Complementary Therapies in Clinical Practice xxx (2015) 1e7
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Barriers and facilitators of the use of mind-body therapies by healthcare providers and clinicians to care for themselves Sylvanus Brenya Mensah, Joel G. Anderson* University of Virginia School of Nursing, Charlottesville, VA, United States
a b s t r a c t Keywords: Mind-body therapies Mindfulness Resilience Stress Healthcare providers
Healthcare providers may experience a high level of stress, fatigue, and anxiety originating from different factors. Mind-body therapies, which include many interventions, have been proposed to alleviate these conditions. These interventions have been reported to decrease the level of stress, and the negative outcomes associated with these factors: high burnout rate, and poor quality of care for patients. Although research validating the effectiveness of healthcare providers' use of mind-body therapies to care for themselves is emerging, there is little focus on barriers and facilitators that healthcare providers encounter with these mind-body practices, thereby questioning the feasibility and sustainability of these interventions. As such, this systematic review examined the barriers preventing healthcare providers from using mind-body interventions to care for themselves and ways that it has been facilitated. Overall, 12 studies addressed the research question with a limited focus on the facilitators and barriers of the use of mind-body therapies. © 2015 Elsevier Ltd. All rights reserved.
In the past 30 years, there has been significant recognition of the work-related stress that healthcare providers experience [3]. These work-related psychological issues have numerous causes that include increased acuity of patients and healthcare provider shortages, to name a few [3,13,18]. Most of these issues are not only experienced by healthcare providers providing direct patient care, but also are experienced by faculty members and students in the healthcare profession. With healthcare professionals handling situations whereby an individual's health can easily deteriorate, the consequences of these work related issues is very concerning for patients, healthcare providers and the healthcare institution [13]. The outcome of work-related stress relating to the healthcare profession includes high burnout rate, low job satisfaction, worse patient outcomes, high mortality and many more [3,5,18]. With the outcomes of these work-related stressors having such a high impact, numerous interventions such as mind-body therapies are being used to address this issue. Mind-body therapies, including modalities such as meditation, yoga, biofield therapies, mindfulness and many more interventions, are used by healthcare providers dealing with work-related psychological issues. These interventions, which have been used since
* Corresponding author. E-mail address: [email protected] (S.B. Mensah).
ancient times under different forms, have unknown mechanisms of actions; however, it is hypothesized that they work at the sympathoadrenal system, hypothalamic pituitary adrenal axis, metabolic system and also on the inflammatory system [1]. With the mechanism of mind-body therapies not that well understood, the National Center for Complementary and Alternative Medicine (NCCAM) defines mind-body therapies as those that “focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health” [16]. According to NCCAM, these therapies include acupuncture, breathing practices, meditation, tai chi, guided imagery, progressive relaxation, yoga, spinal manipulation, massage therapy, Feldenkrais method, Alexander technique, Pilates, hypnosis, Trager psychophysical integration, Reiki, Healing Touch, qi gong, craniosacral therapy, and reflexology [15]. Some of these interventions have been used to address work-related stress among healthcare providers and have been found to be effective. Among the interventions found to be effective are massage, mindfulness, yoga, and Reiki, with the most frequently used therapy being MBSR. Mindfulness-Based Stress Reduction (MBSR) is a program by Jon Kabat-Zinn that enhances present-moment awareness and has been associated with reduced distress, depression, anxiety and increased resilience [6,14,17]. Although these practices have been found to be effective in helping healthcare providers deal with stress, not all healthcare
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Please cite this article in press as: Mensah SB, Anderson JG, Barriers and facilitators of the use of mind-body therapies by healthcare providers and clinicians to care for themselves, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.01.004
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providers use mind-body therapies. In order to better understand what promotes or inhibits the practice of mind-body therapies, a systematic review of the literature was conducted to identify facilitators and barriers to the use of mind-body therapies. 1. Methods 1.1. Data sources Three electronic databases were used for the search to find articles and studies related to the research question: CINAHL, Ovid Medline, and PsychINFO. Terms used while searching CINAHL were “resilience or mindfulness”, and “mind body techniques or mind body therapies.” Terms used in PsychINFO included “Nursing students”, “Mind body therapies”, “Nurses” and “stress.” As for Ovid Medline, the actual interventions of mind-body therapies were listed (“acupuncture”, “breath practices”, “meditation”, “guided imagery”, “progressive relaxation”, “tai chi”, “yoga”, “spinal manipulation”, “massage therapy”, “Feldenkrais method”, “Alexander technique”, “Pilates”, “hypnosis”, “Trager psychophysical integration”, “Reiki”, “Healing Touch”, “qi gong”, “craniosacral therapy”, “reflexology” or “mindfulness”) with other terms such as “stress, psychological or exp resilience psychological” or “Nurses or nursing students or healthcare providers” and “resilience or mindfulness.” Operator codes were used to enhance the search process for example, exp was used to explode resilience. Additionally, the references of relevant articles were reviewed for pertinent studies. For this systematic review, mind-body interventions were limited to those described by the NCCAM