental illness but was quickly adapted to end of life events and traumatic life events. The three main concepts of this theory are vulnerability, self-transcendence, and well-being. Vulnerability is being aware of one’s own mortality, often accompanying aging, life phases, and life crises. Self-transcendence describes the fluctuation of perceived boundaries that can extend a person beyond the immediate and contracted self view. Well-being is feeling healthy within the context of one’s own standards of healthy. Persons experiencing end of life events or traumatic events are in a state of increased vulnerability which can increases self transcendence; self transcendence is positively related with well being and mediates between vulnerability and well being; personal and contextual factors

may influence relationships between the concept(Alligood, 2014). Activities for have been suggested to facilitate growth of self-concept boundaries include journaling, music, art, meditation, life review, and religious expression. Nursing activities that engage self reflection, altruism, hope, faith, in vulnerable populations are associated with increased well being, as well as using group therapy to help clients examine their values and share their experiences with others with similar stories. Alligood (2014) refers to self transcendence perspectives correlating with lower levels of burnout in hospice and oncology nurses and with higher levels or work engagement in acute care nurses. Mindfulness therapy enhances one’s self-transcendence by encouraging awareness, introspection and reflection; which increase wellbeing. Self-transcendence theory serves as the framework to conceptualize Mindfulness Therapy.

 

Review of Literature

      According to the literature, sociological researchers Maslach and Jackson (1981, 1996) have been integral in developing the most widely used instrument for assessing BO, the Maslach Burnout Inventory. Even in the 1970s, researchers had already made the connection that burnout affects the quality of care provided, was predictor for of turnover rates, absenteeism, and low morale. Additionally, burnout was correlated with self-reported incidents of physical exhaustion, insomnia, and increased use of alcohol, drugs, and martial problems.  

       Researchers Cheng, Bartram, and Karimi (2013) examined the relationship between emotional labor, team climate, burnout, perceived quality of care and turnover intention among nurses in Australia. The researchers define emotional labor as the “regulation of emotion during interpersonal transactions.” Major concepts including faking unfelt emotions, hiding genuine emotions, and deep acting where one attempts to influence their inner feelings to induce the appropriate outward countenance. The findings from the study suggest that relative to deep acting, surface acting can have negative effects on nurses’ wellbeing and self rated performance, and is more predictive of burnout.. The researchers define emotional labor as the “regulation of emotion during interpersonal transactions.”  Major concepts explored in the study included faking unfelt emotions, hiding genuine emotions, and deep acting which pertains to one’s attempt to influence their inner feelings to induce the appropriate outward expression. The findings from the study suggest that relative to deep acting, surface acting can have negative effects on nurses’ wellbeing and self rated performance, and is more predictive of burnout.

        Cricco-Lizza (2014) uses an ethnography framework to guide her qualitative approach to examine the emotional labor and coping strategies of NICU nurses by firsthand observation of the nursing culture in a children’s hospital in the northeastern United States. This study examined 114, level-4, NICU nurses over 14 months in their everyday lives in order to better understand their emotional labor and coping strategies for dealing with the stressors of the field. Glimpses into these first hand experiences and self reported accounts of  NICU nurses illuminates the true toll high stressors can have on all aspects of one’s life and the various methods of coping that are employed at this particular facility. Moreover, organizations can and do contribute to the stressors as well as buffer for them. This study highlighted how offering flexible aid and adequate staffing acted to offset the high intensity work load per participant interviews; this is a positive coping mechanism for the nurses.  On the other hand, the lack of formal emotional health promotion implemented by the organization and failure to replace the psychologist available for debriefing nurses just may be contributing to the stress of the job.   

        Trauma nurses encounter many stressors in their work environments that can precipitate burnout (BO), compassion fatigue (CF), secondary traumatic stress (STS), or compassion satisfaction (CS). Hinderer, Von Ruden, Friedman, McQuilan, Gilmore, Kramer, and Murray (2014) explore the relationship of BO, CF, CS, and STS to personal/environmental characteristics, coping mechanisms, and exposure to traumatic events in a 128 trauma nurses (p. 160-169). Of the sample,  35.9% had scores consistent with BO, 27.3% reported CF, 7% reported STS, and 78.9% had high CS scores. High BO and high CF scores predicted STS. Common characteristics correlating with BO, CF, and STS were negative coworker relationships, use of medicinals, and higher number of hours worked per shift. High CS correlated with greater strength of supports, higher participation in exercise, use of meditation, and positive coworker relationships.

       In a descriptive non experimental study, researchers Gallagher and Gromley (2014) explore work-related stress, burn out, and support systems in 30 pediatric bone marrow transplant nurses from a large pediatric medical center in Midwestern United States. The researchers found that acuity of patients or critical illness was reported as most stressful factor and long working hours was least stressful factor. Moreover, 73.7% perceived moderate to high levels of emotional exhaustion, and 33.3% reported moderate levels of depersonalization. Additionally, 50% perceived high levels of personal accomplishment regardless of perceived obstacles and reported levels of emotional exhaustion and depersonalization.

