Nurses’ Burnout Management

Introduction

Background and Rationale

In recent years, there have been significant concerns about how the growing mismatch between the supply of health professionals and their demand is to be solved. Most countries in the west have since resorted to importing these professionals from developing nations, with evidence asserting that of the 1.9 million individuals employed in the U.K. in 2018 alone, 6% were from the developing world. However, this has yet to help mitigate this issue as the baby boomers, who account for about 20% of the country’s population, continue getting sicker and needing more outstanding care. The deficiency has led to heightened nurse burnout which further leads to more shortages considering the stressful work environment and emotional strain that these professionals go through as they provide care. In 2021, 40.5% of midwives and nurses asserted that their work always left them unhappy. Another study established that burnout was responsible for 28% of all nurses quitting. With such statistics, this issue must be addressed considering the position of healthcare in society and its importance. Moreover, nurses’ health cannot be downplayed, considering the stress levels they endure willingly and unwillingly. Besides, in more severe cases, it is characterized by physical, emotional, and mental exhaustion translating to various mental health and physical problems while contributing to low-quality care and patient mortality. This is why recently, burnout was labeled by the World Health Organization (WHO) as an official medical diagnosis. In this regard, there is a need to find a proper management technique for burnout to ensure that nurses remain in the right mindset with adequate energy levels to perform their duties as required.

As such, various interventions have been proposed in the recent past to curb this issue. Employee assistance programs have been seen as a pathway to help solve the problem. A study by Husaker et al. found that in an extensive hospital system, those who utilized these programs reported lower stress, anxiety, and burnout levels than those who did not. Toker et al.’s study supported this, which found that job resources provided a layer of protection against burnout, translating to higher job satisfaction levels. Other interventions proposed over time include work-life balance, communication and collaboration, self-care programs, and reducing workload, with studies showing that these are also vital steps towards eradicating nurse burnout in the U.K.’s healthcare delivery system. Despite their successes, as identified by multiple researchers, most of these intervention techniques are impractical. For instance, workload reduction is tricky considering that people are bound to have healthcare complications, so nurses are expected to work 12 straight-hour shifts, which makes the rewarding profession quite straining. However, there is little the NHS can do, considering they have a duty to the people to ensure adequate care access with quality maintained at all times. Therefore, there is a need for a more specific and targeted intervention.

This is why there is a need to explore mindfulness-based interventions. According to Huma, these are therapeutic interventions that focus on mindfulness. Mindfulness is a mental practice that requires one to be entirely aware and deliberate in understanding a person’s present experience. Under it, there are mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), which have all proven to be critical in reducing stress and burnout among nurses. However, it is essential to focus on mindfulness meditation which is the most common pathway through which mindfulness-based approaches are delivered. Huma describes it as a medication where one focuses on awareness of feelings and senses at the moment without judgment. It entails paying attention to the breath and being involved in the present moment instead of lingering on the past or worrying about the future. There are several methods to practice mindfulness meditation, including sitting quietly, doing yoga, and participating in mindful movements such as walking or stretching. The purpose of mindfulness meditation is to cultivate a more profound feeling of awareness and acceptance, which may result in less stress, enhanced emotional regulation, and enhanced well-being overall. Considering its comprehensiveness and how it promotes one’s engagement with themselves, it promises better results with enhanced coping with burnout for these health professionals. With such evidence and considering the grievousness of the issue, it is critical to explore mindfulness meditation to ensure it is fully applied as required and to the desired extent so that the case of nurse burnout is extinguished.

Objective

Therefore, with these issues considered, this systematic review will focus on exploring mindfulness meditation as a critical intervention to the growing problem of nurse burnout in the U.K. while reducing overall nurse turnover.

Research Question

As tabulated above, the research question provided in a PICO format will be: In nurses working in the U.K. (P), how does the implementation of mindfulness meditation (I) compared to standard stress management techniques (C) reduce the level of burnout (O)?

