REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION

Reducing Burnout in Bedside Nurses Through Guided Meditation

Christine A. Panopio
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Christine A. Panopio is a registered nurse at St. Joseph’s Hospital in the nursing department.
She has no known conflict of interest to disclose.
Correspondence should be addressed to Christine A. Panopio, Edson College of Nursing and
Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street,
Phoenix, AZ 85004. Email: cpanopio@asu.edu

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Abstract
Purpose & Background: Nurses regularly have encounters with traumatic and stressful events
which can have deleterious effects on their physical and psychological well-being and lead to
burnout. The Covid-19 pandemic has further exacerbated the stress on nurses. The purpose of
this project is to evaluate if an evidence-based, guided mindfulness-based intervention would
reduce burnout levels among registered nurses (RNs) working in in-patient settings.
Methods: Participants enrolled in nursing programs from a local university were recruited for
the project with the following inclusion requirements: (1) RNs working in an in-patient setting,
(2) aged 18 years old or older; (3) fluent in the English language. Participants completed a presurvey and then enrolled in a free mindfulness application via their phone or computer.
Participants listened to one ten-minute mindfulness session for a consecutive ten days and then
completed a post-survey.
Results: Data collected from the pre and post surveys included the use of the following valid and
reliable instrument tools: Copenhagen Burnout Inventory, Brief Resiliency Coping Scale, and
Short Form Health Survey. Data was analyzed using descriptive statistics and the Wilcoxon
Signed Ranks Test. The analyzed data showed that there was statistical significance in decreased
burnout levels, increased resiliency, and increased health perceptions of the participants.
Conclusion: By finding ways to cope with the experience of burnout in nurses, nurses’ mental
health wellness can improve in order for nurses to continue to be an integral part of the
healthcare system.
Keywords: nurses, burnout, guided meditation, mindfulness, stress

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Nurse Burnout
Burnout has become increasingly prevalent among high-stress occupations including
bedside nurses. Burnout is defined as a consequence of chronic stress in the workplace that has
not been adequately addressed and can manifest in the forms of emotional exhaustion,
depersonalization, and reduction in job satisfaction (World Health Organization [WHO], 2019).
Symptoms of burnout can include frustration, fear, being overwhelmed, hopelessness, and lack
of empathy (Moss et al., 2016). With the on-going uncertainty of the current Covid-19 pandemic,
burnout has been much more prevalent among healthcare workers. In April 2020, Dr. Lorna
Breen was tragically lost to suicide as a result of the emotional and physical exhaustion from
working the frontlines in New York City during the height of the pandemic (Romine, 2020). As a
result, the Dr. Lorna Breen Health Care Provider Protection Act (2019) was introduced to reduce
and prevent burnout, behavioral disorders, and suicide among health care professionals. Without
sufficient support, healthcare workers, including nurses, are likely to continue to experience high
levels of stress and anxiety that can eventually lead to burnout and loss of nurses in the
workforce (Fernandez et al., 2020).
Purpose and Rationale
According to the National Academies of Sciences, Engineering, and Medicine (2019),
35% of physicians and nurses in the United States have experienced symptoms of burnout.
Burnout affects the individual healthcare professional by an increased risk of workplace injury,
absenteeism, and professional dissatisfaction. Additionally, burnout can have an effect at the
healthcare systems level with decreased quality of care, decreased patient satisfaction, and
increased turnover rate for nurses (National Academies of Sciences, Engineering, and Medicine,
2019). The Covid-19 pandemic has only further exacerbated the issue of burnout. The pandemic

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has become a contributing factor in the significantly higher levels of stress, fear of contagion,
anxiety, and burnout in nurses working with Covid-19 patients (Trumello et al., 2020). The
purpose of this paper is to provide an in-depth review of the current literature on burnout in
nursing and discuss the methods and findings of a project that used a guided mindfulness-based
intervention to address burnout in nurses.
Background and Significance
Burnout has become a common issue among those who work in high-stress occupations
such as nursing. In nurses’ line of work, regular encounters with traumatic and stressful events
are all too common (Moss et al., 2016). The daily stress incurred at work and the emotional
weight of confronting patient morbidity and mortality can have deleterious effects on their
physical and psychological well-being (Moss et al., 2016). Incorporate a worldwide pandemic on
top of a nurse’s daily physical and emotional toll and it has led to an exacerbation of anxiety,
stress, exhaustion, and burnout. Covid-19 has increased the propensity of burnout in nurses by
the increased workload, limited resources, and insufficient amount of time to adequately care for
acutely ill patients with the diagnosis of Covid-19 (Dincer & Inangil, 2021).
If pandemics can produce disastrous effects in the well-being and health of the world’s
population, they can especially affect the population’s healthcare professionals and caregivers
(Trumello et al., 2020). Events such as the 2002 Severe Acute Respiratory Syndrome (SARS)
outbreak, Hurricane Katrina in 2004, Hurricane Rita in 2005, and the 2004 Southeast Asian
tsunami have demonstrated how vital healthcare professionals are in caring for and protecting
citizens in the aftermath of a disease or disaster (Benedek et al., 2007). After these events, the
potential for negative emotional impact is significant for healthcare professionals due to the high
level of exposure to trauma, the increased work demand, and the sacrifice of being separated