and listed previously. In terms of exclusion criteria, there were two stages. During the first stage, articles and studies were excluded if these were related to patients or children, in a foreign language, not a research article, related to medical students, were more than 10 years old, did not address healthcare providers, focused on a specific race, or related to healthy individuals. Additionally, systematic reviews and dissertations were excluded. The exclusion criterion for the second stage was articles not addressing facilitators or barriers of healthcare providers' self-use of mind-body therapies. Articles were assessed based on title, abstract and/or reading the full text. 1.2. Data extraction and quality assessment One reviewer retrieved articles and received assistance from researchers as to the selection of articles. Information related to these studies were stored in Refworks and the quality of the articles were assessed using a modified Jadad Score. This score, which has been used in other reviews related to mind-body therapies awards a total of five points for methods relating to the research [1]. One point was awarded each for randomization, randomizing appropriately, a controlled study design, blinding the evaluator and finally, description of withdrawals and dropouts. Study outcomes were extracted and are displayed in Table 1. 2. Results 2.1. Study description The search of the database resulted in 102 potentially relevant articles, with 85 articles being excluded in the first stage and five articles being excluded in the second stage of the review. These five articles excluded in the second stage did not address facilitators and barriers of healthcare providers' self-use of mind-body therapies; however, these articles did provide findings supporting the
effectiveness of mind-body therapies for providers' self-use [2,8,9,11]. A flow chart outlining article selection is shown in Fig. 1. 2.2. Quantitative studies There were seven quantitative studies. The first study by [3] was a randomized controlled trial that sought to determine the effect of massage therapy in reducing stress in nurses working at hospitals. This study had a sample of 60 nurses with the group being divided into an experimental group and a control group. The experimental group received massage therapy while the control group did not receive any intervention. Outcomes measured stress finding that there was a decrease (P ¼ .006) in stress for the experimental group. The study identified providing therapy at a reduced cost as a facilitator. The researchers acknowledged a need for additional evidence. The second quantitative study which was conducted by [4] determined if computer guided meditation helped nurses reduce stress. The study had 11 participants, all of whom were nurses. These nurses were involved in a program that used computer sessions to reinforce training. This study measured stress, anxiety and quality of life and found that improvements in stress and anxiety were statistically significant: STAI (p ¼ .03), LASA stress (p ¼ .01) and LASA anxiety (p ¼ .01). Also, the nurses were satisfied with the program. Barriers that were encountered by the practitioners included high work demands, time constraints and also, overwhelming personal and professional challenges. [5] et al. evaluated the effectiveness of an abbreviated mind-body therapy. The study had a sample of 30 with the participants belonging to different healthcare specialties from family medicine, internal medicine and pediatrics. These participants did receive a modified MBSR program that included guided sitting, and walking mindfulness practices. After the interventions, the participants responded to four surveys, at different times through emails. The outcome of the study showed that an abbreviated mindfulness intervention improved accomplishment (p ¼ .001), decreased stress (p ¼ .002), depression (p ¼ .001), burnout (p ¼ .009) and anxiety levels (p ¼ .006). A facilitator in this study was an affordable and timeefficient intervention can increase usage. Ref. [12] conducted a cross sectional on-line survey study that sought to understand factors that influenced the form of training that nurses chose to receive mind-body interventions. The method of this study was a cross-sectional on-line survey of nurses in different specialty areas through email. The study had a sample of 342 nurses that was diverse in race, gender and level of education. Information obtained in the survey included health conditions, stress levels, experiences with mind-body practices and expected health benefits. Outcome measured many factors and found that time whether in completing training (58%) or daily practice (60%) and self-guidance (58%) affected the choice of mind-body therapy that nurses used. Facilitators that were somewhat important in this study included knowing the instructor and their professional qualifications. Another quantitative study in this literature review was done by [13]. This study focused on finding effective ways for nurses to decrease stress. This study which was a controlled, randomized pilot study found that mind-body interventions helped decrease emotional exhaustion while at the same time increasing job-related accomplishment and general wellbeing. There were 30 participants in this study comprised of nurses and nurse aides. The study found that there was a positive influence on personal accomplishment (p ¼ .06), improvement in perceived sense of coherence (effect size ¼ .09) and a statistically significant improvement in job-related accomplishments (p ¼ .04). A barrier to clinicians self-use of mindbody therapies included time restraint and intensity of the intervention. A facilitator was the use of a shortened MBSR that is suitable for the hectic schedule of healthcare providers. The next
Please cite this article in press as: Mensah SB, Anderson JG, Barriers and facilitators of the use of mind-body therapies by healthcare providers and clinicians to care for themselves, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.01.004
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Table 1 Results of electronic search for facilitators/barriers of mind-body therapies. Author Mind body (Date) intervention Quantitative studies [3] Back massage
[4]
[5].
