International Journal of Stress

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

Integrating Mindfulness Into Nursing Education: A Pilot Nonrandomized

Controlled Trial

Simone Cheli Paola De Bartolo

Guglielmo Marconi University and University of Florence Guglielmo Marconi University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

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.

Keywords: acceptance, burnout, compassion, education, mindfulness

Supplemental materials: http://dx.doi.org/10.1037/str0000126.supp

Over the past 20 years, many studies and reviews have been
published about the prevalence and the risk factors of nurses’
burnout. Such a multidimensional construct describes “the exhaus-
tion of employees’ capacity to maintain an intense involvement
Simone Cheli, Department of Human Sciences, Guglielmo Marconi
University and School of Human Health Sciences, University of Florence;
Paola De Bartolo, Department of Human Sciences, Guglielmo Marconi
University; Antonella Agostini, School of Human Health Sciences, Uni-
versity of Florence.
The ideas and data reported in the present article have been previously
discussed and disseminated in different contexts. The theoretical back-
ground has been presented as a part of a wider training project for nurses
at the 18th International Psycho-Oncology Society Congress. The prelim-
inary data have been disseminated at the postgraduate course in mindful-
ness and psychotherapy at the University of Barcelona.
Correspondence concerning this article should be addressed to Simone
Cheli, who is now at Centro di Psicologia e Psicoterapia, Tages Onlus, via
della Torretta 14, Firenze 50137, Italy. E-mail: simone.cheli@unifi.it
that has a meaningful impact at work” (Schaufeli, Leiter, &
Maslach, 2009, p. 205). Burnout is traditionally considered to be a
particularly serious feature of chronic stress and one that can
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
responses to the job with different antecedents (Pines & Keinan,
2005). We can cautiously state that burnout is a chronic work-
related stress that is recurrent in emotionally demanding profes-
sions (Schaufeli et al., 2009).
The majority of the data reports a high prevalence of burnout
symptoms that seem to significantly affect quality of life and job
performance of nurses (Cañadas-De la Fuente et al., 2015; Mealer,
Burnham, Goode, Rothbaum, & Moss, 2009). Cross-national stud-
ies show relevant costs of nurses’ burnout in terms of reduced
quality of care, generally speaking (Dall’Ora, Griffiths, Ball, Si-
mon, & Aiken, 2015; Poghosyan, Clarke, Finlayson, & Aiken,
2010), and specifically in terms of direct costs such as medical
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
seems to be defined by a complex pattern of risk factors
(Cañadas-De la Fuente et al., 2015) that start operating at the early
beginnings of nurses’ careers (Beck, 1995; Foster, Benavides-
Vaello, Katz, & Eideet, 2012; Rella, Winwood, & Lushington,
2009). There is not a consensual agreement upon levels and
sources of burnout in nursing students, even though most of the
studies highlight recurring symptoms that affect the overall per-
formance (Pulido-Martos, Augusto-Landa, & Lopez-Zafra, 2012).
When trying to understand the risk factors of burnout and,
consequently, the possible prevention or management strategies,
we traditionally consider two types of concurrent perspectives
(Maslach, Schaufeli, & Leiter, 2001): (a) an organizational frame-
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
This document is copyrighted by the American Psychological Association or one of its allied publishers.
job characteristics) and (b) a personal framework mainly focused
on individual factors (e.g., personality and job attitudes). The
majority of the interventions aimed at preventing or reducing
burnout symptoms in nursing students focus on the latter frame-
work (Awa, Plaumann, & Walter, 2010; Galbraith & Brown,
2011). Indeed, the general objective of university training is to
prepare the candidate to adapt to different possible contexts. The
recent research trends try to understand how the match/mismatch
between individual and situational characteristics stands at the core
of the onset of burnout itself (Maslach et al., 2001; Ríos-Risquez,
García-Izquierdo, Sabuco-Tebar, Carrillo-Garcia, & Martinez-
Roche, 2016). Therefore, a nursing education training should pro-
mote those characteristics that better match the nursing job’s
demands.