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from home and loved ones. Healthcare professionals are an essential component of recovery
from disastrous events and disease outbreaks (Benedek et al., 2007).
Nurses are known for their strong sense of duty to their patients and their desire to
provide quality care for all of their patients. Nurses’ commitment to quality care can lead them to
be particularly susceptible to high levels of psychological distress and burnout due to the nature
of their work (Fernandez et al., 2020). Nurses are in continued contact with the most vulnerable
patients in their work at the bedside. During the SARS epidemic in Hong Kong, nurses
statistically had higher stress levels and more psychological morbidity during the outbreak than
other professionals (Tam et al., 2004). Nurses were highly susceptible to negative emotional
responses and mental distress due to the increased risk of becoming victims to disease while
working as caregivers amid the epidemic (Tam et al., 2004). The increased frequency of
exposure to Covid-19 for nurses is a propellent for more exposure to chronic stressors in nurses.
These chronic stressors that nurses encounter lead to higher prevalence of anxiety, depression,
insomnia, and low levels of professional fulfillment (Tiete et al., 2021).
Mindfulness and Resilience
Research has shown that there is a strong correlation between burnout and resilience.
Nurses who had high levels of resilience were associated with low levels of emotional
exhaustion and depersonalization. Increased resilience is associated with less stress and more
positive psychological effects (Rushton et al., 2015). Stress lowering interventions for nurses
have been effective for nurses physiologically and psychologically. Cognitive-behavioral and
relaxation interventions have been the most effective at helping nurses cope with their work
demands (Richardson & Rothstein, 2008). Nurses who participated in a stress management
program showed significant improvement in perceived stress after completing the program

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(Hersch et al., 2016). Mindfulness-Based Stress Reduction (MBSR) focuses on stress reduction
through interventions that cultivate mindfulness, such as meditation, deep breathing exercises,
and mindful yoga. Evidence supports MBSR as a tool to improve the psychological health of
those working in high-stress environments (Fjorback et al., 2011).
Current and Desired State
In 2018, to combat burnout, the Institute for Healthcare Improvement launched the
National Steering Committee for Patient Safety to focus on workforce safety, including issues
related to burnout (Institute for Healthcare Improvement [IHI], 2020). Despite efforts, only 5%
of healthcare professionals indicated that their work organization was highly effective at
addressing burnout in staff (The Joint Commission, 2019).
Lack of social support was indicated as the most prevalent risk factors for developing
negative psychological outcomes in disasters (Hu et al., 2020). The Dr. Lorna Breen Health Care
Provider Protection Act (2019) was formed after the death of Dr. Lorna Breen. Her death was
thought to be facilitated by the overwhelming exhaustion and burnout she incurred during her
time working in the pandemic (Romine, 2020). The act is indicative of the desired state of
healthcare. The purpose of the bill is to establish grant programs that the Department of Health
and Human Services (HHS) can award to healthcare professional programs to provide education
on improving mental health and well-being. The bill also determines that the HHS must study
and develop recommendations to preventing burnout among healthcare professionals. It also
requires the Center for Disease Control and Prevention (CDC) to coordinate a campaign to
encourage those suffering from mental and behavioral concerns to seek support and treatment
(Dr. Lorna Breen Health Care Provider Protection Act, 2019).

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PICOT Question
Preliminary interest in this problem led to an inquiry of current evidence to determine the
best interventions to address the burnout issues in nurses. This literature review has led to the
clinically relevant PICOT question, “In nurses working in the in-patient settings during the
Covid-19 pandemic, what impact does a guided mindfulness-based intervention have on their
burnout levels?”
Evidence Synthesis
This literature review included an exhaustive search of the following databases: PubMed,
Academic Search Premiere, and PsycINFO. Keywords included: burnout, moral distress,
psychological distress, high stress, compassion fatigue, disaster, war, pandemic, crisis, covid,
epidemic, nurses, first responders, frontline workers, healthcare workers, stress reduction,
mindfulness, relaxation, stress reduction, and meditation. The initial search of burnout and
nursing and disaster yielded 30 results in PubMed and 37 results in Academic Search Premier.
The initial search of nurse burnout and psychological distress and pandemic yielded 376 results
in PsycINFO. Due to the small volume of results yielded, the combination of the keywords was
changed to include nursing and burnout or psychological distress. This resulted in 113 results in
PubMed, 213 results in Academic Search Premier, and 376 results in PsycINFO. Search limits
were set to include journal articles between 2013 – 2021, randomized controlled trials or clinical
trials, and English language. This resulted in a final yield of 179 results in PubMed, 42 results in
Academic Search Premier, and 46 results in PsycINFO. Grey literature of news articles regarding
Covid-19 and nurse burnout were also searched.
After reviewing the abstract and titles of the final yield, inclusion criteria included
articles that addressed nurse burnout, stress, and mindfulness strategies. Exclusion criteria