        Mindfulness-based cognitive therapy (MBCT) or just mindfulness therapy combines cognitive therapy with meditative practices. Mindfulness is the capacity to be actively aware of what is happening in the present moment or experience; it is taking direct notice of what is happening and accepting the experience in a nonjudgmental way for what it is regardless of the experience being negative, positive, or neutral. The current research literature shows that mindfulness therapy, even though in its nascent state of being explained and tested, is a promising intervention for plethora of symptoms associated with mood disorders, chronic fatigue, pain, multiple sclerosis, stroke and stress (Hoffman, et al., 2010;  Lawerence, 2013;  Rhimes & Wingrove, 2013; Simpson, et al., 2014 ).

             

Methodology

 

Research Design

       This study will be a quasi-experiment nonequivalent control group pretest-posttest design that will evaluate the effectiveness of an eight week long mindfulness therapy training program on self reported levels of burnout, compassion fatigue, secondary post traumatic stress, and attrition rates.   Comparing changes of the intervention group on self reported data collected pre and post intervention versus a comparison group not receiving the intervention.

 

Sample and Setting

       Approximately 40 participants will be purposively selected from two pediatric ICU settings in two different metropolitan hospitals. Group A of twenty PICU nurses will participate in one hour long weekly mindfulness therapy training sessions during their day off for eight weeks. Group B will be serving as a comparison group and will only receive pre and post testing inventories to complete. Inclusion criterion will be a minimum of one year current experience in the PICU as a floor nurse. Nurse mangers and educators will be excluded from the sample size as well as advanced nursing degrees.

 

Ethical Considerations

       Prior to collecting any data, approval from each metropolitan hospital’s ethics committee and the Institutional Review Board (IRB) will be obtained. Study introductory letters and informed consents will be attached by unit managers to paystubs of potential participants. The letter will indicate the purpose of the study, that participation will be voluntary, minimal risk will be involved, that all information will be strictly confidential through removal of visible personal information and a unique coding system of a letter and number will be assigned to each participant. Signed informed consents from eligible voluntary participants will be collected prior to administering any questionnaires.  Questionnaires will be available to participants via hardcopy, email, or automated telephone prompt.

 

.

Instruments

       A Demographic/Behavioral instrument will assess demographics, personal/environmental characteristics (age, years nursing, sex, ethnicity, education and marital status),  coping strategies, stress relief strategies, support systems, and relationship with coworkers, percentage of time in direct patient care, hours per shift, hours worked per week and unit. Multiple choice and Likert-style questions will be included in this instrument.  (Hinderer, et al., 2014).

The Professional Quality of Life Scale (ProQOL) is a 30 item tool that uses Likert-type responses that range from 0(never) to five (very often) on BO, CF, CS. The reliability in Cronbach alpha for each subscale is CS = 0.87, CF = 0.80, BO = 0.72. (Hinderer, et al., 2014). The Maslach Burnout Inventory (MBI) is a 22 item scale measuring burnout. The MBI subscales focus on three aspects of BO: personal accomplishment, depersonalization, and emotional exhaustion. Reliability coefficients for each subscale are 0.9. Retention or turnover probability was assessed with the turnover intention subscale of the Michigan Organizational Assessment Questionnaire. It is a three-item scale, which is measured on a 7-point Likert scale with anchors ranging from 1 = ‘Strongly disagree’–7 = ‘Strongly agree’. Cronbach’s alpha for this scale was 0_90.

 

Data Analysis

       Multiple regression analysis will be used to determine the impact that the mindfulness therapy has upon the group as compared to pre and post testing.  Factor analysis will be used to detect relationships between the variables being studied. Analysis of covariance (ANCOVA) will be utilized to reduce the effects of the initial differences between the comparison and intervention group.

 

Ethical Considerations

      The ethical considerations of this study will entail obtaining approval from the necessary facilities’ ethics committee and the IRB, as well as obtaining informed consent from voluntary participants. Moreover, another ethical consideration is whether the intervention has a strong efficacy, then should comparison group receive as well. Additionally, ethical consideration should be given to the fact that if the intervention negatively affects the participants, then the study should be stopped.

 

Conclusions

        Understanding how to enhance job satisfaction and retention while reducing the emotional labor, burnout and compassion fatigue associated with high stress nursing jobs is integral in the development of organizational guided social interventions to address this problem. Researching interventions that organizations can implement to enhance the coping mechanisms and wellbeing of their medical staff members is vital to sustaining a system of quality care simply because if a nurse cannot care for him or herself, then how can he or she be expected to care for a patient’s wellbeing?

