Introduction
It is well accepted that physical illness causes considerable stress and that stress is both a physical and emotional experience. Stress causes suffering and the alleviation of suffering is fundamental to effective nursing practice. Thispaper reviews the theories surrounding
mindfulness-based stress reduction practices and explores the use of simple, accessible methods of incorporating stress reduction techniques nursing care. With the growing interest in
mindfulness itself within Western society in general and Western medicine in particular, and the availability of mindfulness-based stress reduction techniques, it is time to explore how these techniques could be effectively applied to the care of our patients within nursing practice.
The research on mindfulness can be difficult to decipher as mindfulness is often used as an umbrella term that represents many different approaches and is often referred to in the literature synonymously with ways in which one can practice mindfulness, when in reality the terms are not mutually exclusive. For example, meditation is a technique used to practice mindfulness, yet one can be mindful without the use of meditation. However, because the research often uses such terms interchangeably it is difficult to find true efficacy data within the research reports. Because there is misunderstanding about the techniques themselves and the theoretical underpinnings that support their use, part of this paper is devoted to reviewing the physiological and psychological foundations of mindfulness-based stress reduction methods and making a case for their potential effectiveness in patient care.
meditation, focused breathing, and yoga are not religious practices. Rather, they are practices used to strengthen awareness and enhance well-being (Raphael-Grimm, 2014, p. 177). As such, this paper also will provide evidence that mindfulness-based practices have physiological rather than spiritual origins and effects.
The ideas expressed herein are provided as an effort to describe these viable therapeutic interventions (that are complementary to Western approaches of medicine), and create a better understanding of how concepts and practices of mindfulness can enhance patient care. It is the hope that with clarity around the science behind effective stress reductions methods and a better understanding of the physiological and emotional benefits of these interventions, nurses will have increased confidence in the use and utility of mindfulness-based techniques and increased motivation to employ them in clinical practice. It is also hoped that with easy, web-based access to mindfulness-based stress reduction methods, nurses will be more likely to access these apps for use with patients.
Pathophysiology of the Acute Stress Response
and include: An increased heart rate and blood pressure for better perfusion of vital organs and muscles; increased respiration rate for better oxygenation; increased release of glucose by the body’s natural stores for needed energy; increased cognitive function and short-term memory; increased release of endorphins, which help to block pain reception. In essence, every system becomes geared toward increasing one’s ability to survive the immediate threat.
Other natural processes of the body that are activated during times of rest, are
subsequently suppressed during the activation of the stress response. For example, because one does not need to digest food while fighting a bear, the body’s natural response is decrease gastric motility and decrease gastric secretions. In a prolonged state of stress, such as during
hospitalization, this adaptation poses a risk for developing gastrointestinal distress, reduced appetite and abdominal pain. In addition, increased cortisol levels lead to a decreased
inflammatory and immune response, which subsequently increases susceptibility to opportunistic infections. In essence, these are all primitive neurological and physical responses to perceived threats that are adaptive in nature (Teper, Segal, & Inzlicht, 2013).
Long term activation of this stress response can lead to the development of chronic gastric distress, can cause delayed healing, and can include other downstream consequences associated with prolonged high glucose and high blood pressure. A few examples of
consequences associated with prolonged vasoconstriction, is stomatitis (ulcers in the mouth), necrotizing periodontal disease, and acute renal failure due to decreased perfusion to the kidneys (Gould & Dyer 2011a, p. 196). Although the stress response can be a positive adaptive modality in which we become better equipped to deal with a threat on a short-term basis, it can cause damage with long-term activation. In essence, if a person cannot cope with the stressors, or the stressors are prolonged, then maladaptive responses or physiological distress may ensue.
plays a key role in our physical response, in essence the mind-body connection. Therefore mindfulness is a tool in which one can learn to cultivate this control.
What is Mindfulness?
