BURNOUT IN PSYCHIATRIC NURSING

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Decreasing Burnout in Psychiatric Nursing

Shannon M. Stewart
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Shannon Stewart is a Registered Nurse at Banner Baywood Medical Center in Mesa
Arizona on the Neurology floor.
She has no known conflict of interest to disclose.
Correspondence should be addressed to Shannon Stewart, Edson College of Nursing and
Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix, AZ
85004. Email: Smstewa7@asu.edu

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Abstract
Burnout has become an increasingly popular topic among registered nurses, but unfortunately
burnout among psychiatric nursing is less understood than other nursing specialties such as the
Intensive Care Unit, Emergency Room, or Oncology. Psychiatry is unique and psychiatric
nurses, in particular, are often subjected to physical and verbal violence as well as exposure to
patient’s trauma. The aim of this project was to decrease burnout among psychiatric nurses in a
private practice out-patient family psychiatric facility using Rossworm and Larabee’s change
model (Appendix D). The MBI-HSS was completed by 1 participant (n=1) at pre-intervention
and post-intervention. Between the pre/post MBI-HSS questionnaire the participant was asked to
partake in a mindfulness-based intervention utilizing the smartphone application Headspace to
complete a 10-session meditation course over one week. The results conclude the participant’s
burnout decreased overall from pre-intervention to post-intervention. Internal Review Board
(IRB) was granted in September 2021, and the project was completed in November 2021. The
impact of the project was projected to have a more thorough statistical influence, but due to the
participant size, there is minimal impact of system or polices in the psychiatric facility.
Keywords: burnout, nurses, mindfulness, psychiatry, mental health.

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Decreasing Burnout in Psychiatric Nursing
Working on inpatient psychiatric units can be difficult as nursing and support staff are
often subject to physical and verbal violence as well as exposure to patient’s traumatic events.
Working in such a high-intensity environment may lead to an increased risk of the occupational
phenomenon known as “burnout” and secondary trauma. The University of St. Augustine Health
Sciences (2020) defines burnout as “the state of mental, physical, and emotional exhaustion
caused by sustained work-related stressors.” The extent of burnout is under-researched, but what
is known are the effects of burnout can be significant.
Background and Significance
Problem Statement
Burnout is important as it can affect individuals mentally and physically. Per Kelley
(2020) burnout can lead to mental disorders including depression and several physical disorders
including higher cholesterol and body mass index. It is important to note that studies such as
Johnson et al. (2018) compare burnout in medical nursing to psychiatric nursing and report that
those working in psychiatric wards had higher emotional exhaustion than their medical
colleagues. Burnout is not only present in America, and by studying statistics globally, Johnson
et al. (2018) found that out of 12 countries, nine countries reported significant nursing burnout,
with rates as high as 78% in Greece supporting burnout as a global crisis.
Purpose and Rationale
Burnout in psychiatric nurses continues to be understudied. The purpose of this paper is
to provide a review regarding psychological damage caused by burnout and to explore the
interventions that improve well-being and decrease burnout in mental health nursing.

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Epidemiological Data
Caring can be defined as the main characteristic of the art of nursing which resonates
with the relations of psychiatric nursing (Edward et al., 2017). Role strain in psychiatric nursing
endures when the nursing expectations require suppressed management of emotions that can lead
to burnout and eventually attrition (Edward et al., 2017). Burnout can be attributed to many
factors, some of which may include workplace-violence which can range from physical, verbal,
or emotional harassment. Kobayash et al. (2020) state found that work place violence can impact
psychological injuries including depression and anxiety which can lead to severe mental health
concerns. Guillaumie et al. (2017) estimate burnout to be the second most prominent
occupational health hazard following musculoskeletal disorders.
Anxiety and emotional exhaustion are prominent factors in burnout. Nia et al. (2016)
focused their research on the limited knowledge of death anxiety and the increased prevalence in
psychiatric nurses. The findings conclude nurses are at an increased risk for anxiety related to
death as the stress related to suicidal patients may be overbearing. While research comparing
burnout between the sexes of nurses is scarce, there is a contrast of abuse reported between men
and women. Kobayash et al. (2020) report female nurses are more often victims of verbal abuse
and male nurses are more often victims of physical abuse.
Burnout has increased in recognition, but unfortunately is increasing in prevalence at a
faster rate. Janeway (2020) estimates burnout among registered nurses ranges from 35 to 45
percent. Those statistics favor Ross et al. (2017)’s findings as high demands and unfavorable
work schedules such as work overload and long work hours have proven to increase burnout.
The COVID-19 virus has further increased the burnout rate of all healthcare workers,
especially nurses. Nurses enduring a catastrophic pandemic can lead to traumatic experiences

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increasing the risk for burnout. The trauma nurses endure can easily lead to post-traumatic stress
disorder and burnout (Janeway, 2020). Adding on to the list of negative side effects, PerezFuentes et al. (2018) conducted a study evaluating the development of burnout syndrome and
found that burnout can lead to alcoholism and absenteeism.
Current clinical practice guidelines include a multitude of mindfulness techniques that
focus on stress reduction. As stated by Mills (2020) Mindfulness-Based Stress Reduction
(MSBR) has been used over four decades and has continued to provide evidence that stress
reduction and increased mindfulness are common results. There are many different forms of
mindfulness activities individuals can complete which include techniques that focus attention on
the body’s senses, breathing methods, and guided imagery (Mayo Clinic, 2020).
Psychiatric Nurses
Dall’Ora et al. (2020) examined the relationship between factors that cause burnout
which include individuals, organizations, the patients, nurse to patient ratios, and the
consequences of burnout. Factors that are known to increase burnout and are specific to
psychiatric nursing include a higher patient-to-nurse ratio (Dall’Ora et al., 2020). Psychiatric
nurses commonly have higher patient-to-nurse ratios than medical nurses, reasons reported
include medically ill patients require more one on one time (Dall’Ora et al., 2020). It is important
to note that poor ratios were reported to lead to emotional exhaustion as well as high
psychological demands and patient violence, all of which are seen often when working with the
psychiatric population (Dall’Ora et al., 2020).