       Without healthcare organizations promoting positive coping mechanisms and self care behaviors for the nurses that bare the burden of the most emotionally and physically laborious clients, then the attrition rates for PICUs and other intensive care units alike will likely increase. 

       Throughout the literature, despite self reported levels of burnout, many nurses still reported compassion or job satisfaction and fulfillment with their jobs (Ebb, 2009; Davis, et al, 2013; Cricco-Lizza, 2014; Gallagher & Gromley, 2014).  This speaks to the nature of nursing being that of true nurturance and sacrifice; but the sacrifice of nurses’ personal wellbeing can come at the cost of patient care. PICU nurses need to take care of themselves first and foremost so that they can be in the best state physically, mentally, and spiritually for patients in order to provide quality client-centered care. Healthcare organizations need to focus on providing healthcare workers with support systems that promote self care behaviors, positive coping mechanisms and resilience in the face of the most dire and heart breaking situations imaginable.

 

 References

Cheng, C., Bartram, T., Karimi, L., & Leggat, S. G. (2013). The role of team climate in the management of emotional labour: implications for nurse retention. Journal Of Advanced Nursing, 69(12), 2812-2825. doi:10.1111/jan.12202

Cricco-Lizza, R. (2014). The need to nurse the nurse: emotional labor in neonatal intensive care. Qualitative Health Research, 24, 615-628. doi: 10.1177/1049732314528810

Davis, S., Lind, B. K., & Celeste, S. (2013, July-August). A comparison of burnout among oncology nurses working in adult and pediatric inpatient and outpatient settings. Oncology Nursing Forum, 40(4), E303+. Retrieved from http://db04.linccweb.org/login?url=http://go.galegroup.com.db04.linccweb.org/ps/i.do?id=GALE%7CA336845812&v=2.1&u=lincclin_cfcc&it=r&p=AONE&sw=w&asid=822835deae28650d7fe2e07a5a6449aa

 Epp K. Burnout in critical care nurses: A literature review. Dynamics 2012;23:25-31. Gallagher, R., & Gormley, D. (2009). Perceptions of stress, burnout, and support systems in pediatric bone marrow transplantation nursing. Clinical Journal Of Oncology Nursing, 13(6), 681-685. doi:10.1188/09.CJON.681-685

Hinderer, K. A., VonRueden, K. T., Friedmann, E., McQuillan, K. A., Gilmore, R., Kramer, B., & Murray, M. (2014). Burnout, compassion fatigue, compassion satisfaction, and secondary traumatic stress in trauma nurses. Journal Of Trauma Nursing, 21(4), 160-169. doi:10.1097/JTN.000000000000005

Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal Of Consulting And Clinical Psychology, 78(2), 169-183. doi:10.1037/a0018555

 

Khamisa, N., Oldenburg, B., Peltzer, K., & Ilic, D. (2015). Work related stress, burnout, job satisfaction and general health of nurses. International Journal Of Environmental Research And Public Health, 12(1), 652-666. doi:10.3390/ijerph120100652

Lawrence, M., Booth, J., Mercer, S., Crawford, E. (2013).  A systematic review of the benefits of mindfulness based interventions following transient ischemic attack and stroke. Int J Stroke 8(6): 465-474.

Maslach, C., Jackson, S. (1981).  The measurement of experienced burnout. Journal of  Occupational Behavior  (2) : 99-113 .

Rimes, K. A., & Wingrove, J. (2013). Mindfulness-based cognitive therapy for people with chronic fatigue syndrome still experiencing excessive fatigue after cognitive behaviour therapy: a pilot randomized study. Clinical Psychology & Psychotherapy, 20(2), 107-117. doi:10.1002/cpp.793

 Rosseter, Robert. "Nursing Shortage." American Association of Colleges of Nursing. 1 Jan. 2014. Web. 10 Feb. 2015. <http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage>.

Simpson, R., Booth, J., Lawrence, M., Byrne, S., Mair, F., & Mercer, S. (2014). Mindfulness based interventions in multiple sclerosis - a systematic review. BMC Neurology, 14, 15. Retrieved from http://db04.linccweb.org/login?url=http://go.galegroup.com.db04.linccweb.org/ps/i.do?id=GALE%7CA356489389&v=2.1&u=lincclin_cfcc&it=r&p=AONE&sw=w&asid=b49ebe117869f53922c7abca066dd8df

Stewart, W., & Terry, L. (2014). Reducing burnout in nurses and care workers in secure settings. Nursing Standard, 28(34), 37-45. doi:10.7748/ns2014.04.28.34.37.e8111

Vargas, C., Cañadas, G. A., Aguayo, R., Fernández, R., & de la Fuente, E. I. (2014). Which occupational risk factors are associated with burnout in nursing? A meta-analytic study. International Journal Of Clinical Health & Psychology, 14(1), 28-38.