Despite the huge amount of individual characteristics that may
define the nursing role inside health-care organizations, we fo-
cused on two constructs that are receiving great attention: (a)
compassion fatigue (CF) and (b) mindful compassion (MC). CF is
a recurring conceptualization of a core component of the job-
related stress of health-care providers. It may be generally defined
as “the caregiver’s cost of caring and results when caregivers are
exposed to repeated interactions requiring high levels of empathic
engagement with distressed clients” (Sorenson, Bolick, Wright, &
Hamilton, 2016, p. 457). Even though such a construct may be
conflated with burnout itself, it seems to highlight a specific
pattern of onset and maintenance of a health-care provider’s stress:
the continuous and exhausting process of empathizing with the
suffering of others. Such a pattern is described in terms of a
compassionate resonance with the suffering of clients/care receiv-
ers and a continuous arousal that is comparable with the one of a
posttraumatic experience (Sheppard, 2015; Sorenson, Bolick,
Wright, & Hamilton, 2017). Assuming that a health-care profes-
sion, especially when defined by a high commitment and engage-
ment, necessarily and paradoxically exposes the person to CF, we
need to outline education programs aimed at offering personal and
professional tools that may serve as protective factors.
This need is probably one of the main reasons why mindfulness-
based interventions (MBIs) and mindfulness-based education pro-
grams (MBEPs) are receiving great attention in the field of health
care, and, specifically, of nursing (Botha, Gwin, & Purpora, 2015;
van der Riet, Levett-Jones, & Aquino-Russell, 2018). In the past
20 years, different definitions and conceptualizations of mindful-
ness have been proposed (Williams & Kabat-Zinn, 2011). We
maintain that “mindfulness is a key component of several stan-
dardized therapy models, most of which are included in the
cognitive-behavioral approach” (Didonna, 2009, p. 10) and is
especially suited for supporting people in facing chronic physical
or psychological stress.
Given the flourishing of different studies and models of mind-
fulness practices, we may assume a recognized role in terms of
regulation processes, or more specifically of the ability to regulate
psychological or self-processes (Dahl, Lutz, & Davidson, 2015;
Tang, Hölzel, & Posner, 2015; Vago & Silbersweig, 2012). There-
fore, we may maintain that mindfulness “functions to reduce
suffering and create a sustainable healthy mind using a framework
of self-processing” (Vago & Silbersweig, 2012, p. 24) alternatively
focusing on the ability of modulating our self-awareness, our own
behaviors, and our relationships with others. Thus, the ability to
manage suffering, such as that of care givers and care receivers,
passes through a kind of aware and sustained acceptance, de-
scribed as “opening oneself to the context, striving to wait for
understanding rather than leap in precipitously, acknowledging
distress as an understandable outcome in clients and in ourselves
rather than as a problem to be solved” (Robins, Schmidt, &
Linehan, 2004, p. 38). The compassion itself, through the lens of
mindfulness and acceptance, is no longer a source of suffering and
burnout. It may be defined by two distinct abilities: “one that helps
us to engage with suffering, to understand it; and another that
arises from our skilful actions and our efforts to alleviate it”
(Gilbert & Choden, 2013, p. xxxvii). Mindfulness offers a source
of practical methods to cultivate compassion as a path of personal
enhancement and self-regulation (Gilbert, 2009). The construct of
MC turns out to be a very practical tool in alleviating one’s own
and others’ suffering, which may refer, at least, to three subsets of
validated interventions: (a) mindful self-compassion (MSC; Neff
& Germer, 2017), (b) compassion-focused therapy (Gilbert, 2009),
and (c) compassion-focused acceptance and commitment therapy
(Tirch, Schoendorff, & Silberstein, 2014). All of these systematic
interventions assume that the construct of MC “unites Buddhism
psychology and the current psychological science of self-
compassion” (Tirch, Silberstein, & Kolts, 2016, p. 148), by en-
hancing cognitive– behavioral change and working against expe-
riential avoidance. More specifically, cognitive– behavioral
therapy interventions that are based on MC have proved to pro-
mote emotional regulation and psychological flexibility, and to
foster relational and ethical skills (Gilbert, 2009; Tirch et al., 2014;
Vago & Silbersweig, 2012). Therefore, we may assume that the
psychological flexibility derived from MC, “as the ability to con-
tact the present moment fully, as a conscious and emotionally
responsive human being” (Tirch et al., 2014, p. 43), may signifi-
cantly support the nursing practices.