Defining “mindfulness” can be difficult, as it is an ambiguous term, which holds several definitions and subsequent applications. For purposes of this paper, “mindfulness” is used only as a secular term, and refers to a practice of non-judgmental, open awareness, that can be
harnessed for use therapeutically. To reiterate, it is important to clarify that there is a distinction between the terms “mindfulness” and “meditation.” Simply stated, meditation is one of many tools in which to cultivate and then practice mindfulness but is not a necessary precursor to effective use of mindfulness-based stress reduction measures.
Mindfulness as described by Raphael-Grimm (2015) is,
A state of awareness, or consciousness, that is fostered by the consistent and deliberate effort to take notice of what is occurring in one’s inner and outer worlds, with a capacity to be fully engaged in the present moment, rather than distracted by, preoccupied with, or focused on the past or future, (p. 11).
She goes on to describe that mindful awareness fosters one’s capacity to be attuned to their internal climate in such a way that subsequently enables a person to respond more consciously (rather than impulsively), to the conditions they experience in the present moment.
Jon Kabat-Zinn’s concept and application of mindfulness is often referred to in the literature. Goldberg & Del Re’s (2014) interpretation of Kabat-Zinn’s definition of mindfulness is, “A cognitive skill which involves present focused attention that is intentional,
her long-term boyfriend. She recognizes that she feels anger toward him, and that these negative thoughts are all consuming. She has had difficulty sleeping for the past several weeks since the breakup. At night she lies awake with her thoughts ruminating about the various reasons for why this has happened. In fighting the impulse to call him and give him “a piece of her mind,” she instead plays these scenarios over and over in her head without resolution. When she finally is able to fall asleep, she has disturbing dreams about the situation, and wakes up in the mornings feeling restless and fatigued. As the anger builds up, her body is tense and her heart feels like it is pounding inside of her chest. The obsessive negative thoughts make her feel sick to her stomach causing her to lose her appetite, and subsequently she has lost an unhealthy amount of weight. Zoe is a full time student. She recognizes how her negative reactions have impacted her ability to concentrate, focus, and succeed in her classes. The physiological impacts are beginning to take a toll on her physical, emotional and mental wellbeing.
she is within the grief process and to assume a posture of non-judgment. Now, if the old thought patterns arise, and Zoe notices her body’s response to those thoughts, she will be better equipped to take a few deep breaths, disrupting the negative thought pattern and return to a state of non-judgmental acceptance.
This is not to say that Zoe is no longer dealing with the loss of a significant relationship in her life, rather mindfulness has enabled Zoe to calm down, and to cope with her emotions in a more productive and healthy manner. She has stopped trying to find fault or blame and has accepted that relationships end, sometimes for reasons that are difficult to pinpoint, and that she doesn’t need to search for a villain, or demand justice or restitution. As her awareness deepens, it enables her to disrupt the pattern of negative rumination, and replace those thoughts with questions such as, “How have I grown from this experience? What gift did I give or get out of that relationship? How can I understand my boyfriend’s decision rather than condemn him for it?” In doing so, she can continue to work her way through the process of grief and acceptance. Mindfulness can increase one’s regulatory capacity, and one’s ability to empathize with others (Brown, 2007).
Bringing Mindfulness Into Western Medicine
Perhaps the biggest barrier to incorporating mindfulness into Western society is its strong association with Eastern religion. Jon Kabat-Zinn is known as the pioneer who brought a
Kabat-Zinn has helped to redefine mindfulness in a way that disassociates it with religion. In his paper entitled Mindfulness in Medicine, he writes, ‘‘Historically a Buddhist practice, mindfulness can be considered a universal human capacity proposed to foster clear thinking and open heartedness. As such this form of meditation requires no particular religious or cultural belief system,’’ (Ludwig & Kabat-Zinn, 2008, p. 1350). He goes on to compare that the words ‘mindfulness’ and ‘medicine’ as sharing the same etymological origin of the Latin word ‘mederi’ meaning ‘‘to heal,’’ (Ludwig & Kabat-Zinn, 2008).
