Professional Documents
Culture Documents
International Journal of Stress Management
International Journal of Stress Management
Management
Integrating Mindfulness Into Nursing Education: A Pilot
Nonrandomized Controlled Trial
Simone Cheli, Paola De Bartolo, and Antonella Agostini
Online First Publication, March 7, 2019. http://dx.doi.org/10.1037/str0000126
CITATION
Cheli, S., De Bartolo, P., & Agostini, A. (2019, March 7). Integrating Mindfulness Into Nursing
Education: A Pilot Nonrandomized Controlled Trial. International Journal of Stress Management.
Advance online publication. http://dx.doi.org/10.1037/str0000126
International Journal of Stress Management
© 2019 American Psychological Association 2019, Vol. 2, No. 999, 000
1072-5245/19/$12.00 http://dx.doi.org/10.1037/str0000126
BRIEF REPORT
Antonella Agostini
University of Florence
There is an increasing base of evidence that mindfulness-based interventions are effective in reducing
stress in nurses. Little is known about the potential effect of mindfulness in fostering nursing education.
The present article reports the preliminary data of a pilot study aimed to introduce a mindfulness-based
education program for nursing students. Such a program, namely, the Self-Aware Nurse Project, aspires
to promote mindful compassion and reduce burnout in nurses. The study is a nonrandomized controlled
trial with pre- and postassessment. The control group attended a standard course, and the experimental
group attended our mindfulness-based education program. We enrolled nursing students (n ⫽ 82)
attending two concurrent classes of the same School of Nursing at the University of Florence. The
program is a mindfulness-based education program that progressively focuses on three different dimen-
sions (personal, relational, and organizational) of nursing experience, and integrates standard mindfulness
practices together with specifically designed meditative exercises and psychoeducation. The results
highlight that changes between pre- and postassessment in the experimental group, and between control
and experimental group in the postassessment exhibit medium to very large effect sizes among outcome
measures (Cohen’s d ranging from 0.57 to 1.25). The described mindfulness-based education program
reports a significant increase of dispositional mindfulness and a significant decrease of perceived
burnout. Further studies are needed to overcome the main limitations of the study: a low sample size and
the absence of randomization.
Over the past 20 years, many studies and reviews have been that has a meaningful impact at work” (Schaufeli, Leiter, &
published about the prevalence and the risk factors of nurses’ Maslach, 2009, p. 205). Burnout is traditionally considered to be a
burnout. Such a multidimensional construct describes “the exhaus- particularly serious feature of chronic stress and one that can
tion of employees’ capacity to maintain an intense involvement impair the worker’s effectiveness (Maslach, Jackson, & Leiter,
1996). Alternative perspectives describe burnout and stress either
as linked work-related problems reciprocally incrementing each
other (McManus, Winder, & Gordon, 2002), or as similar adverse
Simone Cheli, Department of Human Sciences, Guglielmo Marconi responses to the job with different antecedents (Pines & Keinan,
University and School of Human Health Sciences, University of Florence; 2005). We can cautiously state that burnout is a chronic work-
Paola De Bartolo, Department of Human Sciences, Guglielmo Marconi related stress that is recurrent in emotionally demanding profes-
University; Antonella Agostini, School of Human Health Sciences, Uni- sions (Schaufeli et al., 2009).
versity of Florence. The majority of the data reports a high prevalence of burnout
The ideas and data reported in the present article have been previously symptoms that seem to significantly affect quality of life and job
discussed and disseminated in different contexts. The theoretical back- performance of nurses (Cañadas-De la Fuente et al., 2015; Mealer,
ground has been presented as a part of a wider training project for nurses
Burnham, Goode, Rothbaum, & Moss, 2009). Cross-national stud-
at the 18th International Psycho-Oncology Society Congress. The prelim-
inary data have been disseminated at the postgraduate course in mindful-
ies show relevant costs of nurses’ burnout in terms of reduced
ness and psychotherapy at the University of Barcelona. quality of care, generally speaking (Dall’Ora, Griffiths, Ball, Si-
Correspondence concerning this article should be addressed to Simone mon, & Aiken, 2015; Poghosyan, Clarke, Finlayson, & Aiken,
Cheli, who is now at Centro di Psicologia e Psicoterapia, Tages Onlus, via 2010), and specifically in terms of direct costs such as medical
della Torretta 14, Firenze 50137, Italy. E-mail: simone.cheli@unifi.it errors and indirect costs such as job dissatisfaction and turnover
1
2 CHELI, DE BARTOLO, AND AGOSTINI
(Aiken et al., 2012; Zangaro & Soeken, 2007). This phenomenon cognitive-behavioral approach” (Didonna, 2009, p. 10) and is
seems to be defined by a complex pattern of risk factors especially suited for supporting people in facing chronic physical
(Cañadas-De la Fuente et al., 2015) that start operating at the early or psychological stress.