Recent existing reviews have reported that mindfulness medi-
tation has a positive impact on nurses’ and nursing students’
distress, anxiety, depression, burnout, sense of well-being, and
empathy. All that said, the majority of the articles described
studies with small effect sizes that limit the generalizability of the
results (Guillaumie, Boiral, & Champagne, 2017; van der Riet et
al., 2018). Additionally, the requirement of personal mindfulness
practice (i.e., outside the school setting), which could not be
monitored, turns out to be a limitation too. Most of the MBEPs try
to replicate the format and techniques of MBIs, rather than trying
to integrate mindfulness into standard nursing curricula. Accumu-
lating evidence on the effectiveness of MBI in nursing practice
(Botha et al., 2015; Guillaumie et al., 2017) and MBEP in nursing
 INTEGRATING MINDFULNESS INTO NURSING EDUCATION
schools (van der Riet, Rossiter, Kirby, Dluzewska, & Harmon,
2015) urge the universities to rethink their programs and evaluate
possible strategies of coherently including mindfulness in their
curricula. Such a challenge requires outlining new programs aimed
at considering mindfulness as an integrative part of the standard
education (Walker & Mann, 2016). Moreover, this development
may foster a new, data-driven perspective (i.e., nurse errors, burn-
out costs, patient compliance, etc.) on the construct of compassion
as a component of mindfulness skills and programs in nursing
(Brass, 2016).
In 2015, we started a new project to integrate mindfulness into
the nursing school curriculum. The Self-Aware Nurse Project
(SANP) has been developed to (a) explore the constructs of MC
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
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-
inary data of a pilot study intended to fulfill these two SANP
objectives. The present research investigated the effectiveness of a
specifically designed MBEP within the nursing school curriculum.
The program is intended to substitute an existing class, general
pedagogy course (GPC), with a tailored MBI. The standard cur-
riculum goals of this course are to (a) promote reflexivity as a
general ability to monitor personal and interpersonal experience
(Skovholt & Trotter-Mathison, 2016) and (b) provide strategies
and tools for promoting health-care education in patients. We
maintain that reflexivity can be better understood through the lens
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
MBEP applies theoretical and practical skills of mindfulness as the
foundation of the class, and is tailored to meet the two goals
described earlier. We assume that MC, as the ability to monitor
and decenter from one’s own and others’ suffering, may serve as
a protective factor against CF, as a pattern of automatic pilot
reactions that are triggered by compassion itself.
Method
Participants
Data were obtained from two groups (n ⫽ 82) of students
(respectively Groups 1 and 2) enrolled in two concurrent classes of
the same GPC of the School of Nursing at the University of
Florence, Italy (see Table 1). All the participants were attending
their third (and last) year of the nursing degree and were recruited
through a self-selection process. Group 1 (n ⫽ 36; the experimen-
tal group; EG) was composed of 28 females (77.7%) and eight
males (22.3%), with a mean age of 24.9 years (SD ⫽ 3.9). Group
Table 1
Background Characteristics of the Sample
Group 1 Group 2 Groups 1 and 2
(n ⫽ 36) (n ⫽ 46) (n ⫽ 82)
Characteristics Treatment Control Sample
Age, M (SD) 24.9 (3.9) 24.7 (3.5) 24.8 (3.7)
Sex
F, n (%) 28 (77.7%) 34 (73.9%) 62 (75.6%)
M, n (%) 8 (22.3%) 12 (26.1%) 20 (24.4%)
Note. F ⫽ female; M ⫽ male.
3
2 (n ⫽ 46; the control group; CG) was composed of 34 females
(73.9%) and 12 males (26.1%), with a mean age of 24.8 years
(SD ⫽ 3.7).
Procedures
The study was designed as a nonrandomized controlled trial in
accordance with the TREND Statement (Des Jarlais, Lyles, Cre-
paz, & The TREND Group, 2004). The participants were enrolled
in the same year of their nursing degrees (i.e., the third and last
one) and the same course in two concurrent classes (i.e., GPC). We
randomly selected a class for the MBEP (i.e., the treatment) and
delivered the standard course in the other group. All of the par-
ticipants were asked to be assessed before and after the GPC and
did not receive any credit or benefit in return for their participation.
We counted dropouts during and after the GPC in both the exper-
imental (n ⫽ 2) and control group (n ⫽ 5). None of participants
who concluded the pre- and the postassessment were classified as
nonresponders; that is, they completed all of the items on all of the
questionnaires (see Figure 1). We defined a participant as a drop-
out whenever they missed at least one session in either the CG or
the EG. The study was conducted according to the Declaration of
Helsinki; the protocol was reviewed and approved by the institu-
tional review board of the School of Nursing, and all participants
provided written informed consent.