Mindfulness-based interventions initially implemented to combat chronic pain over 30 years ago, have continued to grow in their applications (Goldberg & Del Re, 2014). Kabat-Zinn defines MBSR as a means in which one can take responsibility for, and modify lifestyle factors which lead to chronic illness, cardiovascular disease, diabetes and cancer (Ludwig & Kabat-Zinn, 2008). Such techniques include but are not limited to: Body scans, deep breathing, focusing and intentionally relaxing specific muscles or muscle groups, visualizations or guided imagery (Praissman, 2007).
techniques that can be implemented as interventions with hospitalized patients, quickly and easily.
Mindfulness Through Cognitive Behavioral Therapy
Mindfulness based practices complement many of the principles found in Cognitive Behavioral Therapy (CBT), developed in the 1970s. The central idea of CBT revolves around the role that cognition or thoughts play in how people feel and act (Tasman & Mohr, 2011, p. 335). The theory includes the notion that if a person can alter the way in which they think more accurately about the causes and issues that surround their circumstances, they will discover that many of their underlying automatic assumptions are false. They will discover that their faulty assumptions contribute to their own suffering. By replacing their erroneous thoughts (my boyfriend has done me wrong and deserves retribution) with more accurate, less emotionally charged thoughts (I understand that we had not been getting along for a long time and that he did not want us to continue when it was clear that the relationship could not work) then a person’s emotions change and they then behave in more effective ways.
Applying this concept on a physiological level: when there is a perceived threat, a
message is sent to the amygdala portion of the brain, which then activates the emotional response to that stimuli (Brown, 2007). As described earlier, this response may trigger the activation of the sympathetic nervous system’s “fight or flight” physiological cascade and is often
accompanied by feelings of fear, dread, anger, panic, etc. Interventions consistent with mindfulness and CBT can be learned, and used as tools, to interrupt negative thought patterns, allowing an individual to have a means of engaging with the stimulus and the response on a more effective emotional, behavioral, and physiological level.
Why Mindfulness-Based Interventions Could be Useful in Clinical Practice?
The following description of the effective applications of mindfulness are drawn from the work of Teper, Segal & Inzlicht, 2013). As mentioned earlier, a prominent theme of mindfulness is cultivating present moment awareness and non-judgmental acceptance. One school of thought is that mindfulness is about emptying the mind of all thoughts, however others view it as a tool in which one can cultivate openness and awareness and subsequently become attuned to the ability we have to regulate our own thoughts and emotions. This perspective has grown in popularity among psychologists who see mindfulness as an accepted means of coping with thoughts and emotions. In essence, emotion regulation is significantly enhanced by mindfulness because mindfulness-based practice enhances executive functioning. This theory is based on the idea that our emotions give us information about a situation. That information is useful when it can be considered thoughtfully rather than just acted upon reflexively. Whether we perceive the situation as a direct threat or not, influences the way in which we respond to it.
As discussed earlier, the emotional response produced in the amygdala starts a chain reaction of physiological responses. Therefore, if one can learn to be attuned to the
physiological symptoms that often accompany emotions, a person can learn to recognize their distress and mindfully redirect their attention and focus, and then, deliberately choose to engage in other stress reduction techniques (deep breathing, etc.) (Teper, Segal & Inzlicht, 2013).
increasing respiratory rate, and feeling of the inability to breathe. At the onset of these physiological responses, the nurse could instruct the patient in initiating stress reduction
techniques that would interrupt the fight or flight response and lessen negative consequences of long term activation. ‘‘Being aware of, and able to identify the emotions we are experiencing are the first steps to recalibration,’’ (Raphael-Grimm, 2014, p.26).
Therapeutic Applications and Theoretical Underpinnings of Mindfulness
The hospital setting is filled with stimuli that could result in the activation of the stress response. From diagnostic procedures to invasive treatments, surgeries, debridement, and chemotherapy, to name a few, the hospital is an epicenter of experiences that patients could interpret as threatening. An example of simple visual stimuli, which could result in a stress response for an individual in the hospital setting, is the sight of a needle or a bag of
sense of receptivity within her body. She can better embrace the idea that achieving a sense of calm during her infusion will be helpful in allowing her to rest and restore a sense of strength in being able to deal with the cancer. If she is calm, it will decrease her likelihood of triggering her physiological stress response and of suffering the negative consequences of long-term activation of that response. She will experience less fatigue and exhaustion while she fights this cancer.