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Mindfulness Interventions
Mindfulness is becoming an increasingly popular resource to deter burnout. Mindfulness
has been studied to compare the relationship between burnout and nursing. Many studies provide
the same literature and state there are benefits to mindfulness activities that may reduce burnout
symptoms (Jones, 2020).
Guillaumie et al. (2017) reviewed the effects of mindfulness-based interventions for
registered nurses and reports there are benefits of using mindfulness activities such as decreasing
depression and anxiety. While mindfulness activities have been proven to help the nurse, the
activity has also been shown to improve patient care. Johnson et al. (2018) found that nurses who
work in acute psychiatric facilities while utilizing mindfulness-based stress-reduction
interventions not only decreased patient safety events but resulted in improved patient
satisfaction scores.
Lack of Burnout Interventions
Although research proves mindfulness-based activities may help reduce burnout, there is
a lack of research and evidence to support mindfulness long-term (Guillaumie et al, 2017). As
previously stated death anxiety among psychiatric nurses may require management strategies. An
intervention for nurses experiencing death anxiety may lead to a decrease in decrements in
personal health (Nia et al., 2016). Sarazine et al. (2020) examined the impact of a four-hour
mindfulness workshop for nurses who were experiencing symptoms of burnout, the authors
reported a decreased in burnout, but further research is needed to determine the long-term impact
of mindfulness training on burnout.
Considerable evidence is still required for understanding burnout related to psychiatric
nurses. While there is evidence that states mindfulness techniques may be beneficial, future

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evidence should aim towards reducing factors that contribute to burnout rather than reversing the
effects of burnout.
Internal Data
An examination of internal data in a psychiatric ward in the greater area of Phoenix
showed the facility was lacking appropriate mindfulness activities for their nursing staff, which
they believe may contribute to higher rates of self-reported burnout. This is consistent with
previous literature from the Centers for Disease Control and Prevention [CDC] (2020) as
engaging in mindfulness techniques, which may include breathing exercises, can help increase
resilience decreasing the risk for burnout. However, hard data for continued mindfulness
activities and the correlation of burnout are difficult to trace.
PICOT
While searching for possibilities to decrease depression and anxiety for nurses working in
psychiatry this inquiry has led to the PICOT question: “In psychiatric nurses who have selfreported burnout, how can participating in mindfulness activities compared to not participating in
mindfulness activities affect rates of burnout?”
Evidence Synthesis
Search Strategy
An extensive review of the literature was performed using the following databases:
Cumulative Index of Nursing and Allied Health Literature (CINAHL), Academic Search
Premier, PsycINFO, and PubMed. Three out of four databases searched provided robust, high
yields and were selected for their focus on nursing, psychiatry, and psychological wellbeing.
PubMed was excluded due to the lack of evidence. The databases were searched using key terms

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that addressed the PICOT question. The explicit strategy utilized to obtain studies for this
literature review is described below.
Key terms burnout, mindfulness, psychiatric nursing, and stress reduction were used for
the initial search. Boolean connectors were applied to increase results as psychiatric nursing
initially reported limited results. Key terms then searched include secondary trauma, mindfulness
interventions, psychiatry, psychiatric nursing, mental health, and emotional exhaustion. Which
reported more favorable data.
Limitations, Inclusion, and Exclusion Criteria
Filters applied include a publication date of within five years, systematic reviews,
randomized controlled trials, meta-analysis, and the English language. Due to limited evidence,
qualitative and quantitative studies were both evaluated. The majority of the data includes
qualitative studies rather than quantitative, most likely due to the questionnaire that are
subjective in nature. The evidence gathered is of high level evidence which ranges from level
one to level three based on the hierarchy of research evidence.
Search Yield
The exhaustive search yielded 104 articles in CINAHL, 1250 from PsycINFO, and 88
from Academic Search Premier. Each search was then narrowed down using specific terms to
yield more precise articles related to the PICOT. For example, psychiatry nursing was preferred
over medical nursing, although medical nursing provided greater results as psychiatric nursing is
understudied. Narrowing of terms reported a final yield of 12. Ten of those articles were chosen
using rapid critical appraisals. Preference was given to articles with a higher level of evidence
and the United States of America as the country of origin.

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Critical Appraisal and Synthesis of Evidence
Rapid critical appraisal tools were used to filter through quantitative and qualitative
articles. The majority of the evidence provided a distinct tool to measure burnout for psychiatric
nurses and due to the subjective data the tool produced, nearly half of the articles found were of
qualitative data. A combination of qualitative (see Appendix A, table 1) and quantitative data
(see Appendix B, table 1) was included in the evaluation and synthesis table (See Appendix C,
table 1) to support the evidence of practicing mindfulness-based techniques to decrease burnout
symptoms among healthcare providers, with focus on psychiatric nurses.
Demographics of tables include a substantial majority of female subjects with ages
varying from the early 20s to late 50s for both male and female subjects. Research studies
included in the tables were not confined to the United States of America as results were limited;
~30 % of studies used were based in Asia. Each study was dedicated to nursing burnout, with a
focus on mental health nursing. Unfortunately, results were scarce and medical nursing data was
then included, see synthesis table (Appendix C, table 1) for categorization. Each study
incorporated mindfulness-based intervention ranging from workshops, social work lead classes,
and sessions that focused on dialectal behavioral therapy focusing on body scanning and
breathing exercises. Each intervention used in these studies focused on mitigating stress,
emotional labor, and depersonalization as well as promoting emotional regulation and awareness
of participants’ cognition. Measurement interventions were heterogeneous as the MBI-HSS
questionnaire was utilized in each study calculating the rate of burnout. Most studies stressed the
importance of preventing burnout rather than completing activities to decrease established
burnout symptoms in nurses. Most of the studies were of small populations with less than 100
individuals.