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included articles dated prior to 2013, articles that did not address nurse burnout, and articles that
did not address strategies for mindfulness. Rapid critical appraisals were then completed for 15
articles and the final 10 articles were chosen for this literature review. This included seven
randomized controlled trial studies, two mixed-methods studies, and one cross-sectional study.
Critical Appraisal & Synthesis of Evidence
In the literature review, 50% of studies that were conducted in the United States with the
other half of studies conducted in other countries. The foundational theories varied among the
studies; the Stress and Coping Theory was used in two studies. The overall quality and strength
of the evidence was very high as all studies were level II studies (Burns et al., 2011). All of the
selected articles were randomized controlled trials involved with investigating interventions that
can reduce the levels of stress, depression, anxiety or other similar concepts related to burnout in
healthcare workers. Significant homogeneity was apparent in the chosen sample population of
the studies as all studies chose healthcare workers with a majority focused on nurses in
particular. All of the studies chose an intervention that involved some form of education on
methods to reduce stress levels such as mindfulness-based training, conflict management classes,
or peer support groups.
The most common outcome measure to assess burnout among the studies included the
Maslach Burnout Inventory and the Perceived Stress Scale. Overall, the strengths of these studies
included the use of random sampling and the use of randomized control trials. The weakness in
the majority of the studies was the small sample size. Homogeneity was apparent within all the
outcomes of the studies as each study resulted in a reduction of stress or an increase in resiliency
among the intervention group (see Appendix G, Table 2).

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Current literature confirmed the prevalence of burnout and high stress levels in healthcare
workers and most specifically, nurses. Burnout can be combated in a multitude of ways including
mindfulness-based training, peer support groups, and education on techniques to enhance
resiliency. Establishing specific time set aside to reflect and learn about coping mechanisms to
combat stress is necessary to mitigate against burnout. The evidence extracted suggested the
significance effect of a mindfulness-based intervention on reducing burnout and stress in
healthcare professionals. By harnessing healthcare workers with the tools necessary to fight high
levels of burnout and stress, it can result in lower turnover rates of staff, less fatigued nurses, and
promote greater overall health in nurses.
Theoretical Framework
Theory is the driving force behind evidence-based practice and is a facilitator for practice
change. The Neuman System Theory (NST) was chosen for the theoretical framework that is
applicable to the concept of nurse burnout and resiliency. The NST is based on the philosophy of
“helping each other live” (Neuman, 1996, p. 675). The NST assumes that energy is necessary for
optimal function of systems and if one system is not functioning properly, other systems will be
affected. Stressors are the main source of client instability (see Appendix D, Figure 1). In
applying the NST to the evidence, the client is assumed to be the nurse. Wellness retention is the
goal of NST, and it is influenced by lines of defense that protect the core of the client. Variables
can influence the client system and these variables can be psychological, physiological,
sociocultural, developmental, or spiritual. The lines of defense serve as protective barriers to the
core (see Appendix D, Figure 2).
There are three dimensions of stressors that can alter the core and include intrapersonal,
interpersonal, and extra-personal (Butts & Rich, 2018). In reviewing the current literature and

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evidence pertaining to nurse burnout, it is evident that burnout is a psychological variable that
has influenced the core of the nurse. The nurse can also be affected by each dimension of
stressor. The emotional toll of the nurse role can be seen as intrapersonal stress, the expectations
of the nurse role can be seen as interpersonal stress, and the lack of policy and procedure to
combat burnout can be seen as extra-personal stress. By addressing the three dimensions of stress
that are affecting the nurse, it will enable the nurse to reach optimal function, decrease burnout,
and increase resiliency.
Implementation Framework
Ensuring the wellness and resiliency of nurses is paramount to the health and wellness of
patients and has become even more apparent during the Covid-19 pandemic. When nursing staff
is overworked, under high amounts of stress, and have high level of burnout, it can lead to more
potential for errors and unsafe care of patients. Creating resiliency techniques and education for
nurses in order to uphold their wellness in order to provide care for the vulnerable is of upmost
importance. Change is necessary in order to promote the health of the nurse and reduce burnout.
For this reason, the Rosswurm and Larrabee Model is fitting for its applicable stepwise process
to change (see Appendix E, Figure 1). This model is comprised of six steps: (1) assess the need
for change in practice; (2) problem interventions and outcomes; (3) synthesize best evidence; (4)
design practice change; (5) implement and evaluate change in practice; and (6) integrate and
maintain change in practice (Rosswurm & Larrabee, 1999).
A need for change was identified through the evidence of increased burnout and stress
levels among nurses. The first three steps of the model have been complete thus far and
therefore, a design of a potential project would include mindfulness-based sessions conducted
through the use of an electronic online application. The practice change is to routinely include