There is a growing body of research that supports the clinical effectiveness of
One study conducted by Haythornthwaite, Lawrence and Fauerbach (2001), looked at the effects of using sensory focusing during dressing changes for burn patients. Participants
receiving the sensory focusing intervention, were given 20 minute long audiotapes that presented the skill, and were given opportunities to practice the coping strategy prior to dressing changes. The directions of the sensory focusing intervention included; a) monitor variations in sensory stimuli; b) stay present (rather than drifting to future or past thoughts); c) limit interpretations of the sensory experience (Haythornthwaite, Lawrence & Fauerbach, 2001). The results of the study concluded that patients using this technique reported a greater decrease in pain and less remembered pain compared to those in a distraction group, and compared to those receiving the standard care (Brown, 2007). This is an example of how a mindfulness tool can be applied at the bedside to help alleviate physical discomfort on a short-term basis.
Another mindfulness-based technique that deliberately redirects a person’s thought processes is guided imagery. One plausible explanation of the efficacy of this technique is the Gait Control Theory. Gould & Dyer (2011b) describe the theory as follows: When a stimulus travels via messenger pathways along the spinal cord to the brain, the integration and input of a positive stimulus may lessen the ability for a negative stimulus (such as pain), to be fully processed. In other words, competing nerve pathways have a way of opening or closing the gates, in a manner that permits impulses generated by peripheral nerves to be sent up the
sensory pathway and helps to decrease the person’s perception of pain. These methods of thought refocusing serve as examples of the ways in which mindfulness techniques can easily and effectively be implemented at the bedside.
Research Supporting Benefits of Mindfulness Practices
There has been an increasing interest on the effects and efficacy of Mindfulness Based Stress Reduction (MBSR) techniques. The research that supports positive physiological and psychological effects has been compelling. Holzel and colleagues (2010) focused on the physiological impact of MBSR techniques, on the brain: Specifically, this study demonstrates measurable neural plasticity of grey matter noted with the application of mindfulness techniques. In other words, changing one’s thought pattern can change the physical structure of the brain.
Grey matter is the area of the brain that is involved in, “Learning, memory process, emotional regulation, self-referential processing, and perspective taking,” (2010, p. 36). Other areas of the brain, which seemed to show improved structural plasticity with mindfulness training, are the hippocampus (critical in learning, memory processes, emotional regulation and modulation of memory control) and the insula (which is thought to be linked to awareness and empathic responses). In addition a lack of age related decline in some regions of the brain were found among those who use MBSR techniques but were not found in the control group.
two main parts: Mindfulness training classes aimed at inducing present-moment, non-judgmental, and compassionate awareness and MBSR techniques in which to practice
mindfulness. One technique that was taught was a body scan, which consists of focusing one’s attention to specific regions of the body sequentially, and non-judgmentally observing physical sensations. The second technique was mindful yoga which utilizes coordinated stretching and breathing exercises to bring one’s awareness to the moment-to-moment experience of the body, thus becoming more attune to and honoring one’s own physical limitations. The last technique taught was a sitting meditation the purpose of which was to practice open awareness and
consisted of focusing one’s attention to both internal and external sensations as well as breathing patterns present in the here and now. Participants were then given guided audiotapes to help them practice those three MBSR techniques (body scan, yoga, and sitting meditation) on their own (p. 37).
The study examined pre and post brain MRIs of participants who underwent the
mindfulness training program versus a control group who did not. Those who participated in the MBSR had a measurable increase in the amount of grey matter present in the brain, specifically in the left hippocampus, the cerebellum (involved in sensory perception, coordination and motor control), posterior cingulate cortex (associated with self referential elements), and the temporo-parietal junction (involved in social cognition). This evidence supports the hypothesis that there are brain-enhancing benefits of implementing MBSR techniques.
the strong possibility of physical benefits improved emotional regulation derived from
mindfulness practices resulting in increased neuro plasticity and structural changes of the brain matter (Holzel et al., 2010). While more data is needed to build a stronger case for the benefit of these methods, this preliminary evidence certainly supports their use.