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Conclusion
While the evidence for mindfulness-based interventions for psychiatric nurses is limited,
the evidence still suggests a beneficial outcome. The role strain psychiatric nurses endure
instigates burnout and secondary trauma. From the included studies, the evidence displays a
considerable benefit psychiatric nurses may gain from completing mindfulness-based activities
whether it is independently completed or accomplished in groups. A decrease in burnout
symptoms in psychiatric nurses is not only favorable for the nurses but the patients as well.
There appears to have a trickle-down effect to decreased call offs which can lead to safer nurseto-patient ratios, increased patient satisfaction, and ultimately improve patient and nurse safety.
Optimizing mindfulness-based treatment programs should be considered in psychiatric nursing
settings to better the mental and physical wellbeing of the nurses.
Theoretical Framework and Implementation Framework
Theory Application
As previously stated, mindfulness-based activities can help decrease the risk of burnout.
Practicing interventions allows one to be present in the moment focusing on accepting feelings
and sensations to help increase overall well-being. The theory of Self-Transcendence presents a
systematic way of understanding the behaviors of mindfulness-based activities for psychiatric
nurses. The central concept of the theory focuses on characteristics of developmental maturity as
enhanced awareness of the environment broadens perspectives of life and is expressed and
measured through life perspectives and reflects on boundaries (Smith & Liehr, 2018).
Self-Transcendence is built upon two key concepts: well-being and vulnerability (Reed,
1991). Psychiatric nurses are a vulnerable population due to the emotional trauma they may
endure as the patient population can become physically and verbally aggressive including

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exposure to trauma. Well-being is defined as a sense of feeling whole and healthy and depending
on the individual, indications may include health and wellness, happiness, morale, self-care, and
a sense of meaning (Smith & Liehr, 2018). Mindfulness-based activities strive to allow
individuals to correlate positive help promoting activities to increase well-being. This theory
supports nursing interventions that facilitate well-being as it increases vulnerability (see
Appendix D, figure 1).
Vulnerability involves awareness of personal mortality. This theory suggests that life
events that heighten inadequacy may further develop identity if the experiences do not crush the
inner self (Smith & Liehr, 2018). Psychiatric nursing has many chronic illnesses and life crises,
but through mindfulness-based activities such as meditation, self-transcendence can be evoked
transforming difficulties to progression. Research provides constant evidence that is linked with
positive health-promoting experiences which are predictors for well-being.
Implementation Framework
The Rosswurm and Larrabee model for change is suitable for this population as it
assesses the need for change in the first step to integrating the change in the final step. Although
this model has concrete steps, the researcher can alternate between steps as analyzing, designing,
and implementing research is not without flaw. Using this model for the framework of
implementing mindfulness-based activities, the research will mirror the steps effortlessly. Step
one includes the need for change in practice, without mindfulness-based interventions, the
wellbeing of psychiatric nurses will diminish and the rate of burnout will surge. Step two
includes research that provides considerable evidence of the rate of burnout among psychiatric
nurses. Step three synthesizes the extensive review of the literature which confirms the benefits
of mindfulness-based activities. Steps four and five of the Rosswurm and Larrabee model require

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the design of practice change and the implementation and evaluation of change. This is
comparable to psychiatric nurses completing mindfulness-based activities 2 times a day for 5
days and completing a self-evaluation of a mindfulness-based intervention questionnaire before
and after implementation studying the results. The final step requires integration into standards
of practice (see Appendix D, figure 2).
Implication for Practice Change
A private practice out-patient family psychiatric facility located in Scottsdale, Arizona
sees psychiatric patients with diagnoses ranging from depression, anxiety, bipolar, schizophrenia,
personality disorders, substance abuse and psychosis. These diagnoses can increase susceptibility
to secondary trauma which increases the risk of nursing burnout. Stakeholders include the
nurses, nurse manager, and educator for psychiatry, all of whom have approved nursing burnout
data to be collected using the MBI-HSS. Data collected included emotional exhaustion,
depersonalization, and professional accomplishment which measured the extent and likely cause
of burnout. After the initial questionnaire, nurses completed a mindfulness-based activity, two
times a week for 5 days. The time spent on the mindfulness-based activity was estimated to be 10
minutes per session. Many apps including Headspace are free to download and results can be
uploaded to the cloud. Allowing individuals to engage with an app permits autonomy for where
and when the mindfulness-based activities can be completed. After the intervention was
completed, the participant completed the MBI-HSS a second time. Questionnaire scores were
evaluated and the evidence was synthesized and presented to Stakeholders.

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Methods
Implementing mindfulness-based intervention for psychiatric nurses has proven to
decrease burnout, increase emotional wellbeing, and has the potential to improve the milieu and
patient satisfaction. Implementing mindfulness-based interventions are valuable to an institution
as a decrease in burnout symptoms may decrease nursing turnover which can be cost-effective.
Implementing mindfulness-based interventions once a day for five days is a low-risk high-reward
activity to better the physical and mental well-being of psychiatric nurses, as symptoms of
burnout can be detrimental. Ethical consideration and human subject protection was used as
participation and results were kept anonymous. Internal Review Board (IRB) approval was
granted through Arizona State University.
There was no funding for this project needed as the budget is estimated to be under 200
dollars. Once the data was collected, it was processed through Status Intellectus for an accurate
statistical analysis. Descriptive statistics were used due to the limited number of participants.
Data was then presented to the shareholders to educate on the benefits of mindfulness based
interventions for nurses who may have signs and symptoms of burnout.
Challenges encountered included multiple sights dropping this project right before IRB
permission was granted and troubles downloading the smart phone Headspace, per participant
complaints. In person help was required for one nurse to learn how to utilize the app per project
guidelines. Recommendations for further research study includes a step by step visual and audio
video for what will be required for participants to complete the study. The participants were
agreeable to complete the study, but a majority of the participants interviewed stated they were
not aware of the time commitment.