beginnings of nurses’ careers (Beck, 1995; Foster, Benavides- Given the flourishing of different studies and models of mind-
Vaello, Katz, & Eideet, 2012; Rella, Winwood, & Lushington, fulness practices, we may assume a recognized role in terms of
2009). There is not a consensual agreement upon levels and regulation processes, or more specifically of the ability to regulate
sources of burnout in nursing students, even though most of the psychological or self-processes (Dahl, Lutz, & Davidson, 2015;
studies highlight recurring symptoms that affect the overall per- Tang, Hölzel, & Posner, 2015; Vago & Silbersweig, 2012). There-
formance (Pulido-Martos, Augusto-Landa, & Lopez-Zafra, 2012). fore, we may maintain that mindfulness “functions to reduce
When trying to understand the risk factors of burnout and, suffering and create a sustainable healthy mind using a framework
consequently, the possible prevention or management strategies, of self-processing” (Vago & Silbersweig, 2012, p. 24) alternatively
we traditionally consider two types of concurrent perspectives focusing on the ability of modulating our self-awareness, our own
(Maslach, Schaufeli, & Leiter, 2001): (a) an organizational frame- behaviors, and our relationships with others. Thus, the ability to
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
work mainly focused on situational factors (e.g., occupational and manage suffering, such as that of care givers and care receivers,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
job characteristics) and (b) a personal framework mainly focused passes through a kind of aware and sustained acceptance, de-
on individual factors (e.g., personality and job attitudes). The scribed as “opening oneself to the context, striving to wait for
majority of the interventions aimed at preventing or reducing understanding rather than leap in precipitously, acknowledging
burnout symptoms in nursing students focus on the latter frame- distress as an understandable outcome in clients and in ourselves
work (Awa, Plaumann, & Walter, 2010; Galbraith & Brown, rather than as a problem to be solved” (Robins, Schmidt, &
2011). Indeed, the general objective of university training is to Linehan, 2004, p. 38). The compassion itself, through the lens of
prepare the candidate to adapt to different possible contexts. The mindfulness and acceptance, is no longer a source of suffering and
recent research trends try to understand how the match/mismatch burnout. It may be defined by two distinct abilities: “one that helps
between individual and situational characteristics stands at the core us to engage with suffering, to understand it; and another that
of the onset of burnout itself (Maslach et al., 2001; Ríos-Risquez, arises from our skilful actions and our efforts to alleviate it”
García-Izquierdo, Sabuco-Tebar, Carrillo-Garcia, & Martinez- (Gilbert & Choden, 2013, p. xxxvii). Mindfulness offers a source
Roche, 2016). Therefore, a nursing education training should pro- of practical methods to cultivate compassion as a path of personal
mote those characteristics that better match the nursing job’s enhancement and self-regulation (Gilbert, 2009). The construct of
demands. MC turns out to be a very practical tool in alleviating one’s own
Despite the huge amount of individual characteristics that may and others’ suffering, which may refer, at least, to three subsets of
define the nursing role inside health-care organizations, we fo- validated interventions: (a) mindful self-compassion (MSC; Neff
cused on two constructs that are receiving great attention: (a) & Germer, 2017), (b) compassion-focused therapy (Gilbert, 2009),
compassion fatigue (CF) and (b) mindful compassion (MC). CF is and (c) compassion-focused acceptance and commitment therapy
a recurring conceptualization of a core component of the job- (Tirch, Schoendorff, & Silberstein, 2014). All of these systematic
related stress of health-care providers. It may be generally defined interventions assume that the construct of MC “unites Buddhism
as “the caregiver’s cost of caring and results when caregivers are psychology and the current psychological science of self-
exposed to repeated interactions requiring high levels of empathic compassion” (Tirch, Silberstein, & Kolts, 2016, p. 148), by en-
engagement with distressed clients” (Sorenson, Bolick, Wright, & hancing cognitive– behavioral change and working against expe-
Hamilton, 2016, p. 457). Even though such a construct may be riential avoidance. More specifically, cognitive– behavioral
conflated with burnout itself, it seems to highlight a specific therapy interventions that are based on MC have proved to pro-
pattern of onset and maintenance of a health-care provider’s stress: mote emotional regulation and psychological flexibility, and to
the continuous and exhausting process of empathizing with the foster relational and ethical skills (Gilbert, 2009; Tirch et al., 2014;
suffering of others. Such a pattern is described in terms of a Vago & Silbersweig, 2012). Therefore, we may assume that the
compassionate resonance with the suffering of clients/care receiv- psychological flexibility derived from MC, “as the ability to con-
ers and a continuous arousal that is comparable with the one of a tact the present moment fully, as a conscious and emotionally
posttraumatic experience (Sheppard, 2015; Sorenson, Bolick, responsive human being” (Tirch et al., 2014, p. 43), may signifi-
Wright, & Hamilton, 2017). Assuming that a health-care profes- cantly support the nursing practices.