Davidson and colleagues (2003) looked at the influence of Kabat-Zinn’s eight-week mindfulness based training program on brain and immune function. Immune function was measured by looking at antibodies produced after inoculation of the influenza vaccine. Results within the study participants were compared to those of a control group. Blood samples were obtained at three to five weeks and then again at eight to nine weeks. Subjects were female, average age of 36, and predominantly Caucasian. Participants were randomly assigned into either a “meditation group” or the control group. The interventions consisted of a 2.5-3 hour weekly mindfulness course, a silent seven-hour retreat during the sixth week, and guided meditation audiotapes for home practice (suggested use of the audiotapes was one hour per day, six days per week). The results of this study concluded that there was a measurable increase of antibody titers (from weeks four to eight) to influenza among the meditation group versus non-meditation group. These results demonstrate a positive correlation of mindfulness techniques and the physiological effect they can have on the immune response. One could speculate that the improved immune response shown in this study may have positive implications for producing similar effects with other disease processes.
anxiety, eating disorders, and major depressive disorders), and “other medical disorders” (which included fibromyalgia, psoriasis, and cancer) (p. 131). Most of the studies reviewed utilized the 8-10 week MBSR model (described above) as the primary intervention with the designated population.
General findings within the “chronic pain” group, reported statically significant improvements in the ratings of pain, and other physical and psychological symptoms. “Axis I disorders” found statistically significant improvements in areas of anxiety and depression. Studies that examined the use of MSBR with “other medical disorders” reported physical
symptom improvement, overall stress reduction, and reduced mood disturbances. While much of this data sounds promising, Baer emphasizes that nine of the studies evaluated used pre and post research designs but lacked a control group from which to compare study results. This continues to be a criticism of much of the research that has been conducted on MBSR as a whole. The most common and perhaps the most impactful observed patient response to the interventions was reports of, “A new outlook on life, and improved ability to control, understand, and cope with pain and stress,” (p. 138). These patient responses demonstrates strong support for the ability to improve quality of life for patients by simply incorporating mindfulness-based stress reduction techniques into the interventions prescribed as part regular medical and nursing practice.
strategies that reflect those mindfulness-based techniques that overlap with cognitive therapy theory. These include: progressive relaxation, diaphragmatic breathing, and guided imagery that reduce stress and enhance coping skills. Meditation practice was not a component of this set of interventions. The study participants attended two sessions (lasting anywhere between 5 minutes to 1.5 hours) prior to surgery, and were given audiotapes of the relaxation techniques to use on their own at their discretion. The results of the study showed an increase in immune parameters as compared to the control group (Cohen et al., 2011). The importance of this study is in its evidence of a brief, low cost, intervention, having positive effects on immunological outcomes. This study illustrates the positive results of instituting short-term mindfulness-based
interventions to help produce better patient outcomes.