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Results and Discussion
Descriptive statistics were preformed to describe the outcome variables and explain the
clinical significance of the findings. The number of participants was 1, n=1. The participant was
a registered nurse with 10 + years of psychiatric nursing experience. Utilizing a likert scale the
pre-intervention MBI-HSS questionnaire had a mean score of 37 for EE, 26 for D, and 29 for PA
and a post-intervention MBI-HSS mean score 28 for EE, 12 for D, and 35 for PA. These results
conclude the participant’s burnout decreased overall from pre-intervention to post-intervention.
The impact of the project was projected to have a more thorough statistical influence, but due to
the participant size, there was minimal impact of system or polices in the psychiatric facility.
The project intervention can easily be sustained and implemented for long term use in the
psychiatric facility as mindfulness-based interventions are cost effective, especially when they
are completed on a zero-cost self-guided application on a smart phone. Challenges occurred
throughout this project as multiple sites withdrew their agreement, and a diminutive sample size
as many psychiatric nurses chose not to participate in this study portrayed unsatisfactory
statistics. Lack of participation from more nurses may be linked to a lack of initiative to
complete project or misunderstanding of anonymity. Recommendations for further study include
measuring burnout using mindfulness-based interventions with a larger population of psychiatric
nurses would better provide statistical significance.

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Appendix A
Qualitative Studies

Table 1
Evaluation Table
Citation

Theory/Conceptual
Framework

Design/
Method

Sample/Setting

Major Themes &
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/Themes

Citation: Dall’Ora
et al. (2020).
Burnout in nursing:
A theoretical
review.

Maslach (1982)
Theory of burnout.

Design:
TR of empirical
studies without
formal appraisal
of quality.

N=91 in 28
countries.
87 were crosssectional
studies.

Purpose: a
comprehensive
summary of
research that
examines
theorized
relationships
between BO and

Demographics:
Burnout in
nursing, low
control over the
job, low
decision
latitude, poor
social
climate/social
support, and low

Research
Question: What is
the relationship of
burnout and other
variables (high
work load and low
control over the
job)?
Definitions:

Tools used to
Measure
variables:
Theoretical
review
conducted per
the methodology
outlined by
Campbell et al.
Guideline by
PRISMA-CsR.
MEDLINE,
CINAHL,

Qualitative
data was
extracted
from previous
studies from
three
independent
reviewers

Findings:
Adverse job
characteristics
such as high
workload, low
staffing levels,
long shifts were
associated with
BO in RNs.

Country: England
Funding:
University of
Southampton, UK

WorkloadPatient: RN ratio
and hours worked.

Level/ Quality of
Evidence; Decision
for practice/
application to
practice
LOE: I
Strengths: High
level of evidence
Weakness: Grey
literature was not
included and the
characteristics
nurses’ personalities
were not considered.
Application:
Identified plausible
mechanism to
explain associations

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

BURNOUT IN PSYCHIATRIC NURSING
Citation

Theory/Conceptual
Framework

Bias: Not mentioned

20

Design/
Method

Sample/Setting

Major Themes &
Definitions

Measurement/
Instrumentation

other variables,
to determine
what is known
(and not known)
about the causes
and
consequences of
BO in RNs, and
how this relates
to theories of
BO.

rewards as
predictors of
BO. No age,
race, sex of
individuals
stated.

Control- resources
needed to
complete
workload.

and PsycINFO
with search
terms including
‘burnout’ and
‘nursing’.
Articles
comparing BO
among different
settings such as
cancer were
excluded. MBI
was used to
measure BO in
each article.

Setting:
undisclosed
setting of
articles in this
review.
Exclusion: NonEnglish studies
and studies older
than 1975

Reward- Pride or
monetary value,
incentives.
Fairnessinadequate
workload/pay

Data Analysis

Findings/Themes

Level/ Quality of
Evidence; Decision
for practice/
application to
practice
of adverse job
characteristics and
BO.

Attrition: none
stated.

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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21

Citation

Theory/Conceptual
Framework

Design/
Method

Sample/Setting

Major Themes &
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/Themes

Citation: Edward et
al. (2017).
Emotional labour in
mental health
nursing: An
integrative SR.

Benner& Wrubel
(1989); Swanson
(1993); Watson
(1988) Caring is the
defining
characteristic of RN.

Design: SR and
MA

N= 20 articles.
12 quantitative,
8 qualitative.

Research
question: How
does the emotional
labour of MH RNs
manifest and how
can the impacts be
mitigated?

Country: Australia

Hochschild (1983)
Dislocation of
feelings

Tools used to
measure
variables:
multiple
databases
including
CINAHL ,
psycINFO, and
Medline
Complete were
used and key
words such as
‘psychiatric
nurse’ and
‘emotional
labour’ were
included.

The
quantitative
studies
comprised
designs that
were either
crosssectional,
survey,
pretest, or
post-test, and
often based on
self-report.
The eight
qualitative
articles
included
designs such
as naturalistic
inquiry,
critical
feminist
approaches,
and
narrative/story

Findings:
Emotional labour
can manifest as
burnout/stress but
may lead to
resilience and EE
may lead to
personal growth

Funding: This study
was supported by
Gylo hercelinskyj,
School of Nursing.
Bias: These study
designs might have
introduced bias in
the representative
research, and were
considered lowgrade evidence
when considering
the hierarchy of
evidence for

Purpose:
Investigate
emotional labour
of MH work,
how it
manifested, the
impacts of, and
the way to
mitigate these
impacts.

Demographics:
MH RN,
inpatient and
community.
Age, sex, race,
and financial
status not stated.
Setting:
undisclosed.
Exclusion:
International
studies that were
not written in
English.
No date limits
applied.

Definitions:
Emotional labourcaring
Emotional
exhaustionburnout.
Emotional
intelligence- selfprotection.

Quality
assessment of
research was
critiqued using
CASP.

Narrative: Of the
three themes
related to
emotional work
for MH RNs that
may influence
burnout may also
contribute to its
appeal to work in
this area.
Daily stress and
interactions with
individuals who
have complex
needs and

Level/ Quality of
Evidence; Decision
for practice/
application to
practice
LOE: I
Strengths: high
level of evidence,
many articles were
reviewed. High
quality and evidence
based interventions.
Weakness: no
stated bias and older
studies were
included in the
research.
Feasibility: Could
be used in practice
due to relevance and
opportunities to
incorporate decision
making to protect
emotional wellbeing.