Methods

Aim and Objectives

Based on the research question of interest, the study will aim to evaluate mindfulness meditation’s effectiveness in reducing burnout among nurses working in the U.K. compared to standard stress management techniques. As such, the study will pinpoint how mindfulness meditation fits as a more viable solution to nursing burnout. With this precise aim, the research objectives will be as follows:

1. To identify relevant studies investigating the effectiveness of mindfulness meditation and standard stress management techniques in reducing burnout among nurses working in the U.K.
2. To assess the quality of the selected studies using a systematic and rigorous methodology.
3. To synthesize the findings of the selected studies and provide a comprehensive overview of the effectiveness of mindfulness meditation and standard stress management techniques in reducing burnout among nurses working in the U.K.
4. To explore potential moderators of the relationship between mindfulness meditation and burnout reduction, such as the duration and intensity of the intervention, the type of mindfulness practice used, and the nurses’ demographic characteristics.
5. To identify gaps in the literature and provide recommendations for future research on this topic.

Epistemological Approach and Positionality

Considering the scope and extent of this study, the best epistemological approach for it will be critical realism. The method acknowledges that an objective reality exists independent of one’s subjective perceptions and that social and cultural contexts shape their understanding of this reality. Understanding these aspects is critical for this study considering the personal nature of knowledge acquisition and interpretation. As a result, the systematic review will look for and evaluate empirical data on the usefulness of mindfulness meditation in lowering nurse burnout levels while also considering the potential influence of individual characteristics and contextual factors such as social life and culture on the results.

In this study, positionality must also be considered. The researcher’s positionality as a non-nurse and an outsider to some of the localities where some studies are based will be addressed and acknowledged. This will be accomplished via reflexivity, considering one’s positionality and how it could influence one’s study. With the incorporation of pertinent literature and interaction with experts in the area, the systematic review will also attempt to include the viewpoints and experiences of nurses working in the U.K. The researcher’s experiences, beliefs, values, identities, and social and cultural backgrounds, including race, ethnicity, gender, sexuality, and class, will also be integrated. Such factors can affect their assumptions, expectations, and interpretations of the evidence and shape how readers and stakeholders perceive the review. To address such issues, the researcher will be transparent about the biases and perspectives and will explicitly describe the methods used to minimize the effect of the positionality issues on the review and findings. This will be achieved by focusing on multiple data sources and search strategies while also focusing on diverse stakeholders and communities to comprehend their priorities and perspectives. A systematic data extraction and analysis approach will also be utilized to promote transparency and extinguish individual biases.

Results

Characteristics of the Participants

A review of selected literature explored five studies involving mindfulness meditation intervention and their impact on alleviating nurses’ burnout across various departments, including general hospital settings, intensive care and pediatrics. Each study being reviewed was conducted in different countries across diverse cultures. Three studies were born in the United States, while the remaining two were shown in China and England. Most of the studies had a sample size ranging between n= 33 and the smallest sample size, while the largest was n= 234.

Table 1 below summarizes the detailed description of the studies examined in this review. The majority of the participants in the studies were female nurses and nursing students having varying degrees of experience. Notably, three studies found that sociodemographic data had insignificant effects on the results. Two studies included various healthcare practitioners, while the remaining three only nursing staff. Four studies used a mixed sample of participants, while one did not report on the gender of the participants (Van der Riet et al., 2018). Considering the study where gender information was reported, the number of female participants was significantly higher than those of males indicating gender disparity among the healthcare practitioners included in the studies.

Outcome Measures

The mindfulness-based stress reduction (MBSR) technique evaluated the primary outcome measures. The MBSR model developed by Jon Kabat-Zin (1990) is the gold standard in contemporary mindfulness programs. The model emphasizes the need to improve mindfulness by employing techniques such as meditation, mindful movements and formal sitting practices. The studies employed a variety of outcome measures to evaluate the effectiveness of mindfulness meditation as a central measure for managing burnout in nurses and reducing overall turnover. Straus et al. (2021) used mindfulness-based cognitive therapy for life to evaluate if it could cause stress among healthcare practitioners. Montanari et al. (2019) used Maslach Burnout Inventory, pre and post-demographic questionnaires, and Perceived Stress Scales to evaluate stress levels. Two other studies used a modified MBSR model (Li et al., 2019; Green & Kinchen, 2021). However, Van der Riet et al. (2018) used traditional MBSR.