[12]
[13]
[14]
Sample size, design and settings
Purpose/aims
Data collection outcome Method/Jadad measures score
“Investigate the effectiveness of massage therapy in reducing physiological and psychological indicators of stress in nurses employed in an acute care hospital”
Randomized State-Trait Anxiety Control Trial Inventory (STAI), life 4 event questionnaire, urinary cortisol and blood pressure readings Outcome measures: physiologic stress, psychological stress
Major findings/factors
Facilitators/barriers to practice
P-value for State-STAI is Facilitators: .006 and Trait-STAI is “Interventions that .008. reduce stress at individual and organizational level.” Frequent massages at a reduced price. Barriers: More evidence required Facilitators: Pre and Post Study SF-36 (p ¼ .04). STAI Linear Analogue Self“To assess whether a Sample Biofeedback (p ¼ .03). LASA stress (Healing Rhythms number ¼ 11 self-directed, computer- Assessment [LASA], State Design None (p ¼ .01), LASA Anxiety Barriers: Trait Anxiety Inventory 1 guided meditation St Marys meditation (p ¼ .01). Nurses were [STAI], Short-Form 36 training program is Hospital program) High work demands and satisfied with the [SF-36] questionnaires useful for stress time constraints program, rating it 8.6 out Dropouts felt Outcome measures: reduction in hospital of 10. “self-directed, stress, anxiety, quality of nurses.” overwhelmed by computer-guided” life. personal and program is effective in professional challenges. reducing stress. Facilitators: Single sample pre Increased “Investigating whether Maslach Burnout Guided sitting and Sample accomplishment scores “Low cost, collegial, and post design. Inventory, Depression number ¼ 30 an abbreviated walking (p < .001). 1 Anxiety Stress Scales, mindfulness UW Health mindfulness time-efficient way to Improvements in stress improve well-being and Perceived Stress Scale, Mindfulness. intervention could practices. (p ¼ .002), depression increase job satisfaction, Resilience Scale, the manage burnout (p ¼ .001), burnout Santa Clara Brief quality of life, and symptoms among (p ¼ .009), anxiety Compassion Scale. compassion among primary care clinicians” (p ¼ .006). primary care clinicians.” Outcome measures: Barriers: burnout, anxiety, stress, None resilience, compassion, job satisfaction Facilitators: Time wither in Cross Sectional Outcome measures: Sample Understanding Healing touch, completing training health conditions, stress email online therapeutic touch, number ¼ 342 “participants' baseline Scientific findings, (58%), daily practice (60), knowing the instructor levels, experiences with survey experience, prayer, meditation, and self-guidance 0 mind-body practices, expectations, or hypnosis, yoga and their reputation/ affected (58%) choice of credentials preferences for training. expected health benefits, intervention. 90% were Barriers: training preferences, To better plan interested in mind-body Study require access to willingness to participate participant-centered training. mind-body intervention technology trials for nurses to reduce occupational stress.” Facilitators: Reduced emotional Controlled Maslach Burnout Effective ways to Mindful stretching, Sample exhaustion (effect randomized pre Inventory, Smith number ¼ 30 decrease stress among None mindful eating, size ¼ .16), increases job- Barriers: Relaxation Dispositions and post Pilot nurses. large urban body scan related accomplishments Time restraint. Inventory, the Intrinsic Study geriatric (p ¼ .04). Job Satisfaction subscale 3 teaching “The intensity of this Positive influence on from the Job Satisfaction hospital intervention is likely to personal Scale, Satisfaction With be aversive to many accomplishment Life Scale, 13-item individuals who work (p ¼ .06). version of Antonovsky's and live under high Improvement on sense of levels of stress; it also (1987) Orientation to Life coherence (effect Questionnaire. limits opportunities to size ¼ .09), general well- offer on-the-job being and life satisfaction mindfulness training, (effect size ¼ .21). especially in shiftwork occupations.” “Several exceptions were made to accommodate participants' vacation schedules.” “Shortened MBSR program is easier to add to nurses schedule”, “the full MBSR program might not fit into the demanding schedule of nurses and nurse aides” Facilitators: SemiReduce ruminations “How Mindfulness SCL 90-R inventory, Mindfulness-based Sample experimental (Cohen's d of .53), facilitates a distress Survey of Recent Life number stress reduction Instructors experience, distress (p ¼ .16), Experiences (SRLE, N ¼ 29 (MBSR) course is accredited, Sample size ¼ 60 Acute care hospital in Queensland
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Table 1 (continued ) Author Mind body (Date) intervention
Sample size, design and settings
Purpose/aims
reduction in a group of Palma de Mallorca's IB- health professionals” Health
[17]
Mindfulness-based Sample number ¼ 33 stress reduction healthcare (MBSR) system in the southwest United States
Author/ Mind body date Qualitative studies [7] -Based Stress Reduction (MBSR)
“Evaluate a brief stress management intervention for nurse leaders.”