Intervention
The GPC was delivered concurrently with the final internship.
The intervention was an MBEP for nursing students lasting 6
weeks (see online supplemental material). It was composed of five
regular 3-hr sessions and one all-day class lasting 4 and a half
hours that were partially based on the mindfulness-based stress
reduction tradition (Kabat-Zinn, 1982, 1990), together with a few
components of mindfulness-based cognitive therapy (Segal, Wil-
liams, & Teasdale, 2002) and compassion-focused therapy (Gil-
bert, 2009).
The present MBEP was aimed at integrating an MBI into a
regular setting. Therefore, it included both a theoretical part (based
on the standard GPC and on the mindfulness psychoeducation) and
standard mindfulness practices (mindfulness meditation exercises)
together with a few specifically designed practices. The GPC
general goals are to explain the foundations and the applications of
a continuing education approach in health care and are composed
of five 3-hr weekly sessions (and so lasting 5 weeks). GPC in the
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
nurses, and (c) to explain useful strategies to facilitate and foster
compliance in patients (Skovholt & Trotter-Mathison, 2016). The
proposed intervention yearned to reformulate these objectives
through the lens and within the framework of mindfulness. It did
not pretend to replace a formal mindfulness program that has to be
based on standardized training and on a sustained experiential
engagement (Woods, 2009). It was aimed at introducing students
to the understanding and the practice of mindfulness as the foun-
dation of compassion (Feldman & Kuyken, 2011). Moreover, to
minimize the confounding effect of personal practices, we did not
 4 CHELI, DE BARTOLO, AND AGOSTINI
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
Figure 1. Experimental design of the study.
include mandatory homework (see online supplemental material).
The rationale of the intervention maintains that this perspective has
proven to be effective in promoting resilience both in professionals
and in patients (Creswell, 2017).
Treatment Fidelity
To enhance the treatment fidelity, we defined the following
procedures that are based on standard guidelines (Bellg et al.,
2004; Borrelli et al., 2005):
1. Treatment design. The treatment dose (length, number,
type, and duration of contact) was defined for both the
intervention and the control group. A manual of the
intervention for the two conditions was written and the
GPC components were the same in both groups (same
issues and same materials). The manual was based on a
previous theoretical narrative review and metasynthesis,
and a focus group with six nursing students.
2. Provider’s profile. We defined the required skills and
curriculum for the providers: a specific training and su-
pervision, at least 2 years of experience as a professor in
GPC for the control group; a specific training and super-
vision, at least 2 years of experience as a Mindfulness
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
defined the following format: (a) the same provider (with
the required skills) delivered the interventions for both
the experimental and control group and (b) two different
independent experts supervised the provider’s training
and the treatment’s fidelity for the two groups respec-
tively.
3. Delivery and receipt of treatment. Three specific check-
lists (one for the provider and two for the supervisors)
were prepared for each session of the two conditions. The
duration of the sessions and the completion of the objec-
tives were controlled by the supervisor independently and
by a focus group with the participants (5 Subject ⫻
Group). The two independent experts delivered weekly
supervisions with the provider. To define valid and reli-
able indices, we included the following variables: (a) no
significant difference between EG and CG for primary
and secondary outcomes at preassessment, (b) comple-
tion of at least 90% of tasks in sessions’ provider’s
checklist, (c) completion of at least 90% of tasks in
sessions’ supervisors’ checklists, and (d) no significant
difference between EG and CG at the course evaluation
questionnaire and at the GPC learning test.
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,
2013; Fiorilli et al., 2015; Kristensen, Borritz, Villadsen, & Chris-
tensen, 2005). All three subscales can be subtotaled into a score of
0 to 100 and averaged into a total score of 0 to 100, with a higher
score indicating a higher level of burnout. Similarly, a general
score can be obtained by aggregating all of the items and subscales
(Milfont, Denny, Ameratunga, Robinson, & Merry, 2008; Stein &
Sibanda, 2016). Across subscales, Cronbach’s ␣s ranged from .79
to .85 in the present sample and .85 to .87 in the normative sample
(Kristensen et al., 2005).