sion, especially when defined by a high commitment and engage- Recent existing reviews have reported that mindfulness medi-
ment, necessarily and paradoxically exposes the person to CF, we tation has a positive impact on nurses’ and nursing students’
need to outline education programs aimed at offering personal and distress, anxiety, depression, burnout, sense of well-being, and
professional tools that may serve as protective factors. empathy. All that said, the majority of the articles described
This need is probably one of the main reasons why mindfulness- studies with small effect sizes that limit the generalizability of the
based interventions (MBIs) and mindfulness-based education pro- results (Guillaumie, Boiral, & Champagne, 2017; van der Riet et
grams (MBEPs) are receiving great attention in the field of health al., 2018). Additionally, the requirement of personal mindfulness
care, and, specifically, of nursing (Botha, Gwin, & Purpora, 2015; practice (i.e., outside the school setting), which could not be
van der Riet, Levett-Jones, & Aquino-Russell, 2018). In the past monitored, turns out to be a limitation too. Most of the MBEPs try
20 years, different definitions and conceptualizations of mindful- to replicate the format and techniques of MBIs, rather than trying
ness have been proposed (Williams & Kabat-Zinn, 2011). We to integrate mindfulness into standard nursing curricula. Accumu-
maintain that “mindfulness is a key component of several stan- lating evidence on the effectiveness of MBI in nursing practice
dardized therapy models, most of which are included in the (Botha et al., 2015; Guillaumie et al., 2017) and MBEP in nursing
INTEGRATING MINDFULNESS INTO NURSING EDUCATION 3
schools (van der Riet, Rossiter, Kirby, Dluzewska, & Harmon, 2 (n ⫽ 46; the control group; CG) was composed of 34 females
2015) urge the universities to rethink their programs and evaluate (73.9%) and 12 males (26.1%), with a mean age of 24.8 years
possible strategies of coherently including mindfulness in their (SD ⫽ 3.7).
curricula. Such a challenge requires outlining new programs aimed
at considering mindfulness as an integrative part of the standard
Procedures
education (Walker & Mann, 2016). Moreover, this development
may foster a new, data-driven perspective (i.e., nurse errors, burn- The study was designed as a nonrandomized controlled trial in
out costs, patient compliance, etc.) on the construct of compassion accordance with the TREND Statement (Des Jarlais, Lyles, Cre-
as a component of mindfulness skills and programs in nursing paz, & The TREND Group, 2004). The participants were enrolled
(Brass, 2016). in the same year of their nursing degrees (i.e., the third and last
In 2015, we started a new project to integrate mindfulness into one) and the same course in two concurrent classes (i.e., GPC). We
the nursing school curriculum. The Self-Aware Nurse Project randomly selected a class for the MBEP (i.e., the treatment) and
(SANP) has been developed to (a) explore the constructs of MC delivered the standard course in the other group. All of the par-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
and CF in nursing practice and (b) integrate an MBI into an ticipants were asked to be assessed before and after the GPC and
This document is copyrighted by the American Psychological Association or one of its allied publishers.
existing class. The present article is devoted to report the prelim- did not receive any credit or benefit in return for their participation.
inary data of a pilot study intended to fulfill these two SANP We counted dropouts during and after the GPC in both the exper-
objectives. The present research investigated the effectiveness of a imental (n ⫽ 2) and control group (n ⫽ 5). None of participants
specifically designed MBEP within the nursing school curriculum. who concluded the pre- and the postassessment were classified as
The program is intended to substitute an existing class, general nonresponders; that is, they completed all of the items on all of the
pedagogy course (GPC), with a tailored MBI. The standard cur- questionnaires (see Figure 1). We defined a participant as a drop-
riculum goals of this course are to (a) promote reflexivity as a out whenever they missed at least one session in either the CG or
general ability to monitor personal and interpersonal experience the EG. The study was conducted according to the Declaration of
(Skovholt & Trotter-Mathison, 2016) and (b) provide strategies Helsinki; the protocol was reviewed and approved by the institu-
and tools for promoting health-care education in patients. We tional review board of the School of Nursing, and all participants
maintain that reflexivity can be better understood through the lens provided written informed consent.
