Implications for practice and research

• Mindfulness can help relieve symptoms of depression and anxiety among nurses and may improve patient care.

• There is a need for future quantitative studies to measure the nurse-perceived benefits of mindfulness identified in qualitative research.

• Mixed-methods reviews can help develop a more complete and clinically relevant understanding of a given topic.

Context

Work-related stress is now the most common occupational health problem among nurses after musculoskeletal disorders.1 Its impact on the workplace includes increased sickness and suboptimal levels of patient care, with practitioners adopting strategies such as task-orientation or reaching burnout, with its associated depersonalisation of patient relationships and negative attitude towards one's work.2 Mindfulness, an adaptation of a Buddhist meditation practice, is increasingly proposed as a mechanism for decreasing stress among nurses and reconnecting them with the emotional and relational aspects of care. The primary aim of this review was to establish whether the nurse-perceived benefits and challenges of mindfulness identified in qualitative research have been measured and confirmed in quantitative studies.

Findings

Thirty-two studies were identified, including 16 randomised controlled trials (RCTs) and 4 qualitative studies. Only one of the qualitative studies included a specific mindfulness intervention (the others consisted of a mix of practices including meditation, yoga and Tai-Chi), indicating that further work is warranted in this area. RCTs tended to focus on improvements in negative psychological states such as depression and anxiety (significant improvements were identified in both these domains); only five included follow-up data measuring the extent of sustained change. Qualitative data explored the underlying causes of these traits, such as work overload, and also exposed nurse-perceived benefits of mindfulness such as increased calmness and patient-focused care. There was thus a degree of discrepancy between what was being measured and the benefits that were being experienced. Challenges to sustaining mindfulness practice were identified in the qualitative synthesis, such as insufficient time and the difficulty of sustaining practice on one's own. Ways of mitigating these could be included in future RCT interventions.

Commentary

This review demonstrates how a mixed-methods approach can move beyond presenting a summary of current knowledge to establishing how appropriate, complete and ultimately clinically useful that knowledge might be. Qualitative research can tell us about the nature of a problem (or, in this case, solution), before we start to measure effectiveness.3 Here, qualitative research is used to critique current and direct further quantitative enquiry—essentially asking whether quantitative researchers have been asking the right questions. Not only do the qualitative findings provide some context to the depression and anxiety measured in the quantitative studies, they also suggest improvements in well-being and patient care that have not yet been measured in quantitative research. Harden3 further points out that qualitative enquiry can work alongside quantitative research to explore how and why an intervention works—simply being able to state that mindfulness reduces depression and anxiety among nurses tells us nothing about how that is achieved, or whether and how it impacts on patient care. Guillaumie et al suggest that a larger corpus of qualitative work on the impact of mindfulness training would enable theory to be developed to explain its effects and their underlying causes. This work has been started by Hunter4 who used the limited research available to propose a Mindfulness Cascade, illustrating how increased calmness ultimately leads to improved patient care. Future qualitative research can build on this theory, while quantitative studies can measure the effectiveness (or otherwise) of the mechanisms suggested.