Mindful Attention Awareness Scale. The Mindful Attention
Awareness Scale (MAAS) is a 15-item questionnaire scored ac-
cording to a Likert-type scale with a range going from 1 to 6
(Brown & Ryan, 2003; MacKillop & Anderson, 2007; Veneziani
& Voci, 2015). The scale measures the frequency of the state of
mindfulness in daily life (e.g., I find myself doing things without
paying attention), and its application does not require any specific
training on the part of the respondent. A single scale score aver-
ages the scores across all 15 items, and higher scores indicate a
greater dispositional state of mindfulness. Although MAAS has
been criticized as a nonspecific measure, it is widely used as an
easy-to-apply tool aimed at assessing baseline tendency to attend
to present moment experiences in everyday activities (Baer,
Walsh, & Lykins, 2009). The present sample showed a good
internal consistency (Cronbach’s ␣s ⫽ .91) when compared with
the normative data in undergraduate and general adult samples
(Cronbach’s ␣s ⫽ .82 and .87, respectively; Baer et al., 2009).
Objectives
The main objectives were to prove that (a) a Mindfulness Based
Education Program (MBEP) is suitable for nursing students, by
promoting an acceptable adherence rate (i.e., dropouts ⱕ10%) and
(b) the proposed MBEP is effective in reducing burnout and
increasing dispositional mindfulness (i.e., Cohen’s d ⱖ 0.5).
 INTEGRATING MINDFULNESS INTO NURSING EDUCATION
Data Analysis
The research design included one categorical random effect
(class), one categorical fixed effect (group: intervention and
control), and two ordinal fixed effects (time-burnout: pretest,
posttest; time-dispositional mindfulness: pretest, posttest). Be-
cause the categorical random effect and the categorical fixed
effect coincided, we outlined different data analysis strategies
to reduce the main biases of the present pilot study. On the one
hand, we explored the variance between and within EG and CG
through common permutation methods (Ernst, 2004), without
considering the clustered nature of the data: one-way analysis
of variance (ANOVA) for pretest comparison; paired samples t
test for posttest comparison. On the other hand, the psychomet-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ric data (CBI; MAAS) were analyzed with multilevel mixed
This document is copyrighted by the American Psychological Association or one of its allied publishers.
effects linear regression models as implemented through
SPSS’s generalized linear mixed models (GLMMs; SPSS Ver-
sion 20) procedure. GLMM allowed for testing the relationships
between fixed and random effects (group, time, Group ⫻ Time)
by assuming the clustered natured of the data (McCulloch &
Searle, 2001). A separate GLMM analysis was run for each
outcome: burnout through the CBI total score and dispositional
mindfulness through MAAS total score. In the first GLMM
analysis, we included postassessment burnout as target, preas-
sessment burnout as fixed effect, and class as random effect. In
the second GLMM analysis, we included postassessment dis-
positional mindfulness as target, preassessment dispositional
mindfulness as fixed effect, and class as random effect. All the
analyses were performed though SPSS Version 20.
Results
The percentage of dropouts in the EG and the CG were 5.5%
and 12.19%, respectively. Attrition rate did not differ signifi-
cantly between the two groups, even though only the EG
reported a value below the target criterion (⬍10%). In the
whole sample, MAAS total score at the preassessment showed
a significant negative correlation with CBI total score (p ⬍
.001; Pearson’s r ⫽ ⫺.418) and with CBI subscales, that is,
Personal (p ⬍ .001; Pearson’s r ⫽ ⫺.308), Work (p ⬍ .001;
Pearson’s r ⫽ ⫺.334), and Client Burnout (p ⬍ .001; Pearson’s
r ⫽ ⫺.420). No differences were found (p ranging from .443 to
.964; F ranging from .002 to .593) between the CG (n ⫽ 46) and
the EG (n ⫽ 36) at the baseline assessment through one-way
ANOVA. To test the effectiveness of the intervention (i.e., the
MBEP), we compared MAAS and CBI total scores (a) between
baseline and postassessment within both groups, and between
Table 2
Differences in Postassessment Between Experimental and Control Group
Paired sample t test
Measures M SD SEM
MAAS total score 0.43056 1.14764 0.20953
CBI total score ⫺7.33333 18.67561 3.40968
Note. CI ⫽ confidence interval; LL ⫽ lower limit; UL ⫽ upper limit; Sig. ⫽ significance; MAAS ⫽ Mindful Attention Awareness Scale; CBI ⫽
Copenhagen Burnout Inventory.