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these mindfulness sessions on a daily basis for a goal of ten days total. The goal for the
mindfulness-based sessions is to provide a time of relaxation and meditation for the nurses in
order to alleviate stress.
Methods
This project was submitted to the Arizona State University Institutional Review Board as
a quality improvement project and received expedited approval. This quasi-experimental, preand posttest design project provided participants with a consent form describing the purpose,
procedures, potential benefits and risks and confidentiality issues of their participation.
Participants were recruited from a Southwestern University through the use of electronic
announcements via Canvas. Inclusion criteria of participants included (1) those who were
currently working in an in-patient setting at the bedside; (2) aged 18 years or older; and (3) were
fluent in the English language.
Those who agreed to participate in the study were sent an electronic pre-survey via e-mail
which included demographical questions, the Copenhagen Burnout Inventory (Kristensen et al.,
2005), the Brief Resiliency Coping Scale (Sinclair & Wallston, 2004) and the Short Form Health
Survey-20 (Stewart et al., 1988). Those who completed the initial pre-survey were given
instructions on how to complete the intervention. Participants downloaded the HeadSpace
application from either their computer or phones and were instructed to listen to a different tenminute guided mindfulness track for a consecutive ten days. After completion, participants then
completed a post-survey that included the Copenhagen Burnout Inventory, the Brief Resiliency
Coping Scale, and the Short Form Health Survey-20. Participants were compensated with a
nominal $10 electronic gift card for their full participation.

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The Copenhagen Burnout Inventory measured the pre- and post-survey burnout scores of
the participants. The Brief Resiliency Scoping Scale measured the pre-and post-survey scores of
resiliency in the participants. The Short Form Health Survey-20 measured the pre- and postsurvey burnout scores of participants in various domain of health including physical functioning,
mental health, general well-being, pain, and social functioning.
The surveys were input into the statistical data application, REDCap (Project REDCap,
n.d.). Raw data collection was downloaded from REDCap and input into the statistical analysis
application, Intellectus (Intellectus Statistics, 2021). Descriptive statistics was used to describe
the sample characteristics and distribution of key measures. A two-tailed Wilcoxon signed rank
test was conducted to examine whether there was a significant difference between burnout scores
before and after the guided meditation intervention.
Results
Descriptive statistical data analyzed included gender identified, race/ethnicity, level of
education, number of years of experience as a registered nurse, and number of years employed at
current unit. Overall, 100% of the participants (N = 9) were female; Asian (44%) was the most
common race identified. The majority of participants had completed at least a Bachelor’s degree
and the majority of participants had 11-15 years of nursing experience (see Table 1).

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Table 1
Demographic and Nursing-Related Variables
Variable
Gender Identified
Female
Missing
Race Identified
Asian
Non-Hispanic White
Latino/Hispanic
Black
Missing
Highest Level of Education Completed
Bachelor's degree
Master's degree
Associate's degree
Missing
Number of Years of Experience as a Registered Nurse
0-5
6-10
11-15
Missing
Number of Years Employed on Current Unit
<1 year
1-2 years
3-5 years
6-10 years
Missing
Note. Due to rounding errors, percentages may not equal 100%.

n

%

9
0

100
0

4
3
1
1
0

44
33
11
11
0

4
3
2
0

44
33
22
0

3
2
4
0

33
22
44
0

2
3
3
1
0

22
33
33
11
0

Outcome variables for this project included level of burnout, level of resiliency, and
Quality of Life measured by the SF-20.
Burnout. The average score of pre-intervention burnout level was 62.5 and the average
score of post-intervention burnout level was 41.6. The results suggested a significant decrease in

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
the mean score after the intervention, indicating a lower level of burnout (z = -2.55; p = 0.11).
Figure 2 presents the score changes after the intervention.
Figure 2

Resiliency. The average score of resiliency pre-intervention was 3.5 and the average
score of resiliency post-intervention was 4. The results suggested a significant increase in the
mean score after the intervention, indicating an increased resiliency level (z = -2.53; p = 0.11).
Figure 3 presents the score changes after the intervention.
Figure 3