Four studies investigated the impact of mindfulness meditation on burnout in nurses. However, one study other than examining such effects also evaluated the effect of mindfulness meditation on overall turnover (Montanari et al., 2019). The five studies in this review explored the impact of mindfulness meditation on other workplace-associated chronic stress, which are closely linked to burnout and turnover rates. Such factors included secondary traumatic stress, depression, and tension, anxiety mostly induced by chronic or acute exposure to the suffering of patients commonly linked to nurses with burnouts.

Few studies (n=1) investigated the impact of mindfulness meditation on nursing errors. Additionally, two studies explored the impact of mindfulness meditation on factors that offer alleviating effects to burnout, such as compassion satisfaction, resilience, and self-compassion. Some studies (n=2) question the participants’ perceived benefits of mindfulness meditation programs on their job satisfaction, well-being and personal life during the post-intervention phase. The majority of the studies (n=4) employed consistent methods of measurement. However, one study (Montanari et al., 2019) used Self-Compassion Scale. All the measures used in the studies (n=5) were tested for reliability and validity.

Findings

Depression and Stress

The five studies reported a significant positive impact of mindfulness meditation on alleviating burnout of nurses and a reduction in overall nurse turnover. Montanari et al. (2019) reported that nursing staff participating in the MBSR program substantially reduced work-related distress following 2 hours of active sessions for eight weeks accompanied by a retreat. The session focused primarily on improving attention and mindfulness through meditation, yoga and formal sitting practices. Montanari et al. (2019) found that more than double the number of participants in their study who underwent MBSR intervention had at least a 50% reduction in stress levels than their peers in the control group who had not received any intervention.

Moreover, nearly all the study participants (94.5%) considered the intervention beneficial and showed interest in continuing with the program after the study’s conclusion. Besides, 76% of the nurses who participated in the study rated the perceived benefits of the MBSR program on their work performance and productivity to be at least 4 out of five. Montanari et al. (2019) reported that 25% of the participants who made errors during work before the intervention admitted that they experienced a reduced frequency of making such errors after 3 months post-intervention.

Burn Out

Straus et al. (2021) established that pre-intervention scores showed that all the participants, particularly those from intensive care units, had significantly higher rates of diminished personal accomplishment and depersonalization. Besides, they had higher levels of perceived stress than the national average in England. They explored a modified MBSR intervention involving the introduction of the session, weekly sessions for six times and final group sessions spreading to a total of about 16 hours across 8 weeks involving formal group practice. The sessions emphasize the need for the participants to develop awareness of noticing reactions to stress, identifying personal biases and exploring self-care. The study reported minimal changes on stress and burn out. Nonetheless, it was reported that the majority of the participants (91.6%) admitted to having experienced perceived benefits from the program. Some of the reported benefits included improved focus and reduced stress and anxiety levels.

Li et al. (2019) found that modified MBSR had a profound impact on attenuating burn outs in nurses. They used a modified MBSR program running for 8-weeks divided into 2 hour weekly programs involving group sessions accompanied by 20 minute independent meditation sessions for six days in a week. The researchers found that nurses enrolled in the study experienced statistically significant improvements in stress and reduction in burn outs before the termination of the study at the end of the 8 weeks program. Similar results were reported during the three months post-intervention period with more nurses reporting a reduction in depression and distress.

Green and Kinchen (2021) used mindful self-care and resiliency intervention to examine their impacts burn outs in nurses. They found that the intervention substantially reduced burn outs and improved self-compassion and compassion satisfaction in nurses. The researchers developed an intervention program involving educational workshops on mindfulness meditation and fatigue resiliency for four weeks with additional requirement to practice at home. Green and Kinchen (2021 reported that the intervention was effective in reducing depressive moods, burn out and self-compassion. However, it was observed that change in burn out levels during six months follow up was insignificant.

Turnover

One study reported significant positive impacts of mindfulness meditation in reducing overall nurses’ turnover. Van der Riet et al. (2018) used Nurse Occupational Identity scale to investigate nurses’ turnover intentions following the introduction of mindfulness meditation intervention. They found that a statistically significant (p<0.01) differences existed before and after the intervention indicating an improvement in nursing turnover rate following the introduction of mindfulness meditation programs. Further, the study reported improved attitude on self-determination and grasp of profession identity thus showing that mindfulness meditation can effectively minimize turnover among nursing staff, particularly those working in highly intensive departments.