5
experimental and control groups at the postassessment. Two
cases were missing at the postassessment in the EG, five cases
in the CG (see Figure 1). The paired samples t test highlighted
significant (p ⬍ .05) differences between EG and CG for both
the MAAS and the CBI total scores at postassessment (see
Table 2). The differences between EG and CG showed a very
large effect size in respect to the CBI total score (Cohen’s d ⫽
1.250), and a medium effect size in respect to the MAAS total
score (Cohen’s d ⫽ 0.578).
The single sample t test showed significant differences in the
EG between pre- and postassessment for MAAS (p ⫽ .002; t ⫽
3.087) and CBI (p ⫽ .020; t ⫽ 2.369) total scores, whereas the
differences in the CG were not significant for CBI (p ⫽ .897;
t ⫽ 0.115) and MAAS (p ⫽ .879; t ⫽ 0.152) total scores. The
differences between pre- and postassessment in the EG high-
lighted a very large effect size in respect to MAAS total score
(Cohen’s d ⫽ 1.221), and a medium effect size in respect to CBI
total score (Cohen’s d ⫽ 0.648). The GLMM confirmed the
previous results (see Table 3), highlighting that the Group ⫻
Time interaction was significant for both CBI total score
(Model 1; F ⫽ 6.462; p ⫽ .013) and for MAAS total score
(Model 2; F ⫽ 55.717; p ⫽ .000). The Akaike information
criterion (AIC) was lower for MAAS total score model (AIC ⫽
152.133) than for CBI total score model (AIC ⫽ 572.413),
suggesting the former may be the preferable one.
Furthermore, we performed an ex-post comparison on the rate of
graduation 1 year after the baseline assessment (10 months after
the postassessment). We compared the rate (i.e., number of grad-
uated students/overall number of students) of the CG (n ⫽ 46;
M ⫽ .52; SD ⫽ .505) and the EG (n ⫽ 36; M ⫽ .83; SD ⫽ .378),
respectively, including the dropouts too. The independent sample
t test showed a significant difference (p ⫽ .003; t ⫽ 3.085)
between the two groups’ rates, exhibiting a medium effect size
(Cohen’s d ⫽ 0.695).
The treatment fidelity was assessed throughout the entire proj-
ect. As previously reported, ANOVA showed no differences be-
tween EG and CG for burnout and mindfulness measures at
baseline assessment. Moreover, all of the sessions’ checklists
highlighted the expected completion rate (ⱖ90%) for the provider
(six checklists for EG and five for CG; M ⫽ 96.36; SD ⫽ 5.04),
the CG supervisor (five checklists; M ⫽ 96.66; SD ⫽ 5.16), and
the EG supervisor (six checklists; M ⫽ 95; SD ⫽ 5.47). Finally,
the participants reported significant differences between CG and
EG neither at the course evaluation questionnaire (t ⫽ .050; p ⫽
.960) nor at the GPC learning test (t ⫽ .352; p ⫽ .725).
95% CI
Sig. Cohen’s
LL UL t df (two tailed) d
0.00202 0.85909 2.055 29 .049 0.578
⫺14.30692 ⫺0.35975 ⫺2.151 29 .040 1.250
 6 CHELI, DE BARTOLO, AND AGOSTINI
Table 3
Generalized Linear Mixed Models: Fixed Coefficients
Models Model term Coefficient
Model 1 Intercept 20.458
CBI total score 0.248
Model 2 Intercept 1.834
MAAS total score 0.0632
Note. CI ⫽ confidence interval; LL ⫽ lower limit; UL ⫽ upper limit; CBI ⫽ Copenhagen Burnout Inventory; MAAS ⫽ Mindful Attention Awareness
Scale. The targets are the postassessment variables (Model 1: CBI t2 total score; Model 2: MAAS t2 total score). The fixed effects are the preassessment
variables (Model 1: CBI t1 total score; Model 2: MAAS t1 total score). The random effect is always the class (experimental group or control group).