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation

quantitative
research.

Theory/Conceptual
Framework

Design/
Method

22
Sample/Setting

Attrition: none
stated and none
inferred.

Major Themes &
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/Themes

telling. Data
were collected
through
participant
observations
and
interviews/
focus groups.

behaviours creates
EL for RNs.

Level/ Quality of
Evidence; Decision
for practice/
application to
practice

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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23

Citation

Theory/Conceptual
Framework

Design/
Method

Sample/Setting

Major Themes &
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/Themes

Citation: RuizFernandez et al.
(2020). Mindfulness
therapies on health
professionals.

Lazarus
(1991)
Transactional Model
of SS

Design: SR and
MA

N= 15
n= 9 SR
n= 6 MA

Research
Questions: What
mindfulness
interventions
reduce stress?

Cochrane
Review
Managermeasured bias
and lack of
information.
MSRB used in
SR.
Databases used
include
CINHAL,
PsycINFO, and
Science Direct.
Search strategy
included key
terms such as
Physician,
Doctor, nursing,
and health
professional.

Qualitative
data was
extracted
from previous
studies by two
independent
reviewers.

Findings: MBSR
is effective to
examine improved
stress; individuals
who practiced
meditation daily
saw a greater
decrease in stress
and increase in
mindfulness.

Country: Spain
Funding: This study
was supported by
Health, Regional
Government of
Spain.
Bias: Cochrane
Collaborations’ risk
of bias assessmentno bias found.

Purpose: to find
which MI are
being used for
HCP and their
effectiveness.

Demographics:
Physicians and
nurses. Article
did not disclose
age, race, or sex.
Setting:
undisclosed
setting of
articles in this
review.
Exclusion:
duplicates and
“different
reasons”
Attrition: none
stated and none
inferred.

Definitions:
Self- compassionunderstanding
self-inadequacy.
Stress- feeling
overwhelmed,
unable to cope.

Narrative: each
mindfulness based
stress reduction
tool helped

Level/ Quality of
Evidence; Decision
for practice/
application to
practice
LOE: I
Strengths: high
level of evidence
Weakness: Low
Number and
unknown population
demographics or
number of years
working in
healthcare.
Application:
Identified what
clinicians need to
address to decrease
stress and improve
mindfulness related
to healthcare.

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation

Theory/Conceptual
Framework

Design/
Method

24
Sample/Setting

Major Themes &
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/Themes

Level/ Quality of
Evidence; Decision
for practice/
application to
practice

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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25

Citation

Theory/Conceptual
Framework

Design/
Method

Sample/Setting

Major Themes &
Definitions

Measurement/
Instrumentation

Data Analysis

Findings/Themes

Citation: Wampole
& Bressi (2020).
Exploring a social
work lead
mindfulness-based
intervention to
address burnout
among inpatient
psychiatric nurses: a
pilot study.

Maslach (1982)
Theory of burnout.

Design: not
stated but
inferred: MA

N= 8 MHRNs

Research
Question: Does
SWL-DBT MBI
decrease BO in
MHRNs

Tools used to
measure
variables: MBI.

Descriptive
statistics
including
means and
ranges of
results of MBI
were
computed.
Name of
software not
stated.

Findings: Scores
indicated mild
symptoms of EE
and D.

Country: USA
Funding: not stated
Bias: none stated,
none inferred.

Purpose: BO
among MHRNs,
factors that
induce BO and
experiences of
the job that lend
to BO.
Feasibility and
usefulness of
SWL-DBT MBI.

Demographics:
All white, all
Caucasian, 4 had
BSN, mean age
42.
Settings: 63 bed
inpatient
psychiatric
facility.
Exclusions:
MHRNs over
90-day
probationary
period for new
hires.
Attrition: none
stated and none
inferred.

Definitions:
Depersonalizationnot feeling like
one’s self.

Narrative: Of the
8 open ended
questions from the
MBI, MHRNs had
noted key
stressors including
interpersonal
conflicts, poor
management, and
feeling
undervalued. All
lead to increased
BO.

Level/ Quality of
Evidence; Decision
for practice/
application to
practice
LOE: II
Strengths: MBI
questionnaire asked
the same question to
each participant with
open ended
questions allowing
for more personal
data.
Weaknesses:
Demographics of
individuals are the
same.
Feasibility: Could
be used in practice
due to relevance and
opportunities to
incorporate decision
making to protect.

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Appendix B
Quantitative Studies
Table 1
Evaluation Table
Citation
Citation: Barattucci et al.
(2019). Mindfulness-based
IARA model proves
effective to reduce stress and
anxiety in healthcare
professionals. A six-month
follow-up study.
Country: Italy
Funding: No external
funding

Theoretical/
Conceptual
Framework
Not stated
but
Maslach
(1982)
Theory of
burnout is
inferred.

Design/ Purpose

Sample/Setting

Variables

Measure/
Instrument

Data
Analysis

Findings

LOE/ Application to
practice/Generalization

Design: Selfreported
questionnaires
before the first
IARA meeting
and 6 months after
the last meeting
using DERS-36,
ZSRAS, and
PSS.

N=594 HCP

IV= ARA
meeting
intervention

Self-reported
questionnaires
- DERS-36,
ZSRAS, PSS,
and
SWOT
analysis.

SPSS 24
statistical
package,
ANOVA,
and t-test.

No differences were
revealed between
training and control
groups for any
demographic
information or work
characteristics. Results
indicate difficulties
with emotional
acceptation and
awareness are

LOE: III

Control group
n=202

Definitions:
IARA
intervention
n= 295
Setting:
multiple HCP

Adaptation:
becoming
better suited to
environment

Strengths: Control
group, demographics are
stated.
Weaknesses: IARA
requires individuals to
take 4 days off work.
The training does not
effectively reduce
anxiety,

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation

Theoretical/
Conceptual
Framework

Bias: None stated and none
inferred.