of decentering, as a way to look at experience as a mental state
rather than as a part of the identity (Teasdale et al., 2002). The new
Intervention
MBEP applies theoretical and practical skills of mindfulness as the
foundation of the class, and is tailored to meet the two goals The GPC was delivered concurrently with the final internship.
described earlier. We assume that MC, as the ability to monitor The intervention was an MBEP for nursing students lasting 6
and decenter from one’s own and others’ suffering, may serve as weeks (see online supplemental material). It was composed of five
a protective factor against CF, as a pattern of automatic pilot regular 3-hr sessions and one all-day class lasting 4 and a half
reactions that are triggered by compassion itself. hours that were partially based on the mindfulness-based stress
reduction tradition (Kabat-Zinn, 1982, 1990), together with a few
Method components of mindfulness-based cognitive therapy (Segal, Wil-
liams, & Teasdale, 2002) and compassion-focused therapy (Gil-
Participants bert, 2009).
The present MBEP was aimed at integrating an MBI into a
Data were obtained from two groups (n ⫽ 82) of students regular setting. Therefore, it included both a theoretical part (based
(respectively Groups 1 and 2) enrolled in two concurrent classes of on the standard GPC and on the mindfulness psychoeducation) and
the same GPC of the School of Nursing at the University of standard mindfulness practices (mindfulness meditation exercises)
Florence, Italy (see Table 1). All the participants were attending together with a few specifically designed practices. The GPC
their third (and last) year of the nursing degree and were recruited general goals are to explain the foundations and the applications of
through a self-selection process. Group 1 (n ⫽ 36; the experimen- a continuing education approach in health care and are composed
tal group; EG) was composed of 28 females (77.7%) and eight of five 3-hr weekly sessions (and so lasting 5 weeks). GPC in the
males (22.3%), with a mean age of 24.9 years (SD ⫽ 3.9). Group School of Nursing especially focuses on three learning objectives:
(a) to explore the concept of reflexivity as a tool in monitoring and
revising nursing practice and illness experience, (b) to explain
useful strategies to prevent burnout and promote engagement in
Table 1
nurses, and (c) to explain useful strategies to facilitate and foster
Background Characteristics of the Sample
compliance in patients (Skovholt & Trotter-Mathison, 2016). The
Group 1 Group 2 Groups 1 and 2 proposed intervention yearned to reformulate these objectives
(n ⫽ 36) (n ⫽ 46) (n ⫽ 82) through the lens and within the framework of mindfulness. It did
Characteristics Treatment Control Sample not pretend to replace a formal mindfulness program that has to be
Age, M (SD) 24.9 (3.9) 24.7 (3.5) 24.8 (3.7) based on standardized training and on a sustained experiential
Sex engagement (Woods, 2009). It was aimed at introducing students
F, n (%) 28 (77.7%) 34 (73.9%) 62 (75.6%) to the understanding and the practice of mindfulness as the foun-
M, n (%) 8 (22.3%) 12 (26.1%) 20 (24.4%) dation of compassion (Feldman & Kuyken, 2011). Moreover, to
Note. F ⫽ female; M ⫽ male. minimize the confounding effect of personal practices, we did not
4 CHELI, DE BARTOLO, AND AGOSTINI
Measures
Copenhagen Burnout Inventory. The Copenhagen Burnout
Inventory (CBI) is a 19-item inventory that measures three subdi-
mensions of burnout (e.g., How often do you feel tired?): Personal,
Work Related, and Client Related (Avanzi, Balducci, & Fraccaroli,
Figure 1. Experimental design of the study.