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The SF20 Quality of Life was used to measure physical functioning, mental health,
general well-being, pain, and social functioning. The overall total SF20 scores pre-intervention
and post-intervention were not statistically significant as indicated by an alpha value of 0.05, z =
-1.48, p = .139. However, the score of “health perceptions” domain was statistically higher post
intervention (z = -2.66; p = .008), suggesting that nurses perceived better health after the
intervention.
Impact of Project
The results indicate that a guided meditation intervention has statistically significant
impact on the burnout, resiliency, and health perception levels of nurses working in in-patient
settings. The use of a guided meditation intervention can provide a means for decreasing burnout
and increasing resiliency and health perceptions of nurses in order to maintain the nurses’ mental
health wellness. The feasibility of creating a scalable application to promote nurses’ well-being
is somewhat difficulty in terms of production, but can be cost-effective and effective means of
promoting nurses’ well-being. Curbing levels of burnout for nurses can make an impact by
ensuring that nurses’ health is addressed and can facilitate longevity of the nurse working at the
bedside.
Conclusion
Mindfulness intervention can reduce burnout levels and increase resiliency among
bedside nurses. By finding solutions to burnout experienced by nurses, it can ensure the mental
health wellness of the nurse. Ensuring that nurses have decreased burnout levels and increased
resiliency levels can make an impact on the quality of care provided to their patients (Fernandez
et al., 2020). The results of this project coincide with the findings of the literature review by
Green & Kinchen (2021) in which their findings indicated that mindfulness-based interventions

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
have been shown to significantly decrease stress and improve burnout levels. The barriers
encountered for this project include a small sample size and short time frame for completion.
Recommendations for further study include obtaining a larger sample population and an
increased period of time for the intervention.

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REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Appendix A
PubMed Advanced Search

23

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Appendix B
Academic Search Premier Advanced Search

24

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Appendix C
PsycInfo Advanced Search

25

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Appendix D
The Neuman Systems Theory
Figure 1

26

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Appendix D
The Neuman Systems Theory

Figure 2

27

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Appendix E
Rosswurm and Larrabee Model

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Appendix F

29

Evaluation Table
Table 1
Evaluation of Quantitative Studies
Citation
Ameli et al.
(2020)
Effect of a brief
mindfulnessbased program
on stress in
health care
professionals at a
US biomedical
research
hospital: A
randomized
clinical trial
Country: USA
Funding: not
stated

Conceptual
Framework
Theory of
Stress and
Coping
(inferred)

Design/Method

Sample/Setting

Major Variables &
Definitions

Measurement
PSS
MBI

Design: RCT

N=82

IV: MBSC

Purpose: Assess
the efficacy of a
MBSC program
during work
hours to reduce
stress among
HCP

AR: 4.8%

DV1: stress level

IC: NIH
employees

DV2: anxiety

EC: those with
medical and
psychiatric
conditions were
advised to consult
their HCP prior

DV3:
depersonalization

Analysis
2-sample t
tests

Findings
Stress level:
CI -4.28 to -0.72
P=.009
Anxiety:
CI -2.79 to -1.48
p<.001
Depersonalization:
CI -0.85 to -0.12
p=.04
Stress level,
anxiety, and
depersonalization
were all
significantly
reduced after
intervention.

Decision for Use
LOE: II
Strengths: randomization
of sample size; high
validity and reliability of
measurement tools used
Weakness: small sample
size; one institution used
for sample
Feasibility: High
Ease of intervention and
study replication
Conclusion: MBSC
program is feasible and
effective in reducing stress
among a mixed group of
HCP

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

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Citation

Dincer & Inangil
(2021)
The effect of
Emotional
Freedom
Techniques on
nurses’ stress,
anxiety, and
burnout levels
during the
Covid-19
pandemic: A
randomized
controlled trial

Conceptual
Framework

Maslach
Burnout
Theory
(inferred)

Design/Method

The Community
Resiliency
Model to
promote wellbeing

Measurement

SUDS
STAI
BI

N=80

IV: EFT

Purpose:
Investigate the
efficacy of EFT
in the prevention
of stress,
anxiety, and
burnout in
nurses working
during the
Covid-19
pandemic

Attrition rate:
10%

DV1: stress level

Funding: None

Trauma
Resiliency
Model

Major Variables &
Definitions

Design: RCT

Country:
Turkey

Grabbe et al.
(2020)

Sample/Setting

IC: nurses
working with
Covid-19 patients
in a university
hospital in Turkey
Did not have any
psychiatric
diagnoses
Not taking any
courses about
coping with
anxiety and stress
Volunteered to
participate

Design: RCT

N=77

Purpose:
Investigate stress
and well-being
in RNs to
determine if a
short resiliency
intervention

IC: nurses
employed at two
large, urban
tertiary care
hospitals that
volunteered to
participate in a

DV2: anxiety
DV3: burnout

Analysis

Findings

Wilcoxon
Signed
Rank test

Stress level:
CI -3.89
p<0.001

MannWhitney U
test

Anxiety:
CI -29.16
P<0.001
Burnout:
CI -0.511
p<0.001
Stress level,
anxiety level, and
burnout levels were
significantly
reduced after the
intervention.