Citation: Guillaumie et al.
(2016). A mixed-methods
systematic review of the
effects of mindfulness on
nurses.
Country: Canada

Thomas et
al. (2004)
and
Thomas &
Harden
(2005)

27

Design/ Purpose

Sample/Setting

Purpose: Analyze
the efficacy of the
mindfulnessbased IARA to
ameliorate
perceived SS, AX,
and enhance ER
among HCPs.

including RNs,
doctors, and
HCP assistants.
Mean age was
40.35. Average
organizational
seniority was
10.98 years,
168 subjects
were single,
280 were
married, 24
were divorced.
231 had a
university
degree.

Design: SR of
qualitative and
quantitative data.
Purpose: To
review the effects
of MBI of RNs

N= 32 studies
n= 17
controlled
design
n= 11 pre-postdesign

Variables

Measure/
Instrument

Data
Analysis

Findings
significantly related to
SS and AX levels.
IARA scale:
-DERS: 3.13 (p=
<0.01)
-Anxiety: 2.32
(p=0.05)
-Stress: 6.90 (p=0.001)

LOE/ Application to
practice/Generalization
Application to Practice:
Further research should
apply psychometrically
robust measures of AX
and perceived work SS
for further evaluation.

Control group:
-DERS: 1.87 (p=not
stated)
-Anxiety: q.02 (p= not
stated)
-Stress: -1.94 (p=not
stated)
No CI stated.

IV= MBI
DV1=
Decreased
depression

MAAT and
Cochrane risk
of bias tool.

Research
assistants
independentl
y extracted
data, tools
not stated.

AX was reduced using
MBI (-0.78, 95% CI11.39 to -0.18)
Depression was
decreased using MBI
(-0.51, 95 % CI -0.78
to –0.18).

LOE: I
Strengths: High level
of evidence, Cochrane
risk of bias tool used,
qualitative and

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation

Theoretical/
Conceptual
Framework

Funding: no special grant
from any funding agency in
the public, commercial, or
non-profit sectors.
Bias: not stated and none
inferred.

28

Design/ Purpose

Sample/Setting

Variables

and nursing
students, given
the stressors of
the profession
such as death,
illness, and close
contact with
patients
measuring AX
and depression.

n= 4 qualitative
design.

DV2= RNs
without
mindfulness
activities.

Demographics:
published from
1980-2014.

Definition:
Job Stress:
harmful
physical and
emotional
response that
occurs when
job demands
exceed
worker’s
capabilities.
Anxiety:
Feeling of
worry

Measure/
Instrument

Data
Analysis

Findings

Regarding workrelated variables, MA
showed no significant
impact for work
satisfaction (0.23, 95%
CI -0.27 to 0.72).
RCTs measuring
burnout, work selfefficacy, and work
energy reported
inconclusive.

LOE/ Application to
practice/Generalization
quantitative data
analyzed.
Weaknesses: small
sample size, no
demographic
information given.
Application to Practice:
Work specific variables
required such as
incentives given, patient
load, hours worked in
one shift.

Studies comparing RN
vs nursing students
was preformed and no
significant difference
was demonstrated.

Depression:
Lowering of
mood

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation
Citation: Lou et al. (2019).
An evaluation of a positive
psychological intervention to
reduce burnout among
nurses.
Country: Australia and
China

Theoretical/
Conceptual
Framework
Not stated
but
Maslach
(1982)
Theory of
BO is
inferred.

Design/ Purpose

Sample/Setting

Variables

Measure/
Instrument

Data
Analysis

Findings

LOE/ Application to
practice/Generalization

Design: QES

N= 87

SPSS 20.0
programme,
Fisher’s test,
t-test.

6.9 percent of
participants suffered
from serious burnout
while others suffered
some burnout.
Average scores of
exhaustion, cynicism,
and reduced personal
efficacy were 2.37,
2.03, and 2.19.

Design: preintervention and
post-intervention
questionnaires.

Setting: RNs
from tertiary
hospitals.
Criteria
includes: RNs,
BO score of
higher than
1.49, and had a
phone WeChat
could be
installed on.
97% were
female and
average age was
28.
N= 52 RNs who
attended a
mindfulness
workshop.

MBI,
Cronbach’s
dimensions for
BO. WeChat
for uploading
“three good
things” after
an RNs shift.

LOE: II

Purpose:
Evaluate the PPI
of recording three
good things on
alleviating RN’s
BO.

IV= BO on
RNs
DV1= PPI

LOE: III

Purpose:
Determine
whether a 4-hour
workshop
teaching the

Setting: RNs
had average age
of 38.5 years,
majority were
female, marries,

1 month after
workshop:
-decrease in stress (2.31, p=0.1)
-decrease in EE (-4.78,
p=.03)
-reports of
improvement in selfperceived
mindfulness, personal

Funding: None
Bias: None stated, none
inferred

Citation: Sarazine et al.
(2020). Mindfulness
workshops effects on nurses’
burnout, stress, and
mindfulness skills.
Country: United States of
America

Not stated
but inferred:
Maslach
(1982)
Theory of
burnout is
inferred.

29

Definitions:
Good things:
Positive parts
of the day.

IV= 4-hour
workshop on
MBI
DV1= BO
Definitions:
Mindfulness:
calmly

PSS, MBI,
CAMS-R

Paired t
Tests and
Descriptive
Statistics.

Strengths: high level of
research
Weaknesses: no followup research
Application to Practice:
equal representation of
male and female RNs

Strengths: Fidelity of
intervention was
supported in several
ways-same qualified
instructors was used for
all workshops, content of
workshop was the same
for each class.

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation

Theoretical/
Conceptual
Framework

Funding: Center for Clinical
Research and Scholarship at
Rush University Medical
Center
Bias: No bias stated, and no
bias inferred.

Citation: Suleiman-Martos
et al. (2019). The effect of
mindfulness training on
burnout syndrome in
nursing: A systematic review
and meta-analysis.