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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Discussion
The present article is intended to be a first step in outlining an
MBEP for nursing students, namely, SANP (see online supple-
mental material). The rationale behind this project arose from
dealing with the multifaceted construct of compassion in nursing
practice. From a burnout point of view, compassion is the main
source of the long-standing and exhausting phenomenon of CF
(Sorenson et al., 2016). From a mindfulness point of view, it may
turn out to be a pattern of personal enhancement through processes
of self-awareness and decentering (Gilbert & Choden, 2013). To
ground our education program for nursing students on context-
specific and scientifically validated evidence, we started a pilot
study. The reported study initially tried to validate the effective-
ness of a specifically designed MBEP that aspires to be coherently
integrated into the nursing school curriculum. Such an effective-
ness was defined as an increase of dispositional mindfulness and a
decrease of perceived burnout at the end of the 3-month standard
internship. The SANP’s rationale is based on the assumption that
what we define as CF may be due to a naïve construction of
empathy as a sort of automatic (and thus scarcely aware) resonance
with the other’s suffering. On the contrary, MC may lead to
construct empathy as “a heightened, focused awareness of the
experience of another person that includes understanding, perspec-
tive, and an ability to derive and construe what that persons’
experience would be like” (Tirch et al., 2014, p. 49).
The present nonrandomized controlled trial (n ⫽ 82) highlights
that changes between pre- and postassessment in the experimental
group and between control and experimental group in the postas-
sessment exhibit medium to very large effect sizes among MAAS
and CBI total scores (Cohen’s d ranging from 0.57 to 1.25), that is,
they show a significant increase of dispositional mindfulness and
a significant decrease of perceived burnout. GLMM analyses seem
to confirm these results for both of the outcomes (burnout though
CBI total score and dispositional mindfulness through MAAS total
score) and to exclude biases that are due to the clustered nature of
the data. All of the reported measures of fidelity to treatment show
good provider’s adherence to the MBEP protocol. When compar-
ing the rate of graduated students at 1 year after the end of courses
between the experimental and the control groups, the latter group
shows a significantly lower rate with medium effect size (Cohen’s
d ⫽ 0.695). The results seem to confirm the effectiveness of our
specifically designed MBEP, even considering that the two groups
were comparable in respect to MAAS and CBI scores at the
baseline assessment, and that the percentage of dropouts in the EG
95% CI
SE t Significance LL UL
4.576 4.471 .000 11.337 29.580
0.098 2.542 .013 0.054 0.443
0.447 4.101 .000 0.942 2.725
0.085 7.464 .000 0.463 0.800
was as limited as expected (ⱕ10%). Further studies should deeply
explore how MBIs or MBEPs may improve the clinical (Brass,
2016; Walker & Mann, 2016) and compassion competences (Gil-
bert, 2009) of nursing students. Three main limits of our study
must be taken into account. The reported effectiveness is biased by
the low sample size once excluding dropouts (n ⫽ 75), the gen-
eralizability is reduced by the absence of a randomization of the
subjects, and the significance is biased by the presence of only two
groups and consequently by the overlapping of the main random
(class) and fixed effect (group: intervention, control). Even if these
limits are consistent with a preliminary pilot study, the reported
results should be interpreted with caution.
All that said, the present research shows promising results for
the application of an MBEP that is coherently integrated into the
nursing curriculum. SANP’s rationale seems to be confirmed in
terms of the usefulness of considering compassion from a mind-
fulness point of view, that is, as a pattern of self-enhancement
rather than simply as a source of burnout. Moreover, our MBEP
represents one of the few existing attempts to integrate an MBI
into the nursing curriculum rather than offering it as an extracom-
ponent (Guillaumie et al., 2017; van der Riet et al., 2018). Further
studies are needed to explore the long-term effectiveness of our
MBEP in large sample sizes and to clearly describe the mindful-
ness mechanisms that are operating during the intervention itself,
as well as the theoretical background behind those mechanisms.
Indeed, there may be at least three potential implications of future
confirmatory studies: (a) Standard nursing classes focused on
topics such as general pedagogy and communication may benefit
from a theoretical integration with constructs such as compassion
(Gilbert & Choden, 2013) and decentering (Teasdale et al., 2002),
(b) practical exercises before and supervision during internship
may include standardized mindfulness practices (Segal et al.,
2002), and (c) universities may aim at developing routine MBEPs
rather than simply offering MBIs as possible integrations (Van der
Riet et al., 2018).
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Received August 8, 2018
Revision received January 22, 2019
Accepted January 24, 2019 䡲