IV: Community
Resiliency Model
DV1: well-being
DV2: resilience
DV3: secondary
traumatic stress

WHO-5
CD-RISC
STSS

Pearson’s
correlation
coefficient

Well-being:
(F(3,211.220)=4.99
p=0.006
Resilience:
(F(3, 193.8) = 2.68
p=0.004

30

Decision for Use
LOE: II

Strengths: high validity
tools were used and
randomized sample
population
Weakness: only one
online group treatment
was completed – needs
further replication
Utilize EFT therapists not
part of the research team
Feasibility: High
Ease of replication for the
intervention
Reason for Use: One
session of EFT was
effective in significantly
reducing stress, anxiety,
and burnout amongst RNs
LOE: II
Strengths: randomization
of sample; use of valid
instrument tools
Weakness: small sample
size; dependent on selfreported measurements

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

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Citation

Country: USA

Conceptual
Framework

Funding: Sigma
Theta Tau and
the Mundito
Foundation

Guo et al. (2019)
A WeChat-based
“three good
things” positive
psychotherapy
for the
improvement of
job performance
and self-efficacy
in nurses with
burnout
symptoms: A
randomized
control trial
Country: China

Psychological
Stress System
Theory

Design/Method

Sample/Setting

focusing on
sensory
awareness would
impact their
capacity to
tolerate stress

“Nurse Wellness”
study

Design: RCT

N=102

Purpose:
Hypothesized
that WeChatbased
intervention,
3GT could
promote selfefficacy and job
performance of
nurses with
burnout by
recording three
good things that
were impressive
each day

AR: 28%

Major Variables &
Definitions

Measurement

Analysis

Findings
Secondary
traumatic stress:
(F(3, 204.0)=2.689
p=0.009
Well-being,
resilience, and
secondary
traumatic stress all
significantly
improved over time
with the use of the
intervention.

RNs from
Chinese tertiary
general hospital
Full-time
Direct clinical
care to patients
MBI-GS score
>1.5

IV: Record three
good things that
were impressive
each day on 3GT
app
DV1: job
contribution
DV2: task
performance
DV3: burnout

GSS
MBI

ANOVA

31

Decision for Use

Feasibility: High
Ease of replicating the
intervention and ease of
measurement tools
Reason for Use: A
resilience training such as
CRM appears to be a
promising means to
enhance nurses’ ability to
manage stress related to
their work

Job contribution
F=6.425
p=0.13
Indicating
improved job
contribution

LOE: II

Task performance
F=29.252
p=0.28
Indicating
improved task
performance

Weakness: sample
recruited from only one
hospital

self-efficacy
F=5.058
p=0.28

Reason for Use:
population used in study
relevant to chosen
population; measurable
outcomes significantly

Strengths: Randomization
to eliminate selection bias;
one treatment directly
compared to another

Feasibility: High
Ease of study replication

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

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Citation

Funding:
Science and
Technology
Research Project
of HHEI

Hersch et al.
(2016)
Reducing
Nurses’ Stress: A
Randomized
Controlled Trial
of a Web-Based
Stress
Management
Program for
Nurses
Country: USA
Funding: NIH

Conceptual
Framework

Conservation
of Resources
Theory

Design/Method

Sample/Setting

Design: RCT

N=104

Purpose: Test
effectiveness of
a web-based
stress
management
program
designed for
RNs and the
situations they
experience

AR: 13.4%
IC: employed at 1
of 5 hospitals in a
VA hospital
system or a
metropolitan
hospital in NY
Age 21 or older
EC: Age less than
21 years old

Major Variables &
Definitions

Measurement

IV1: access to the
BREATHE webbased program

NSS

DV1: perceived
stress

Analysis

ANCOVA

Findings

32

Decision for Use

Indicating
improved selfefficacy
The intervention
significantly
improved the
scores of all
variables
measured.

improved with
intervention

Nursing related
stress:
t=-2.95
p=.00

LOE: II

The experimental
group showed
significantly
greater
improvement than
the control group
on perceived stress
levels after the
intervention.

Strengths: randomization
of sample; low attrition
rate
Weaknesses: small
sample size taken from
only two hospital systems
Feasibility: High
Ease of replication using
pre and post-tests after
intervention
Intervention is easily
accessible to study group
Reason for Use:
population group is
relevant to chosen study
group and stress levels
were significantly reduced
through intervention

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

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Citation

Mealer et al.
(2014)

Conceptual
Framework

Resiliency
Theory

Feasibility and
Acceptability of
a Resilience
Training
Program for
Intensive Care
Unit Nurses

Design/Method

Sample/Setting

Design: RCT

N=27

Purpose:
Determine if
multimodal
resilience
training program
for ICU RNs
was feasible to
perform

IC: RNs working
>20 hours at the
ICU bedside
No UMC
contraindicated to
exercise
Score of <82 on
CD-RISC

Country: USA

Major Variables &
Definitions

Measurement

IV: 2-day
educational
workshop on
resilience training

HADS
CD-RISC

Analysis
MannWhitney U
test

Symptoms of
depression
p=0.03
Resilience scores
p=0.05

DV1: symptoms of
depression

After the
intervention, those
that participated in
the workshop had a
significant
reduction in
depression
symptoms and
increased
resiliency.