Not stated
but
Maslach
(1982)
Theory of

30

Design/ Purpose

Sample/Setting

Variables

principles of
mindfulness and
how to apply
them to deal more
effectively with
stress, D, EE,
POS, and PA was
an effective
intervention for
reducing BO
symptoms.
Measured at 1
month and 6months post
workshop.

white, held a
BSN, and
worked days.

acknowledging
one’s feelings.

Design: SR and
MA

N= 17
n= 8 RCT
n= 9 QES

Purpose: Assess
impact of MBI on
RNs and

Measure/
Instrument

Data
Analysis

accomplishment, and
D, although not
statistically
significant.

Stress: feeling
overwhelmed

6 months after
workshop:
Increase in
mindfulness (2.50, p=
.04)
Increase in personal
accomplishment (4.43,
p=.04)
Decrease in EE (-6.21,
p=.05). decrease in
POS and D, but
improvements not
statistically
significant.
No CI stated.

EE: Chronic
state of
emotional
depletion
D: Observing
oneself from
outside one’s
body.

Demographics:

IV- BO
Syndrome on
RNs.

Findings

MSRB/MBI

CINAHL,
LILACS,
Medline,
ProQuest,
PsycINFO,
Scielo, and

EE: 1.32 (95% CI, p=
-9.41-6.78) with lower
mean values than the
intervention group.
D: 1.91 (95% CI, p= 4.50-0.86)

LOE/ Application to
practice/Generalization
Weaknesses: Unknown
what was taught in 4hour class. Small sample
size, most subjects were
female, white, and their
specific RN occupation
was unknown.
Application to Practice:
Geographical, gender,
and age differences
should be considered
when developing and
measuring BO.

LOE: I
Strengths: high level of
evidence, many articles
were reviewed. High

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation

Country: Spain
Funding: Excellence
Research Project
Bias: more females than
males

Theoretical/
Conceptual
Framework
BO is
inferred.

31

Design/ Purpose

Sample/Setting

Variables

subsequent levels
of BO
experienced as
measured through
3 dimensions (EE,
D, LPA)

87 % of RN
were women,
from 29-52
years old, RNs
worked in
hospitals,
Studies in USA
(n=8), MBI
(n=9), CBI
(n=1), MSRB
(n=14).
sample
population RNs
(n=632)

DV1: MI and
effects on EE,
D, and PA.

Setting: not
stated
Exclusion:
International
studies that
were not written
in English,
Spanish,
French,
Portuguese, no
restriction of

DV2: No MI
Definitions:
EE: Chronic
state of
emotional
depletion
D: Observing
oneself from
outside one’s
body.
LPA:
negatively
evaluate one’s
worth

Measure/
Instrument

Data
Analysis

Findings

LOE/ Application to
practice/Generalization

Scopus
databases.
No
restriction
on year of
publication.

PA: 2.2 (95% CI, p=
-9.91-14.14)

quality and evidence
based interventions.
Weaknesses: Grey
literature and external
variables in RN work
environment was not
included
Application to Practice:
equal representation of
male and female RNs
and larger sample sizes
are needed to better
understand the effects of
mindfulness training on
RNs.

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation

Theoretical/
Conceptual
Framework

Design/ Purpose

32
Sample/Setting

Variables

Measure/
Instrument

Data
Analysis

Findings

LOE/ Application to
practice/Generalization

IV- MBI
program
(n=40)

MBI, HADS,
PHQ-9, DSM5.

Descriptive
analysis of
variables
was
preformed,
name of
analysis
omitted.

95% CI for each test
concluded.

LOE: I

year of
publication,
Clinical trial or
QES, analysis
of impact of
MBI of BO.

Citation: Watanabe et al
(2019). Brief mindfulnessbased stress management
program for a better mental
state n working populationsHappy nurse project: A
randomized control trial.
Country: Japan
Funding: Intramural
Research Grant for
Neurological and Psychiatric
Disorders of National Center
of Neurology and Psychiatry,
Japan.

Not stated
but inferred:
Maslach
(1982)
Theory of
burnout is
inferred

Design: RTC
Purpose: Explore
the effectiveness
of the brief
mindfulnessbased stress
management
program for
hospital nurses

Attrition:
varied for each
MBI, raged
from 0-40%
N= 80 RNs
Demographics:
Inclusion
criteria included
20-59 years of
age and female
gender, RNs
working on
inpatient wards,
and RNs who
gave written
consent.
Attrition: 2.4%.
at 26 weeks 37

Definition:

Mean score of HADS
were 7.20 (95% CI:
5.94, 8.45) and 5.97
(4.76, 7.81) in the
program and leaflet
groups.

Presenteeism:
working while
in poor health
either physical
or mentally.

The group coefficient
by time interaction
was not statistically
significant at -1.41 (3.35, 0.54; P=0.156).

DV1: PL
(n=40).

Strengths: High level of
evidence
Weaknesses: Unknown
education for RNs.
Studying specifically
newer RNs.
Application to Practice:
Larger group sizes are
needed, Ages should not
exclusion factor.

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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Citation

Theoretical/
Conceptual
Framework

Bias: None stated, none
inferred.

Design/ Purpose

33
Sample/Setting

Variables

Measure/
Instrument

Data
Analysis

Findings

LOE/ Application to
practice/Generalization

participants (of
40 MBI)
completed
program and 40
individuals (of
40
psychological
leaflet)
completed the
program.

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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34

Key terms: AX- anxiety; BO- burnout; CAMS-R- cognitive and affective mindfulness scale-revised; CASP- Critical Appraisal Skills
Program; CBI- Copenhagen burnout inventory; CR- critical review; D- depersonalization; DERs-36- difficulties in emotional
regulation scale; EE- emotional exhaustion; EL- emotional labor; ER- emotional regulation; HADS- hospital anxiety and depression
scale; HCP- healthcare professional; HO- healthcare organizations, HSS- human service survey, IARA- meeting compliance
responsibility and autonomy, LOE- level of evidence; LPA- low personal accomplishments; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MBI- Maslach Burnout Inventory; MH- mental health; MI- mindfulness intervention; MSRB- mindfulnessbased stress reduction; N- number of participants, PA- personal accomplishments; PCRN- primary care registered nurses; POSperception of stress; PR- peer reviewed; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire; RCTrandomized control trial; RN- registered nurse(s); SR- systematic review; SS- stress; STS- secondary traumatic stress; SWOTstrengths weaknesses opportunities and threats; TR- theoretical review; ZSRAS- zung self-rating anxiety scale.