2013; Fiorilli et al., 2015; Kristensen, Borritz, Villadsen, & Chris-
tensen, 2005). All three subscales can be subtotaled into a score of
include mandatory homework (see online supplemental material). 0 to 100 and averaged into a total score of 0 to 100, with a higher
The rationale of the intervention maintains that this perspective has score indicating a higher level of burnout. Similarly, a general
proven to be effective in promoting resilience both in professionals score can be obtained by aggregating all of the items and subscales
and in patients (Creswell, 2017). (Milfont, Denny, Ameratunga, Robinson, & Merry, 2008; Stein &
Sibanda, 2016). Across subscales, Cronbach’s ␣s ranged from .79
Treatment Fidelity to .85 in the present sample and .85 to .87 in the normative sample
To enhance the treatment fidelity, we defined the following (Kristensen et al., 2005).
procedures that are based on standard guidelines (Bellg et al., Mindful Attention Awareness Scale. The Mindful Attention
2004; Borrelli et al., 2005): Awareness Scale (MAAS) is a 15-item questionnaire scored ac-
cording to a Likert-type scale with a range going from 1 to 6
1. Treatment design. The treatment dose (length, number, (Brown & Ryan, 2003; MacKillop & Anderson, 2007; Veneziani
type, and duration of contact) was defined for both the & Voci, 2015). The scale measures the frequency of the state of
intervention and the control group. A manual of the mindfulness in daily life (e.g., I find myself doing things without
intervention for the two conditions was written and the paying attention), and its application does not require any specific
GPC components were the same in both groups (same training on the part of the respondent. A single scale score aver-
issues and same materials). The manual was based on a ages the scores across all 15 items, and higher scores indicate a
previous theoretical narrative review and metasynthesis, greater dispositional state of mindfulness. Although MAAS has
and a focus group with six nursing students. been criticized as a nonspecific measure, it is widely used as an
easy-to-apply tool aimed at assessing baseline tendency to attend
2. Provider’s profile. We defined the required skills and
to present moment experiences in everyday activities (Baer,
curriculum for the providers: a specific training and su-
Walsh, & Lykins, 2009). The present sample showed a good
pervision, at least 2 years of experience as a professor in
internal consistency (Cronbach’s ␣s ⫽ .91) when compared with
GPC for the control group; a specific training and super-
the normative data in undergraduate and general adult samples
vision, at least 2 years of experience as a Mindfulness
(Cronbach’s ␣s ⫽ .82 and .87, respectively; Baer et al., 2009).
teacher for the experimental group. To minimize the
biases in the study (i.e., the provider’s effect on the two
conditions that were only composed of two classes), we Objectives
defined the following format: (a) the same provider (with
the required skills) delivered the interventions for both The main objectives were to prove that (a) a Mindfulness Based
the experimental and control group and (b) two different Education Program (MBEP) is suitable for nursing students, by
independent experts supervised the provider’s training promoting an acceptable adherence rate (i.e., dropouts ⱕ10%) and
and the treatment’s fidelity for the two groups respec- (b) the proposed MBEP is effective in reducing burnout and
tively. increasing dispositional mindfulness (i.e., Cohen’s d ⱖ 0.5).
INTEGRATING MINDFULNESS INTO NURSING EDUCATION 5
ric data (CBI; MAAS) were analyzed with multilevel mixed t ⫽ 0.115) and MAAS (p ⫽ .879; t ⫽ 0.152) total scores. The
This document is copyrighted by the American Psychological Association or one of its allied publishers.
effects linear regression models as implemented through differences between pre- and postassessment in the EG high-
SPSS’s generalized linear mixed models (GLMMs; SPSS Ver- lighted a very large effect size in respect to MAAS total score
sion 20) procedure. GLMM allowed for testing the relationships (Cohen’s d ⫽ 1.221), and a medium effect size in respect to CBI
between fixed and random effects (group, time, Group ⫻ Time) total score (Cohen’s d ⫽ 0.648). The GLMM confirmed the
by assuming the clustered natured of the data (McCulloch & previous results (see Table 3), highlighting that the Group ⫻
Searle, 2001). A separate GLMM analysis was run for each Time interaction was significant for both CBI total score
outcome: burnout through the CBI total score and dispositional (Model 1; F ⫽ 6.462; p ⫽ .013) and for MAAS total score
mindfulness through MAAS total score. In the first GLMM (Model 2; F ⫽ 55.717; p ⫽ .000). The Akaike information
analysis, we included postassessment burnout as target, preas- criterion (AIC) was lower for MAAS total score model (AIC ⫽
sessment burnout as fixed effect, and class as random effect. In 152.133) than for CBI total score model (AIC ⫽ 572.413),
the second GLMM analysis, we included postassessment dis- suggesting the former may be the preferable one.