Data collection outcome Method/Jadad measures score Perceived Stress Scale, Positive and Negative Affect Scale (PANAS) Outcome measures: stress, negative affect Symptom Checklist 90Revised (SCL-90-R) “explore the lived experience of nurses who practice Reiki for self-care.”, Positive Symptom Distress Index (PSDI), Positive Symptom Total, Positive Symptom Total. Outcome measures: stress, depression, anxiety, caring efficacy
study. 1
Randomized control trial. 4
Major findings/factors
negative affects (Cohen's financial compensation. d of .78) Barriers: Barrier is adhering to MBSR outside of work. Facilitators are Facilitators: Improvement in depression (p ¼ . 05), MBSR is effective for anxiety (p ¼ .04), and nursing leaders and symptom improvement groups. (p ¼ .009). Caring “Exerting leadership improved however it influence to create was not statistically organizational significant (p ¼ .99). environments All p values are Raw P. supporting healthy stress management” Barriers: Reason for dropping out: “personal time management reasons.” Major findings/factors Facilitators/barriers to practice
Design and sample size
Purpose/aims
Data collection/outcome Quality score measures
Sample number ¼ 20 large tertiary care center in the Midwest Sample number ¼ 21 University of Lethbridge
“Describe the perceived effects of a MindfulnessBased Stress Reduction (MBSR) Program on stress and quality of life of women in midlife.” “To gain an understanding of students' experiences related to all aspects of the course content and process”
Guidelines by Strauss and Corbin and Tesch. Outcome measures: stress, coping, quality of life
Author/ Mind body date Quantitative and qualitative [6]. Mindfulness Based Stress Reduction MBSR program
Design and Sample size studies Sample number ¼ 40 Two metropolitan teaching hospitals in NSW
Purpose/aims
Data collection/outcome Quality score measures
“Pilot the effectiveness of an adapted mindfulnessbased stress reduction intervention on the psychological wellbeing of nurses and midwives.”
Pilot study pre and Lots of participants General health quotes about questionnaire (GHQ-12), posttest. effectiveness. sense of coherence (SOC) 0 Improvements in e orientation to life, the relaxation, calm, more depression, anxiety and focused, importance of stress scale (DASS). “me time”, awareness of other, receiving help early on, better control of thoughts and stress. Improved health GHQ-12 p ¼ .11,.031. SOC-Orientation to life p ¼ .009. DASS-Stress p ¼ .004
[18]
Sample number ¼ 84 University of Maryland
To evaluate the effect of a Outcome measures: coping with life, life holistic program stressors, and adverse (Healing Pathway) in events.
[10].
Many different forms of complementary and alternative therapies were offered however the interventions were not listed.
Reiki, guided imagery, yoga, toning, meditation, intuitive scanning,
Qualitative evaluation with experimental and comparison group. 0
Exploratory and Journals, student narratives, projects, class descriptive qualitative study. presentation and 0 scholarly paper
Systematic qualitative and qualitative
Facilitators/barriers to practice
“Strengthened communication through support, Increased awareness and better handling of stress, “living life in the balance” Five concepts that emerged were: engaging, opening, hesitating, understanding, and knowing. Increased personal growth.
Major findings/factors
Facilitators: None Barriers: High demand on time led to less time spent on selfcare Facilitators: None Barriers: Most learners were unprepared to accept evidence that was not concrete in nature although their willingness to learn was evident. Students questioned their perceptions of, and responses to, their experiences as they tried to find an explanation for the “phenomena.” Challenge of adding opportunities into nursing education curriculum Facilitators/barriers to practice
Facilitators: Support of manager. Coworker encouragements Barriers: Taking timeout at work to do the intervention, time constraints, and scheduling conflict related to unit staffing needs. Assimilating mindfulness into work environment. Working night shift was a barrier as participants wanted to rest during the day rather than do the intervention Improvements in stress, Facilitators: self-efficacy, positive Interventions should be comments throughout offered earlier on in the the article from curriculum as a “health
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Table 1 (continued ) Sample size, design and settings
Purpose/aims
creative expression, mentorship
Medical Center
dealing with stress in Data Collection: healthcare practitioners Perceived Stress Scale (PSS), Coping SelfEfficacy Scale
Signature cell healing and reconnection healing, balancing heart energy therapy, acupressure, Reiki, integrative energy, healing touch
Sample number ¼ 11 Proximity to Florida Atlantic University
“Explore the lived experience of nurses who practice Reiki for self-care.”