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35

Appendix C
Table 1

Basics

Watanabe et al.

Wampole et al.

Suleiman-Martos et
al.

Sarazine et al.

Ruiz-Fernandez et
al

Lou et al.

Guillaumi et al.

Edwards et al.

Studies

Dall’Ora et al

Barattucci et al.

Synthesis Table

Year

2019

2020

2017

2016

2019

2020

2020

2019

2020

2019

LOE

III

I

I

I

II

I

III

I

II

I

Design

CS

TR

SR and
MA

SR

QES

SR
and
MA

SR

SR
and
MA

QES

RTC

X

X

X

X

MH RN

X

Mean
Age
(years)

40.35

NS

NS

NS

28

NS

38

NS

42

20-59

Sex

215 F

NS

NS

NS

84F

NS

48 F

NS

8F

80 F

0M

0M

282 M

3M

4M

Bias

NS

NS

NS

NS

NS

LR

NS

NS

NS

NS

# of
particip
ants

497

91
article
s

20
articles

32
studies

87

15
articles

52

17
articl
es/
632

8

80

CASP- Critical Appraisal Skills Program; CAMS-R- cognitive and affective mindfulness scalerevised; CS- cohort study; D- depersonalization; DERs-36- difficulties in emotional regulation
scale; DSM-5- diagnostic and statistical manual of mental disorders; EE- emotional exhaustion;
ED-5D- quality of life instrument; EL- emotional labor; ER- emotional regulation; F- female;
HADS- hospital anxiety and depression scale; HPQ- Work performance questionnaire; IARAmindfulness-based model-Italian; LR- low risk; M- male; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MI- Mindfulness intervention; MBI- Maslach Burnout Inventory;
MBSR-Mindfulness-based stress reduction therapy; MH- mental health; NS- not stated; RNregistered nurse(s); PA- personal accomplishments; PHQ-9- patient health questionnaire; PSperceived stress; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire;
RCT- randomized control trial; SM- self-perceived mindfulness; SR- systematic review; SASself-rating anxiety scale; SS- stress; STS- secondary traumatic stress; TR- theoretical review;
↓ - Reduced, ↑ - Increased, ** no significance

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36
RNs

Cross
sectiona
l Survey
Tools
Utilized

Research

X

IARA

Qualitat
ive

X

Indepe
ndent
resear
chers.
No
specifi
c tools
listed

CASP

X

X

X

Research

MAAT

WeChat
/
Cronbac
h’s
dimensio
ns for
BO

MBSR

MBSR

MS
RB

X
X

X

X

X

MSRB/
DBT

DSM-5/
HPQ/
ED-5D

X
X

X

X

X

X

Quantit
ative

Interventions

MBI

X

X

X

X

CAMSR

X

MI
worksh
op

X

X

X

HADS
DERs36

X

X
X

PHQ-9

X

PSS

X

SAS

X

X

CASP- Critical Appraisal Skills Program; CAMS-R- cognitive and affective mindfulness scalerevised; CS- cohort study; D- depersonalization; DERs-36- difficulties in emotional regulation
scale; DSM-5- diagnostic and statistical manual of mental disorders; EE- emotional exhaustion;
ED-5D- quality of life instrument; EL- emotional labor; ER- emotional regulation; F- female;
HADS- hospital anxiety and depression scale; HPQ- Work performance questionnaire; IARAmindfulness-based model-Italian; LR- low risk; M- male; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MI- Mindfulness intervention; MBI- Maslach Burnout Inventory;
MBSR-Mindfulness-based stress reduction therapy; MH- mental health; NS- not stated; RNregistered nurse(s); PA- personal accomplishments; PHQ-9- patient health questionnaire; PSperceived stress; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire;
RCT- randomized control trial; SM- self-perceived mindfulness; SR- systematic review; SASself-rating anxiety scale; SS- stress; STS- secondary traumatic stress; TR- theoretical review;
↓ - Reduced, ↑ - Increased, ** no significance

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EL
ER

Major findings

↓

↑

↓

↑

↓

↑

EE
SS

↑

↓

STS
PA

37

↓
↓

↓

↑

↓

**

↓
↑

↑

↑

SM-

↑

↑

↓

↓

↑

↑

PS

↓

↓

AX

↓

↓

↓

↑

↑

D

↓

↑

↑

CASP- Critical Appraisal Skills Program; CAMS-R- cognitive and affective mindfulness scalerevised; CS- cohort study; D- depersonalization; DERs-36- difficulties in emotional regulation
scale; DSM-5- diagnostic and statistical manual of mental disorders; EE- emotional exhaustion;
ED-5D- quality of life instrument; EL- emotional labor; ER- emotional regulation; F- female;
HADS- hospital anxiety and depression scale; HPQ- Work performance questionnaire; IARAmindfulness-based model-Italian; LR- low risk; M- male; MA- meta-analysis; MAAT- Mixedmethods appraisal tool; MI- Mindfulness intervention; MBI- Maslach Burnout Inventory;
MBSR-Mindfulness-based stress reduction therapy; MH- mental health; NS- not stated; RNregistered nurse(s); PA- personal accomplishments; PHQ-9- patient health questionnaire; PSperceived stress; PSS- perceived stress scale; QES- quasi-experimental studies questionnaire;
RCT- randomized control trial; SM- self-perceived mindfulness; SR- systematic review; SASself-rating anxiety scale; SS- stress; STS- secondary traumatic stress; TR- theoretical review;
↓ - Reduced, ↑ - Increased, ** no significance

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Appendix D
Models and Framework
Figure 1
Self-Transcendence Model

Reed (1991)

38

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Figure 2
Rosswurm and Larrabee’s Model for Evidence-Based Practice

Rosswurm & Larabee (1999)

39