positional mindfulness as target, preassessment dispositional Furthermore, we performed an ex-post comparison on the rate of
mindfulness as fixed effect, and class as random effect. All the graduation 1 year after the baseline assessment (10 months after
analyses were performed though SPSS Version 20. the postassessment). We compared the rate (i.e., number of grad-
uated students/overall number of students) of the CG (n ⫽ 46;
Results M ⫽ .52; SD ⫽ .505) and the EG (n ⫽ 36; M ⫽ .83; SD ⫽ .378),
respectively, including the dropouts too. The independent sample
The percentage of dropouts in the EG and the CG were 5.5%
and 12.19%, respectively. Attrition rate did not differ signifi- t test showed a significant difference (p ⫽ .003; t ⫽ 3.085)
cantly between the two groups, even though only the EG between the two groups’ rates, exhibiting a medium effect size
reported a value below the target criterion (⬍10%). In the (Cohen’s d ⫽ 0.695).
whole sample, MAAS total score at the preassessment showed The treatment fidelity was assessed throughout the entire proj-
a significant negative correlation with CBI total score (p ⬍ ect. As previously reported, ANOVA showed no differences be-
.001; Pearson’s r ⫽ ⫺.418) and with CBI subscales, that is, tween EG and CG for burnout and mindfulness measures at
Personal (p ⬍ .001; Pearson’s r ⫽ ⫺.308), Work (p ⬍ .001; baseline assessment. Moreover, all of the sessions’ checklists
Pearson’s r ⫽ ⫺.334), and Client Burnout (p ⬍ .001; Pearson’s highlighted the expected completion rate (ⱖ90%) for the provider
r ⫽ ⫺.420). No differences were found (p ranging from .443 to (six checklists for EG and five for CG; M ⫽ 96.36; SD ⫽ 5.04),
.964; F ranging from .002 to .593) between the CG (n ⫽ 46) and the CG supervisor (five checklists; M ⫽ 96.66; SD ⫽ 5.16), and
the EG (n ⫽ 36) at the baseline assessment through one-way the EG supervisor (six checklists; M ⫽ 95; SD ⫽ 5.47). Finally,
ANOVA. To test the effectiveness of the intervention (i.e., the the participants reported significant differences between CG and
MBEP), we compared MAAS and CBI total scores (a) between EG neither at the course evaluation questionnaire (t ⫽ .050; p ⫽
baseline and postassessment within both groups, and between .960) nor at the GPC learning test (t ⫽ .352; p ⫽ .725).
Table 2
Differences in Postassessment Between Experimental and Control Group
MAAS total score 0.43056 1.14764 0.20953 0.00202 0.85909 2.055 29 .049 0.578
CBI total score ⫺7.33333 18.67561 3.40968 ⫺14.30692 ⫺0.35975 ⫺2.151 29 .040 1.250
Note. CI ⫽ confidence interval; LL ⫽ lower limit; UL ⫽ upper limit; Sig. ⫽ significance; MAAS ⫽ Mindful Attention Awareness Scale; CBI ⫽
Copenhagen Burnout Inventory.
6 CHELI, DE BARTOLO, AND AGOSTINI
Table 3
Generalized Linear Mixed Models: Fixed Coefficients
95% CI
Models Model term Coefficient SE t Significance LL UL
Italian validation of the Copenaghen Burnout Inventory (CBI)]. Psico- Ernst, M. D. (2004). Permutation methods: A basis for exact inference.
logia della Salute, 2, 120 –135. http://dx.doi.org/10.3280/PDS2013- Statistical Science, 19, 676 – 685. http://dx.doi.org/10.1214/088342304
002008 000000396
Awa, W. L., Plaumann, M., & Walter, U. (2010). Burnout prevention: A Feldman, C., & Kuyken, W. (2011). Compassion in the landscape of
review of intervention programs. Patient Education and Counseling, 78, suffering. Contemporary Buddhism, 12, 143–155. http://dx.doi.org/10
184 –190. http://dx.doi.org/10.1016/j.pec.2009.04.008 .1080/14639947.2011.564831
Baer, R. A., Walsh, E., & Lykins, E. L. B. (2009). Assessment of mind- Fiorilli, C., De Stasio, S., Benevene, P., Iezzi, D. F., Pepe, A., & Albanese,
fulness. In F. Didonna (Ed.), Clinical handbook of mindfulness (pp. O. (2015). Copenhagen Burnout Inventory (CBI): A validation study in
153–168). New York, NY: Springer. an Italian teacher group. TPM – Testing, Psychometrics, Methodology in
Beck, C. T. (1995). Burnout in undergraduate nursing students. Nurse Applied Psychology, 22, 537–551.