Author Mind body (Date) intervention
[19]
Data collection outcome Method/Jadad measures score
Interview colaizzi method
quantitative study was conducted by [14]. The objective of this study was to determine how MBSR program enabled healthcare providers to deal with stress. This study had a sample of 29 participants with healthcare professionals taking an 8 week class. The study was a semi-experimental study performed at Palma de Mallorca's IBHealth. Of the outcomes measured, negative affect and stress, there was a decrease in distress level (p ¼ .16) and negative affect (Cohen's d of .78). A barrier that participants encountered was that it was difficult to adhere to the program outside of work. Facilitators include instructors experience, course accreditation and financial compensation.
evaluation 0
Major findings/factors
respondents, transferring learned skill to work was a challenging: support and mentoring resolved this. 81% reported frequent Descriptive phenomenological use of Reiki. 72% practiced other forms of approach. energy based therapies. 0 8 major themes emerged about the benefit of Reiki
Facilitators/barriers to practice promotion tool.” Barriers: None
Facilitator: None Barriers: Lacked appropriate place and environment to practice: “bathroom or office space, places where it is not seen or valued.”
The final quantitative study of this literature review was conducted by [17]. This study was a randomized control study that evaluated the effect of MBSR on nurse leaders. The study had a sample of 33 participants all of whom were nurse leaders. These leaders took a mindfulness course and self-reported their stress level at the beginning and at the end of the study. The effect of MBSR was evident with statistically significant reductions in both depression (p ¼ .05) and anxiety (p ¼ .04). The primary barrier to the mind-body intervention in this study was the lack of time. Facilitators include having an organizational environment that supports the intervention.
Fig. 1. Flow chart of article selection.
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2.3. Qualitative studies There were two qualitative studies. The first study which was performed by [7] focused on the effectiveness of MBSR on stress and quality of life in healthcare providers. This study had a sample of 20 all of whom were nurses. The study was a qualitative evaluation of these healthcare providers after taking a MBSR course at a large tertiary care center in the Midwest. Outcomes measured stress, coping and quality of life. The participants in this study reported an increase in the management of stress, and having a wellbalanced life. A barrier that was noted was that due to high demand on participants' time, they were not able to spend much time on their self-care. The final qualitative study is by [10]. The study had 21 participants who were students from different professions: nursing, education, social work, kinesiology, recreation and prepharmacy. The aim of this study was to obtain students' perspective of a mind-body course. Results were obtained from students’ assignments such as journals, narratives, projects, class presentation and scholarly papers. There were five themes that emerged for the students: engaging, opening, hesitating, understanding, and knowing. Barriers that the students encountered include, lack of concrete evidence, lack of an explanation for what they were perceiving and experiencing and finally, the challenge of including these interventions in the educational curriculum. 2.4. Quantitative and qualitative studies There were three quantitative and qualitative studies. The first study is by [6]. This study determined the effectiveness of a modified MBSR program on nurse's health. The study had a sample of 40 participants 20 of whom were midwives while the other 20 were nurses. This study was a pilot study with a pre and posttest with some participants being interviewed. Outcomes measured anxiety, stress, and orientation to life. Participants reported an improvement in stress (p ¼ .004), and other aspect of life: awareness of others, more positive thoughts, and much more. Barriers noted relates to time constraints and time at which intervention was scheduled was not ideal for participants who worked the night shift. Facilitators included coworker encouragement and leaders support. The second study is by [18]. This study focused on the effect of a holistic program on reducing stress in healthcare providers. The study had 82 participants and these participants were nurses or nurse practitioners, massage therapists, social workers and physical therapists. These participants were enrolled in a program called Healing Pathways and they self-reported on stress, coping and much more. The study found that there was an improvement in stress (5.7 less in 8 weeks and 2.5 less in 12 months) and self-efficacy (36.6 points more in 8 weeks and 33.6 more after 12 months). Facilitator of mind-body intervention was to introduce the intervention early in the curriculum as a form of a “health promotion tool” [18]. Ref. [19] focused on nurses' self-care use of Reiki. The study concluded that there was a frequent use of mind-body therapies and that there were eight themes that emerged: “infinite connection and divine guidance, journeying to the centered self, calming oasis for the workday, relationship between relaxation and clarity, awareness of self-healing transformation, personal space of oneness, providing self-Reiki care, relationship between reverence, caring and nursing [19]. A barrier for practitioners in this study was that they did not have a place to practice at the work. A facilitator is to include the intervention into the philosophy of the healthcare system. 2.5. Study quality The quality of the studies varied, with scores ranging from 0 to 4. Of the 12 articles, two obtained a score of four [3,17]. One of the