Proposal for Intervention
Most patients will not have the stamina for, interest in, or opportunity to take an 8-week MBSR program. However, some mindfulness-based stress reduction and relaxation strategies could easily be used at the bedside, helping to benefit patients moment to moment as they cope with difficult emotions, pain, and or the acute stress response. Many mindfulness-based techniques are accessible via the internet. Some of these exist in the form of high quality instructional apps. The number and availability of free mobile apps has grown exponentially over the past few years and among those apps exists many that can be used to enhance personal well-being. For example, through the use of mobile apps, it is possible to give bed-bound
patients access to tools to manage the psychological and physiological impacts of the acute stress response. In an analysis of the use of smart phones and mobile apps to access mindfulness-based stress reduction techniques, Plaza, et al. stated:
These devices are ubiquitous, well accepted in society, relatively inexpensive,
Mindfulness Based Apps
A literature review conducted in 2013 on mindfulness-based mobile applications found that the area of ‘‘medical/health care’’ is the third fastest growing app category (Plaza, Demarzo, Herrera-Mercadal, & Garcia-Campayo, 2013). At the time this survey was conducted, over 100,000 apps were available under the search criteria of “healthcare & fitness,” “medical,” or “lifestyle.” Smartphones and the use of apps have introduced a novel, innovative, and non-intrusive way to deliver health information that can enhance patients’ self-managed, positive outcomes. Through the use of mindfulness-based apps patients can have access to a wide variety of tools. These tools include instruction and cueing for breathing practices, body scans, walking meditation, mindful movements, compassion based meditations, or guided imagery. In their report Plaza, et al discussed user satisfaction between free versions and paid versions of the apps, the users rated the free versions with higher satisfaction. In addition the free versions had a much higher volume of users at 10,309, compared to the paid version comprising of 675 users. This is a notable point when considering the value of offering a low cost intervention accessible to people across our socioeconomic spectrum.
However the authors of this review identify that apps fall short of meeting the needs of all people who may want to use them. One area of weakness was a lack in diversity and availability of the apps in languages other than English. In addition, the authors found that not all apps had a clear definition of mindfulness. While the technology exists to be able to monitor biological variables which may be helpful for the user, at the early stages of the development of
conclusion of this literature review reveals that the use of MBMA remains widely unstudied (Plaza et al., 2013), though the future holds potential to improve this.
Because of the sheer number of MBSR apps now available, it can be overwhelming for patients and clinicians to know where to begin to find those that are most helpful. To gather a deeper understanding of the possible therapeutic applications of nurses using MBSR apps with their patients at the bedside, the author focused on three different mobile phone apps chosen based on their respective reputable affiliations with entities or institutions known for their evidence-based approaches to healthcare. (Note that, individuals can explore several different techniques or various apps to find the best personal fit).
The first app is called “Stop, Breathe, & Think” and may be a good starter app as it offers a basic introduction of how mindfulness methods and simple, focused meditation can help users develop the kind of focused, calm attention that can help them shift into a more relaxed mode. Within the app users are provided with simple explanations of the structures and functions of the Autonomic Nervous System and the impact that mindfulness-based practices can have on brain restructuring. Pictures and charts are included in order to further illustrate concepts and to appeal to the needs of the more visual learner. This simple, clear and evidence-based
allows the mindfulness strategies to be “individualized” to the needs of the user, responding to the user’s unique inner climate at the moment when the user accesses the app. However, if the user does not wish to utilize this functionality, they can skip this step, and simply choose from a long list of mindfulness (tools) that lead them through exercises (lasting anywhere from 3-20 minutes). Each tool has a short written description that provides a brief explanation of the tool’s intended purpose or desired therapeutic effect.
‘‘Stress Free’’ is another mindfulness app built by the Cleveland Clinic and available for free download. At this time, the app offers eight different guided relaxation recordings,
averaging approximately 15 minutes in length and reflecting varying mindfulness-based techniques. Each selection has a short written description of what the practice entails, its intended therapeutic effects, and suggested frequency of use. The introduction defines
mindfulness as ‘‘moment-to-moment’’ awareness, and describes the relaxation techniques as a way in which to empower a person to reduce stress by stimulating the parasympathetic part of the nervous system. Although each session contains elements of relaxation and breathing exercises, each also has a particular focus which is described in short detail below.
The “Guided Imagery” exercise takes the listener on a quiet, peaceful, morning walk down the beach in which relaxation is accessed through the thought focusing on the surrounding sights, sounds, and smells. The “Loving Kindness Meditation” is an exercise geared toward fostering positive emotions to help improve mood. Specifically, the listener is guided to practice empathy, compassion, love, and kindness toward themselves and toward others. This session challenges the listener to imagine the faces of various individuals which represent: Themselves as a child, their adult self, someone they care deeply about, a close friend, a stranger, and a person who represents a difficult relationship. Once the listener cognitively identifies a person for the given category, he or she is asked to acknowledge that individual’s personal struggles and dreams. As the image of each person appears, the listener is instructed through a powerful exercise of looking that person in the eyes and saying the words, “May you be filled with loving kindness, may you be well, may you be at peace and at ease, may you be happy.”