Educator, 20, 19 –23. http://dx.doi.org/10.1097/00006223-199507000- Foster, K. I., Benavides-Vaello, S., Katz, J. R., & Eide, P. (2012). Using
00008 the generative nursing model to reframe nursing student transition to
Bellg, A. J., Borrelli, B., Resnick, B., Hecht, J., Minicucci, D. S., Ory, M., practice. Nurse Educator, 37, 252–257. http://dx.doi.org/10.1097/NNE
. . . The Treatment Fidelity Workgroup of the NIH Behavior Change .0b013e31826f27c1
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Consortium. (2004). Enhancing treatment fidelity in health behavior Galbraith, N. D., & Brown, K. E. (2011). Assessing intervention effective-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
change studies: Best practices and recommendations from the NIH ness for reducing stress in student nurses: Quantitative systematic re-
Behavior Change Consortium. Health Psychology, 23, 443– 451. http:// view. Journal of Advanced Nursing, 67, 709 –721. http://dx.doi.org/10
dx.doi.org/10.1037/0278-6133.23.5.443 .1111/j.1365-2648.2010.05549.x
Borrelli, B., Sepinwall, D., Ernst, D., Bellg, A. J., Czajkowski, S., Breger, Gilbert, P. (2009). The compassionate mind. London, United Kingdom:
R., . . . Orwig, D. (2005). A new tool to assess treatment fidelity and Robinson.
evaluation of treatment fidelity across 10 years of health behavior Gilbert, P., & Choden. (2013). Mindful compassion. London, United King-
research. Journal of Consulting and Clinical Psychology, 73, 852– 860. dom: Robinson.
http://dx.doi.org/10.1037/0022-006X.73.5.852 Guillaumie, L., Boiral, O., & Champagne, J. (2017). A mixed-methods
Botha, E., Gwin, T., & Purpora, C. (2015). The effectiveness of mindful- systematic review of the effects of mindfulness on nurses. Journal of
ness based programs in reducing stress experienced by nurses in adult Advanced Nursing, 73, 1017–1034. http://dx.doi.org/10.1111/jan.13176
hospital settings: A systematic review of quantitative evidence protocol. Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for
JBI Database of Systematic Reviews and Implementation Reports, 13, chronic pain patients based on the practice of mindfulness meditation:
21–29. http://dx.doi.org/10.11124/jbisrir-2015-2380 Theoretical considerations and preliminary results. General Hospital
Brass, E. (2016). How mindfulness can benefit nursing practice. Nursing Psychiatry, 4, 33– 47. http://dx.doi.org/10.1016/0163-8343(82)90026-3
Times, 112, 21–23. Retrieved from https://www.nursingtimes.net/roles/ Kabat-Zinn, J. (1990). Full catastrophe living: How to cope with stress,
mental-health-nurses/how-mindfulness-can-benefit-nursing-practice/ pain and illness using mindfulness meditation. London, United King-
7004433 dom: Piatkus.
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Kristensen, T. S., Borritz, M., Villadsen, E., & Christensen, K. B. (2005).
Mindfulness and its role in psychological well-being. Journal of Per- The Copenhagen Burnout Inventory: A new tool for the assessment of
sonality and Social Psychology, 84, 822– 848. http://dx.doi.org/10.1037/ burnout. Work and Stress, 19, 192–207. http://dx.doi.org/10.1080/
0022-3514.84.4.822 02678370500297720
Cañadas-De la Fuente, G. A., Vargas, C., San Luis, C., García, I., Cañadas, MacKillop, J., & Anderson, E. J. (2007). Further psychometric validation
G. R., & De la Fuente, E. I. (2015). Risk factors and prevalence of of the Mindful Attention Awareness Scale (MAAS). Journal of Psycho-
burnout syndrome in the nursing profession. International Journal of pathology and Behavioral Assessment, 29, 289 –293. http://dx.doi.org/
Nursing Studies, 52, 240 –249. http://dx.doi.org/10.1016/j.ijnurstu.2014 10.1007/s10862-007-9045-1
.07.001 Maslach, C., Jackson, S., & Leiter, M. (1996). Maslach Burnout Inventory
Creswell, J. D. (2017). Mindfulness interventions. Annual Review of Psy- manual. Palo Alto, CA: Consulting Psychologists Press.
chology, 68, 491–516. http://dx.doi.org/10.1146/annurev-psych-042716- Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual
051139 Review of Psychology, 52, 397– 422. http://dx.doi.org/10.1146/annurev
Dahl, C. J., Lutz, A., & Davidson, R. J. (2015). Reconstructing and .psych.52.1.397
deconstructing the self: Cognitive mechanisms in meditation practice. McCulloch, C. E., & Searle, S. R. (2001). Generalized, linear, and mixed
Trends in Cognitive Sciences, 19, 515–523. http://dx.doi.org/10.1016/j models. New York, NY: Wiley.