studies received a score of three [13]. Three articles received a score of one [4,5,14]. Six of the 12 received a score of zero because these studies were not randomized, controlled, or blinded and did not provide a description about withdrawals or dropouts [6,7,10,12,18,19]. 3. Discussion The main aim of each of the included articles was to provide findings about the effectiveness of mind-body therapies. As such, there was not much emphasis on the barriers that the healthcare providers encountered. However, there were some overall themes about barriers that emerged when the articles were analyzed. Of these themes, one barrier identified in relation to clinician self-use of mind-body therapy was time. Clinicians had difficulty scheduling time off to partake in a particular study or just had an increasing demand on their time [6,7]. Another barrier was the high work demand of healthcare providers [4]. Some of the high work demand included participants changing their schedule to assist their unit with staffing. In some cases, the time for the intervention to be delivered was changed promptly to accommodate the schedule of the participants [6]. In terms of facilitators of mind-body therapies, these also were briefly addressed in the 12 articles. One facilitator identified to increase the use of mind-body therapies was supportive evidence [3,10]. Some students found it hard to grasp the phenomenological concept of mind-body therapies given that it is less concrete in its nature [10]. As such, more evidence might yield an increase in the use of mind-body therapies. Another reoccurring facilitator noted was support, either financially or encouragement from leaders. If healthcare providers receive financial assistance in pursuing a mind-body therapy [5,14], which reduces concerns about the financial cost of such therapies, then they may be more likely to engage and adhere to these therapies. 4. Conclusion Work-related issues that have an impact on healthcare providers' abilities to care for themselves have been a topic of interest for numerous years. Some of these issues, which are attributable to healthcare provider shortages, have resulted in emotional exhaustion, a decreased sense of well-being, poor quality of care and depersonalization [3,13]. With these negative outcomes being severe, interventions such as mind-body therapies are being used to address this issue. Mind-body therapies encompass a large group of interventions with underlying mechanisms involving the brain [1,16]. The effectiveness of these therapies in helping to alleviate work-related psychological issues has been documented in numerous studies; however, there is the issue of adherence. Many articles addressed the issue of mind-body therapies in relation to healthcare providers self-use; however, most were excluded based on the predefined inclusion and exclusion criteria (Fig. 1). 12 articles provided brief information relating to facilitators and barriers of mind-body use by healthcare providers to care for themselves. The quality of the articles was assessed using the modified Jadad score with scores ranging from 0 to 4. Some of the facilitators found in the articles included mind-body interventions that fit into the healthcare providers’ schedules and provision of financial assistance [13,14]. Examples of barriers that healthcare providers encountered included high work demand and time [6,7,13]. The primary aim of these articles focused on the effectiveness of mind-body therapies. As such, there is limited data which addresses the primary aim of this systematic review. Even though mind-body therapies are effective, the usage by the healthcare provider is likely to be limited if these barriers and
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facilitators are not addressed. Hence, more research about facilitators and barriers is needed. 5. Distinguished majors project The purpose of this research project was to analyze facilitators of and barriers to healthcare provider/clinicians’ use of mind-body therapies. This systematic review will assist in the experimental aspect of this project in numerous ways including knowledge about effectiveness, questions to place on the survey, ways that barriers and facilitators can be addressed and many more. Nurses will be invited, through emails, posters and word of mouth, to partake in a survey that will analyze barriers and facilitators to their use of mind-body therapies for self-care. Conflict of interest statement The authors have no conflicts of interest to declare. References [1] Anderson JG, Taylor AG. The metabolic syndrome and mind-body therapies: a systematic review of clinical trials. J Nutr Metabol 2011;2011:8. http://dx.doi. org/10.1155/2011/276419. [2] Beddoe AE, Murphy SO. Does mindfulness decrease stress and foster empathy among nursing students? J Nurs Educ 2004;43(7):305e12. Retrieved from: http://ovidsp.ovid.com.proxy.its.virginia.edu/ovidweb.cgi? T¼JS&CSC¼Y&NEWS¼N&PAGE¼fulltext&D¼med5&AN¼15303583. [3] Bost N, Wallis M. The effectiveness of a 15 minute weekly massage in reducing physical and psychological stress in nurses. Aust J Adv Nurs 2006;23(4): 28e33. Retrieved from: http://ovidsp.ovid.com/ovidweb.cgi? T¼JS&CSC¼Y&NEWS¼N&PAGE¼fulltext&D¼med5&AN¼16800217. [4] Cutshall SM, Wentworth LJ, Wahner-Roedler DL, Vincent A, Schmidt JE, Loehrer LL, et al. Evaluation of a biofeedback-assisted meditation program as a stress management tool for hospital nurses: a pilot study. Explore J Sci Heal 2011;7(2):110e2. http://dx.doi.org/10.1016/j.explore.2010.12.004. [5] Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med 2013;11(5):412e20. http://dx.doi.org/10.1370/afm.1511. [6] Foureur M, Besley K, Burton G, Yu N, Crisp J. Enhancing the resilience of nurses and midwives: pilot of a mindfulness-based program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemp Nurse 2013;45(1):114e25. http://dx.doi.org/10.5172/conu.2013.45.1.114.