DV2: resilience

EC: had medical
condition that
would limit
exercise

Funding: NIH

Findings

33

Decision for Use
LOE: II

Strengths: randomized
sample; used high validity
measurement tools; all
participants completed
study
Weakness: pilot study;
sample recruited from only
one location and small
sample size
Feasibility: High
Ease of replication of the
intervention and use of
high validity and high
feasibility instrument tools
Reason for Use:
population used in study is
relevant to potential study
and resilience training has
shown significant
improvement in resiliency

Oman &
Hedberg (2006)
Passage
meditation
reduces
perceived stress

Theory of
Stress and
Coping
(inferred)

Design: RCT

N=58

IV: EPP

Purpose:
Investigate the
effects of EPP
training in
altering stress,

AR: 5%

DV1: perceived
stress

IC: health
professionals with

PSS

2-tailed ttest

Stress:
p<.05
d= -0.63
Stress in the
treatment group
was significantly

LOE: II
Strengths: randomized
sample; high validity
measurement tool used
with pre and post-test
study design

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

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Citation

in health
professionals: A
randomized
controlled trial

Conceptual
Framework

Country: USA

Design/Method

mental health,
and well-being
outcomes among
health
professionals

Sample/Setting

current patient
contact

Major Variables &
Definitions

Measurement

Analysis

Findings
reduced after EPP
in comparison to
the control group

EC: none listed

Reflecting peersupport groups in
the prevention of
stress and
burnout:
Randomized
controlled trial.
Country:
Sweden
Funding: not
stated

Weakness: small sample
size; reliance on selfreported measures
Feasibility: High
Ease of intervention
implementation and ability
replicate study

Funding: Fetzer
Institute of
Kalamazoo,
Michigan and
USNHLI

Peterson et al.
(2008)

34

Decision for Use

Reason for Use: HCP
effectively lowered stress
levels using EPP and
therefore, benefit from
stress reduction
intervention
Social Support
Theory
(inferred)

Design: RCT

N= 151

IV: PSG

Purpose:
Investigate the
effect of
participating in a
reflecting PSG
on self-reported
health, burnout,
and perceived
change in work
conditions

IC: >75th
percentile on the
exhaustion
dimension of
OLBI

DV1: perceived
quantitative
demands at work

EC: not stated
Sample:
Demographics:
Healthcare
workers including
physicians; RNs;
nursing assistants;
social workers;

DV2: perceived
general health
DV3: perceived
exhaustion

OLBI

ANCOVA

Perceived
quantitative
demands:
F=6.25
P=0.014

LOE: II

Perceived general
health:
F=6.91
P=0.010

Weakness: low
percentage of respondents
who agreed to participate;
self-reported data

Exhaustion:
F=4.31
P=0.040

Feasibility: Moderate
May be difficult to
conduct PSG during work
hours depending on
employer and required

Those that
participated in

Strengths: randomization
of sample and high
validity analysis

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

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Citation

Pipe et al. (2009)
Nurse leader
mindfulness
meditation
program for
stress
management
Country: USA
Funding: The
Mayo Clinic
Division of
Nursing Services

Conceptual
Framework

Theory of
Human Caring

Design/Method

Sample/Setting

occupational
therapists,
physiotherapists;
psychologists;
dental nurses and
hygienists;
dentists)

Major Variables &
Definitions

Design: RCT

N=33

IV: MBSR program

Purpose:
Evaluate a
condensed 4week MBSR
curriculum on
outcome
measures of
stress,
depression,
anxiety, and
caring efficacy
over time

IC: RN leaders
employed full
time at a
healthcare system
in the southwest
US that are able
to speak and read
English

DV1: depression

EC: Active
infectious disease;
active
hematological
malignancy;
major psychiatric
disorder; severe
unassisted hearing
loss; previous
participation in an
MBSR program

DV2: anxiety

Measurement

SCL-90-R

Analysis

ANCOVA

Findings

35

Decision for Use

PSG, showed
significantly
improvement in
perceived
quantitative
demands at work,
perceived general
health, and
decreased
exhaustion.

participation in the PSG
from participants

Depression:
p<.05

LOE: II

Anxiety:
P<.05
MBSR education
was able to
significantly
improve scores
related to
depression and
anxiety in the
intervention group.