Discussion

The current research shows that a reliable evidence exists that mindfulness meditation has a profound impact on reducing burn out and overall turnover rates in nurses. Indeed, the primary objective of this systematic review was to examine mindfulness meditation as a key intervention measure to the growing issue of nurse burnout in the United Kingdom while also reducing overall nurse turnover. In summary, the result of the review indicate that implementing mindfulness meditation implementation programs has a substantial impact on reducing burn outs and turnover rates in nurses. The findings are consistent with a substantial body of evidence (Hilcove et al., 2021) which have demonstrated that mindfulness meditation have a positive correlation to improved alleviation of burn outs in nurses. Thus, the findings and relevant to the practice and working lives of nurses in the United Kingdom.

A mounting body of evidence has supported the use of mindfulness meditation interventions in reducing burn out. Xie et al. (2020), denoted that such interventions improved nearly all aspects burn out in nurses such as lack of motivation, and emotional exhaustion. The findings of this review that mindfulness meditations reduces work efficiency in nurse is consistent with previous literature conclusions on the capacity of the interventions to enhance compassion satisfaction and self-compassion (Li et al., 2019; Green & Kinchen, 2021). Most participating nurses in mindfulness meditation have admitted that the intervention alleviates burn outs.

Even though some studies have reported that mindfulness meditation has insignificant or no impact on some burn out variables, others have demonstrated that it has a profound effect on similar variables. The conflicting results are a testaments to the multifaceted and intricate nature of nursing workplace burn out stressors between varying extent of exposure to depression and anxiety (Duarte and Pinto-Gouveia, 2016). Thus, it suggests that implementation of mindfulness meditation intervention particularly targeting the nursing staff with the aim of reducing burn outs needs to implement with consideration for specific needs of the staff and their demographics.

Such a process can be achieved through the administration of surveys using Self-Compassion Scale or Maslach Burnout Inventory to aid in evaluating potential areas of improvements, existing predisposing and protective factors and baseline characteristics. For example, studies have shown that high levels of resilience and compassion in nurses could be a critical predictor of low levels of burn outs while low levels of resilience and self-compassion have been associated with high burn out levels (Suyi, Meredith and Khan, 2017; Duarte and Pinto-Gouveia, 2016). The findings of this review that nurses experiencing low levels of resilience and compassion can benefit significantly from mindfulness meditations programs is congruent with previous literature. Armstrong and Tume (2022, 3) demonstrated that mindfulness meditation interventions programs such as MBSR were effective in attenuating adverse burn out levels in nurses in a given healthcare practitioner population. Therefore, both generalized and self-directed mindfulness meditation programs can be effectively harnessed in nursing with high levels of protective factors as a prophylaxis measure for the maintenance of such traits.

Additionally, mindfulness meditation programs have been shown to have strong sustainability and are typically well-received as an effective mechanism for assuaging high levels of burnout in nurses. The majority of post-intervention studies have demonstrated that participants were willing to continue engaging in mindfulness meditation programs because it had positive in reducing their emotional exhaustion and feelings of frustration (Montantari et al. 2019; Straus et al. 2021). Montantari et al. (2019, 5) noted that modified MBSR intervention lasting more than six months was characterized by low rates of attrition and high attendance with 90% of the participants admitting that the intervention due to its capacity to improving coping with workplace stressors. Similar have been previously reported by Suleiman-Martos et al. (2020) who found that 94% of nurses enrolled in mindful self-comparison and resilience program were more likely to continue with the intervention citing improved ability to manage mental exhaustion and stress reduction.

Some studies have shown that high burn out levels persisted even after introducing mindfulness meditation programs in nurses working in intensive care units. However, such studies have been negated by a substantial body of evidence which have reported that nurses in the same environment have acknowledged the positive impacts of mindfulness meditation programs (Sulosaani et al. 2022). Additional evidence has shown that such nurses describe mindfulness meditation programs to beneficial in alleviating physical discomfort, feelings of ineffective patient outcomes and being overwhelmed with high workloads.

References

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