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[7] Frisvold MH, Lindquist R, McAlpine CP. Living life in the balance at midlife: lessons learned from mindfulness. West J Nurs Res 2012;34(2):265e78. http://dx.doi.org/10.1177/0193945911424171. [8] Geary C, Rosenthal SL. Sustained impact of MBSR on stress, well-being, and daily spiritual experiences for 1 year in academic health care employees. J Altern Complement Med 2011;17(10):939e44. http://dx.doi.org.proxy.its. virginia.edu/10.1089/acm.2010.0335. [9] Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med 2012;43(2):119e28. Retrieved from: http://ovidsp.ovid.com.proxy.its.virginia. edu/ovidweb.cgi? T¼JS&CSC¼Y&NEWS¼N&PAGE¼fulltext&D¼medl&AN¼22849035. [10] Groft JN, Kalischuk RG. Nursing students learn about complementary and alternative health care practices. Complement Health Pract Rev 2005;10(2): 133e46. http://dx.doi.org/10.1177/1533210105280367. [11] Kang YS, Choi SY, Ryu E. The effectiveness of a stress coping program based on mindfulness meditation on the stress, anxiety, and depression experienced by nursing students in Korea. Nurse Educ Today 2009;29(5):538e43. http://dx. doi.org.proxy.its.virginia.edu/10.1016/j.nedt.2008.12.003. [12] Kemper K, Bulla S, Krueger D, Ott MJ, McCool JA, Gardiner P. Nurses' experiences, expectations, and preferences for mind-body practices to reduce stress. BMC Complement Altern Med 2011;11:26. http://dx.doi.org/10.1186/14726882-11-26. [13] Mackenzie CS, Poulin PA, Seidman-Carlson R. A brief mindfulness-based stress reduction intervention for nurses and nurse aides. Appl Nurs Res 2006;19(2): 105e9. Retrieved from: http://ovidsp.ovid.com/ovidweb.cgi? T¼JS&CSC¼Y&NEWS¼N&PAGE¼fulltext&D¼med5&AN¼16728295. [14] Martin-Asuero A, Garcia-Banda G. The mindfulness-based stress reduction program (MBSR) reduces stress-related psychological distress in healthcare professionals. Span J Psychol 2010;13(2):897e905. Retrieved from: http:// ovidsp.ovid.com/ovidweb.cgi? T¼JS&CSC¼Y&NEWS¼N&PAGE¼fulltext&D¼medl&AN¼20977037. [15] National Center for Complementary and Alternative Medicine. Exploring the science of complementary and alternative medicine: third strategic plan 2011e2015. National Center for Complementary and Alternative Medicine; 2011. http://nccam.nih.gov/about/plans/2011. [16] NCCAM Video Series. The science of mind and body therapies. National Center for Complimentary and Alternative Medicine (NCCAM); 2012. http://nccam. nih.gov/video/series/mindbody. [17] Pipe TB, Bortz JJ, Dueck A, Pendergast D, Buchda V, Summers J. Nurse leader mindfulness meditation program for stress management: a randomized controlled trial. J Nurs Adm 2009;39(3):130e7. http://dx.doi.org/10.1097/ NNA.0b013e31819894a0. [18] Tarantino B, Earley M, Audia D, D'Adamo C, Berman B. Qualitative and quantitative evaluation of a pilot integrative coping and resiliency program for healthcare professionals. Explore J Sci Heal 2013;9(1):44e7. http://dx.doi. org/10.1016/j.explore.2012.10.002. [19] Vitale A. Nurses' lived experience of reiki for self-care. Holist Nurs Pract 2009;23(3):129. May-141; Jun, http://dx.doi.org/10.1097/01.HNP. 0000351369.99166.75.
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Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Barriers and facilitators of the use of mind-body therapies by healthcare providers and clinicians to care for themselves Sylvanus Brenya Mensah, Joel G. Anderson* University of Virginia School of Nursing, Charlottesville, VA, United States
a b s t r a c t Keywords: Mind-body therapies Mindfulness Resilience Stress Healthcare providers
Healthcare providers may experience a high level of stress, fatigue, and anxiety originating from different factors. Mind-body therapies, which include many interventions, have been proposed to alleviate these conditions. These interventions have been reported to decrease the level of stress, and the negative outcomes associated with these factors: high burnout rate, and poor quality of care for patients. Although research validating the effectiveness of healthcare providers' use of mind-body therapies to care for themselves is emerging, there is little focus on barriers and facilitators that healthcare providers encounter with these mind-body practices, thereby questioning the feasibility and sustainability of these interventions. As such, this systematic review examined the barriers preventing healthcare providers from using mind-body interventions to care for themselves and ways that it has been facilitated. Overall, 12 studies addressed the research question with a limited focus on the facilitators and barriers of the use of mind-body therapies. © 2015 Elsevier Ltd. All rights reserved.