“Mindfulness of Being” is an exercise to help one practice being in the present moment, by acknowledging thoughts and feelings as they arise, and then letting go and returning to the rhythm of the breath. “Mountain Meditation” is an exercise meant to help the participant to feel grounded and confident in their ability to accept and face life’s circumstances.
Jon Kabat-Zinn takes the listener through an introduction in which he defines mindfulness, and explains the practical applications of MBSR, its universal appeal and its usefulness medical settings. He also addresses the common misconception that mindfulness is defined as, “The heart of Buddhist meditation,” explaining rather, that mindfulness is truly, “About attention and awareness, which is shared by all of us.” Kelly McGonigal, PhD is a mindfulness teacher and researcher whose focus is on, “The Neuroscience of Change,” at Stanford University. Dr. McGonigal’s segment in this app details the “alternative mode” of the brain, which is focused on “experiencing self,” and how the practice of mindfulness alters the neuronal structures of the brain. She details the concept of utilizing mindfulness to change the experience of the inner dialogue which can lead to less suffering in areas such as social anxiety and depression as one moves out of their “default mode.” Daniel J. Siegal, MD is a
psychotherapist who explores the relationship between mindfulness and the brain through his audio presentation on enhancing mental functioning, physiological functioning and relationships. He also addresses the fact that mindfulness has been found to be present in every culture (Eastern and Western) and points to the science whose evidence supports that it promotes human
wellbeing.
Proposed Intervention
intervention, be able to provide a brief teaching on the acute stress response, and introduce the use of mindfulness-based stress reduction techniques. With the knowledge of and familiarity with MBSR apps, a nurse could recommend their use to patients and family members (note: If patients do not have their own smart phone, many units now provide “loaner” Ipads or computers for patient use). The nurse could then suggest that patients listen to one of the apps during the next dressing change, chemotherapy infusion, or at a other times when patients are experiencing distress such as when they are experiencing pain, anxiety, or insomnia. It would be important for the nurse to explain to the patient that the apps will be used as adjuncts to standard care. For example, a patient may still receive an analgesic to combat pain, however perhaps integrating a body scan would produce enhanced therapeutic effects. The idea is that once the intervention is properly introduced by the nurse, then the patient will exercise their own autonomy in accessing the techniques as often as they would like—thus enhancing executive control over emotional and physical responses to acute stress. One of the unique aspects of nursing care is the role of being educators. This role is the key to successful implementation of this intervention.
Dissemination Strategies
patient’s need for MBSR techniques, introduce the idea, deliver the material and then be available to answer questions. These pamphlets could also be accessible on line as part of the institutions continuing education offerings or as a menu item along with other standardized care plans. The set of instructions could be printed out any time a nurse or patient needed them.
The three apps discussed above, “Stop, Breathe, Think,” “Mindfulness Training App,” and Cleveland Clinic’s “Stress Free,” would be described in detail on the brochure/info sheet with a description of their use and with clear directions on how to access them. These three apps were chosen as effective sources of MBSR techniques because they come from reputable
sources, are each unique, and described in a clear, concise manner. However, it is important to note that there are hundreds of thousands of similar apps available, but for purposes of this paper, these three sources are the focus of the described intervention.