Reason for Use: PSGs
can be a useful tool to
combating stress
exhaustion and perceived
health in those working in
healthcare

Strengths:
Weakness: limited ability
to monitor meditation
practices of participants;
small sample; short time
period of study
Feasibility: High
Ease of study replication
with use of condensed
curriculum
Reason for Use: Short
workplace courses on
mindfulness strategies can
be beneficial to anxiety
and depression of RNs

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Citation

Wei et al. (2017)
Active
intervention can
decrease burnout
in ED nurses
Country: China
Funding: None
stated

Conceptual
Framework

Maslach
Burnout
Theory

Design/Method

Sample/Setting

Design: RCT

N=102

Purpose:
Investigate
whether an
active
intervention may
play a role in
reducing job
burnout in ED
nurses

IC: worked in
comprehensive
high-level
hospitals in Jinan,
China
EC: ED RNs that
have worked in
the ED <1 year;
head nurses and
nurse managers

Major Variables &
Definitions

Measurement

IV: regular
management and
active intervention
that includes classes
about
communication
skills, conflict
management,
efficacy elevation,
and emotional
control

MBI

DV1: EE
DV2: DP

Analysis
Sample ttest

Findings
EE
t=-6.928
p<.05
DP
t=-6.442
p<.05
The scores of EE
and DP were
significantly
reduced after the
intervention.

36

Decision for Use
LOE: II

Strengths: randomization
of sample size and ease of
intervention application;
high validity measurement
tool used
Weakness: Small sample
size; short time period
Feasibility: High
Ease of intervention
replication can be easily
done in the working
environment
Conclusion: Active
intervention can have
significant impact on the
reduction of EE and DP in
RNs

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Appendix G

37

Synthesis Table
Table 2
Study Characteristics
Year
RCT/II
Country
Size
Participants
Theory
Measurement Tools
MBI
PSS
SUDS
STAI
BI
WHO-5
CD-RISC
STSS
GSS
NSS
HADS
OLBI
SCLR-90-R
Interventions
MBSC

Ameli

Dincer

Grabbe

Guo

Hersch

Mealer

Oman

Peterson

Pipe

Wei

2020
•
USA
82
HCP
Stress and
Coping
(Inferred)

2021
•
Turkey
80
RN
Maslach
Burnout
(Inferred)

2020
•
USA
77
RN

2019
•
China
102
RN

2016
•
USA
104
RN

2014
•
USA
27
RN

2017
•
China
102
RN

Psychological
Stress System

Conservation
of Resources

Resiliency

2008
•
Sweden
151
HCP
Social
Support
(Inferred)

2009
•
USA
33
RN

Trauma
Resiliency

2006
•
USA
58
HCP
Stress and
Coping
(Inferred)

Human
Caring

Maslach
Burnout

•
•

•

•
•

•
•
•
•
•
•

•
•
•
•
•
•

Ameli

Dincer

Grabbe

Guo

Hersch

Mealer

Oman

Peterson

Pipe

Wei

•
AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute

REDUCING BURNOUT IN BEDSIDE NURSES THROUGH GUIDED MEDITATION
Interventions
EFT
CRM
WeChat App
Web-based program
Educational workshop
EPP
Peer-Support Group
MBSR curriculum
Active Education
Findings
Stress Level
Anxiety
Depersonalization
Burnout
Well-Being
Resiliency
STS
Job Contribution
Task Performance
Self-Efficacy
Depression
Work Demands
General Health
Exhaustion

Ameli

Dincer

Grabbe

Guo

Hersch

Mealer

Oman

Peterson

Pipe

38

Wei

•
•
•
•
•
•
•
•
•
↓
↓
↓

↓
↓

↓

↓
↓
↓

↓
↓
↓
↓

↑
↑
↑
↑
↓

↓
↓
↑
↓

↓

AR: attrition rate; BI: Burnout Inventory; CD-RISC: Connor-Davidson Resilience Scale; CRP: Community Resiliency Model; DP: depersonalization; DV: dependent variable;
EC: exclusion criteria; EE: emotional exhaustion; EFT: Emotional Freedom Techniques; GSS: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale;
HCP: healthcare professionals; HHEI: Hebei Higher Education Institutions; IC: Inclusion criteria; IV: independent variable; LOE: level of evidence; MBI: Maslach Burnout
Inventory; MBSCP: mindfulness-based self-care program; MBSR: mindfulness-based stress reduction; N: number of participants; NIH: National Institute of Health; NSS:
Nursing Stress Scale; OLBI: Oldenburg Burnout Inventory; PA: personal achievement; PSG: peer support group; PSS: perceived stress scale; RCT: randomized controlled trial;
RN: registered nurse; STAI: State-Trait Anxiety Inventory; SCL-90-R: Symptom Checklist 90-Revised Somatization; SUDS: subjective units of distress scale; UMC: underlying
medical condition; US: United States; USA: United States of America; USNHLI: United States National Heart and Lung Institute