.tics.2015.07.001 McManus, I. C., Winder, B. C., & Gordon, D. (2002). The causal links
Dall’Ora, C., Griffiths, P., Ball, J., Simon, M., & Aiken, L. H. (2015). between stress and burnout in a longitudinal study of U.K. doctors. The
Association of 12 h shifts and nurses’ job satisfaction, burnout and Lancet, 359, 2089 –2090. http://dx.doi.org/10.1016/S0140-6736
intention to leave: Findings from a cross-sectional study of 12 European (02)08915-8
countries. British Medical Journal Open, 5, e008331. http://dx.doi.org/ Mealer, M., Burnham, E. L., Goode, C. J., Rothbaum, B., & Moss, M.
10.1136/bmjopen-2015-008331 (2009). The prevalence and impact of post traumatic stress disorder and
Des Jarlais, D. C., Lyles, C., Crepaz, N., & The TREND Group. (2004). burnout syndrome in nurses. Depression and Anxiety, 26, 1118 –1126.
Improving the reporting quality of nonrandomized evaluations of behav- http://dx.doi.org/10.1002/da.20631
ioral and public health interventions: The TREND statement. American Milfont, T. L., Denny, S., Ameratunga, S., Robinson, E., & Merry, S.
Journal of Public Health, 94, 361–366. http://dx.doi.org/10.2105/AJPH (2008). Burnout and wellbeing: Testing the Copenhagen Burnout Inven-
.94.3.361 tory in New Zealand teachers. Social Indicators Research, 89, 169 –177.
Didonna, F. (2009). Introduction: Where new and old paths to dealing with http://dx.doi.org/10.1007/s11205-007-9229-9
suffering meet. In F. Didonna (Ed.), Clinical handbook of mindfulness Neff, K. D., & Germer, C. (2017). Self-compassion and psychological
(pp. 1–15). New York, NY: Springer. http://dx.doi.org/10.1007/978-0- wellbeing. In J. Doty (Ed.), Oxford handbook of compassion science (pp.
387-09593-6_1 371–386). New York, NY: Oxford University Press.
8 CHELI, DE BARTOLO, AND AGOSTINI
Pines, A. M., & Keinan, G. (2005). Stress and burnout: The significant Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., &
difference. Personality and Individual Differences, 39, 625– 635. http:// Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse
dx.doi.org/10.1016/j.paid.2005.02.009 in depression: Empirical evidence. Journal of Consulting and Clinical
Poghosyan, L., Clarke, S. P., Finlayson, M., & Aiken, L. H. (2010). Nurse Psychology, 70, 275–287. http://dx.doi.org/10.1037/0022-006X.70.2
burnout and quality of care: Cross-national investigation in six countries. .275
Research in Nursing and Health, 33, 288 –298. http://dx.doi.org/10 Tirch, D. D., Schoendorff, B., & Silberstein, L. R. (2014). The ACT
.1002/nur.20383 practitioner’s guide to the science of compassion. Tools for fostering
Pulido-Martos, M., Augusto-Landa, J., & Lopez-Zafra, E. (2012). Sources psychological flexibility. Oakland, CA: New Harbinger.
of stress in nursing students: A systematic review of quantitative studies. Tirch, D. D., Silberstein, L. R., & Kolts, R. L. (2016). Buddhist psychology
International Nursing Review, 59, 15–25. http://dx.doi.org/10.1111/j and cognitive– behavioral therapy. A clinician’s guide. New York, NY:
.1466-7657.2011.00939.x
Guilford Press.
Rella, S., Winwood, P. C., & Lushington, K. (2009). When does nursing
Vago, D. R., & Silbersweig, D. A. (2012). Self-awareness, self-regulation,
burnout begin? An investigation of the fatigue experience of Australian
and self-transcendence (S-ART): A framework for understanding the
nursing students. Journal of Nursing Management, 17, 886 – 897. http://
neurobiological mechanisms of mindfulness. Frontiers in Human Neu-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
dx.doi.org/10.1111/j.1365-2834.2008.00883.x
Ríos-Risquez, M. I., García-Izquierdo, M., Sabuco-Tebar, E. L., Carrillo- roscience, 6, Article ID 296. http://dx.doi.org/10.3389/fnhum.2012
This document is copyrighted by the American Psychological Association or one of its allied publishers.