The Intervention:
In order for nurses, and then patients, to successfully use web-based apps, they will need specific instruction on how to move through the steps to access these. While Millennials may find this next section completely unnecessary, it is understood that nurses and patients come from all ages and circumstances and many may be completely unfamiliar with the world wide web. For that reason, the instructional pamphlets designed to introduce the use of mindfulness-based apps, will need to include written instructions for how to access these mindfulness-mindfulness-based stress reduction apps from the access devices. What follows is a version of such instructions: -Power on IPhone or IPad device
-Press the circular button on the base of the device to get to the main screen
-Tap on the App Store Icon to open
-Once inside the App Store, you will see pop-ups and advertisements for various apps -Ignore pop-ups
-Look for “Search” icon with an magnifying glass symbol, located at the bottom right of the screen and tap on the magnifying glass
-This will bring you to the search page
-On the top of the page, there is a faint grey bar with the magnifying glass symbol and the word “Search”
-Tap on the word “search” in the grey bar, and type in the name of the App you are searching for. For example: “Mindfulness Training App” (note: if you would like to search other mindfulness based apps that you do not know the name of, you may enter key terms such as, “Mindfulness,” or, “Stress reduction.”
-Select “Search”
-Once you have found the app you are looking for, select “GET” (note: If there is a cost
associated with the app, it will be listed in place of the word “GET.” All apps described in this paper are free for download).
-Once you have tapped the word “GET,” the word “INSTALL” will appear, tap “INSTALL” -The next screen to appear will read, “Sign In to iTunes Store Enter the Apple ID password for “[email protected]” (the screen will ask for the users respective email address, does not have to be a gmail account)
-Enter your password and click “OK” -The application will begin downloading
-Use your finger to side swipe the screen until you see the icon for the app that you have selected -It may take a few seconds to minutes to completely download, it will say, “Loading,” followed by, “Installing”
-When the app is ready for use, the name will appear below the icon -Tap on the icon and follow instructions to begin
Some hospitals have implemented programs such as the “Get Well Network,” which provide interactive patient care interfaces accessible through the bedside television and remote. The Get Well Network provides a plethora of resources including but not limited to personalized health information, internet access, patient education and entertainment. Hospitals who are currently partnered with businesses like The Get Well Network, may easily be able to add the mindfulness-based stress reduction education and resources to that network, thereby supplying another mechanism for their dissemination and use.
Once the patient has downloaded and practiced using the app, the nurse can then check in with the patient and assess the patient’s response, and satisfaction, with the experience. The nurse can also be instrumental in encouraging the patient to continue to practice the exercises at home. In fact the three apps described above could be equally beneficial to patients after they are discharged and are dealing with things like, post-operative recovery, pain management, adjustment to home life with the uncertainty of illness, etc.
Discussion: Further Applications of Mindfulness for Healthcare Providers
The practice of mindfulness can be an asset not only to the patient, but also to the nurse in his/her professional practice by enabling one to foster healthier communication and
acceptance promoted within MBSR, also increases one’s capacity to empathize with others and respond appropriately, which is a critical element of providing effective health care (Raphael-Grimm, 2015). “Mindfulness keeps us alert to our internal climate changes; prompts us to consider their origin, meaning, and impact; and helps us to choose wisely from a behavioral repertoire that enables us to act deliberately (rather than reflexively) in a manner that is consistent with our values and goals,” (Raphael-Grimm, 2015, p. 12).
In her book entitled, The Art of Communication in Nursing and Health Care; An
Interdisciplinary Approach, Raphael-Grimm outlines a framework in which MBSR methods can
be used to enhance the well-being, effectiveness and compassion of clinicians.
Conclusions:
Mindfulness-based stress reduction techniques are growing in popularity and emerging in mainstream health care. This paper has delineated the theoretical underpinnings behind the stress response and the efficacy of MBSR techniques in mitigating that response. Investigators have been looking at the ways in which mindfulness-based stress reduction techniques effect a person’s brain, immunity, perception of pain, symptom control and emotional regulation. It is suggested that MBSR techniques disrupt the sympathetic nervous system’s fight or flight
response by triggering activation of the parasympathetic response. Nurses can be instrumental in teaching patients how to recognize these subtle physiological or emotional changes, and in using MBSR techniques to relieve stress and enhance well-being.
educators, and have a great opportunity to promote better health outcomes and improved quality of life through cultivating their own, and their patients’ mindful practice.
References
Baer, R. A. (2003). Mindfulness Training as a Clinical Intervention: A Conceptual and Empirical Review. American Psychological Association D12, 10(2), 125-143.
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