In the past 30 years, there has been significant recognition of the work-related stress that healthcare providers experience [3]. These work-related psychological issues have numerous causes that include increased acuity of patients and healthcare provider shortages, to name a few [3,13,18]. Most of these issues are not only experienced by healthcare providers providing direct patient care, but also are experienced by faculty members and students in the healthcare profession. With healthcare professionals handling situations whereby an individual's health can easily deteriorate, the consequences of these work related issues is very concerning for patients, healthcare providers and the healthcare institution [13]. The outcome of work-related stress relating to the healthcare profession includes high burnout rate, low job satisfaction, worse patient outcomes, high mortality and many more [3,5,18]. With the outcomes of these work-related stressors having such a high impact, numerous interventions such as mind-body therapies are being used to address this issue. Mind-body therapies, including modalities such as meditation, yoga, biofield therapies, mindfulness and many more interventions, are used by healthcare providers dealing with work-related psychological issues. These interventions, which have been used since
* Corresponding author. E-mail address: [email protected] (S.B. Mensah).
ancient times under different forms, have unknown mechanisms of actions; however, it is hypothesized that they work at the sympathoadrenal system, hypothalamic pituitary adrenal axis, metabolic system and also on the inflammatory system [1]. With the mechanism of mind-body therapies not that well understood, the National Center for Complementary and Alternative Medicine (NCCAM) defines mind-body therapies as those that “focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health” [16]. According to NCCAM, these therapies include acupuncture, breathing practices, meditation, tai chi, guided imagery, progressive relaxation, yoga, spinal manipulation, massage therapy, Feldenkrais method, Alexander technique, Pilates, hypnosis, Trager psychophysical integration, Reiki, Healing Touch, qi gong, craniosacral therapy, and reflexology [15]. Some of these interventions have been used to address work-related stress among healthcare providers and have been found to be effective. Among the interventions found to be effective are massage, mindfulness, yoga, and Reiki, with the most frequently used therapy being MBSR. Mindfulness-Based Stress Reduction (MBSR) is a program by Jon Kabat-Zinn that enhances present-moment awareness and has been associated with reduced distress, depression, anxiety and increased resilience [6,14,17]. Although these practices have been found to be effective in helping healthcare providers deal with stress, not all healthcare
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providers use mind-body therapies. In order to better understand what promotes or inhibits the practice of mind-body therapies, a systematic review of the literature was conducted to identify facilitators and barriers to the use of mind-body therapies. 1. Methods 1.1. Data sources Three electronic databases were used for the search to find articles and studies related to the research question: CINAHL, Ovid Medline, and PsychINFO. Terms used while searching CINAHL were “resilience or mindfulness”, and “mind body techniques or mind body therapies.” Terms used in PsychINFO included “Nursing students”, “Mind body therapies”, “Nurses” and “stress.” As for Ovid Medline, the actual interventions of mind-body therapies were listed (“acupuncture”, “breath practices”, “meditation”, “guided imagery”, “progressive relaxation”, “tai chi”, “yoga”, “spinal manipulation”, “massage therapy”, “Feldenkrais method”, “Alexander technique”, “Pilates”, “hypnosis”, “Trager psychophysical integration”, “Reiki”, “Healing Touch”, “qi gong”, “craniosacral therapy”, “reflexology” or “mindfulness”) with other terms such as “stress, psychological or exp resilience psychological” or “Nurses or nursing students or healthcare providers” and “resilience or mindfulness.” Operator codes were used to enhance the search process for example, exp was used to explode resilience. Additionally, the references of relevant articles were reviewed for pertinent studies. For this systematic review, mind-body interventions were limited to those described by the NCCAM and listed previously. In terms of exclusion criteria, there were two stages. During the first stage, articles and studies were excluded if these were related to patients or children, in a foreign language, not a research article, related to medical students, were more than 10 years old, did not address healthcare providers, focused on a specific race, or related to healthy individuals. Additionally, systematic reviews and dissertations were excluded. The exclusion criterion for the second stage was articles not addressing facilitators or barriers of healthcare providers' self-use of mind-body therapies. Articles were assessed based on title, abstract and/or reading the full text. 1.2. Data extraction and quality assessment One reviewer retrieved articles and received assistance from researchers as to the selection of articles. Information related to these studies were stored in Refworks and the quality of the articles were assessed using a modified Jadad Score. This score, which has been used in other reviews related to mind-body therapies awards a total of five points for methods relating to the research [1]. One point was awarded each for randomization, randomizing appropriately, a controlled study design, blinding the evaluator and finally, description of withdrawals and dropouts. Study outcomes were extracted and are displayed in Table 1. 2. Results 2.1. Study description The search of the database resulted in 102 potentially relevant articles, with 85 articles being excluded in the first stage and five articles being excluded in the second stage of the review. These five articles excluded in the second stage did not address facilitators and barriers of healthcare providers' self-use of mind-body therapies; however, these articles did provide findings supporting the
effectiveness of mind-body therapies for providers' self-use [2,8,9,11]. A flow chart outlining article selection is shown in Fig. 1. 2.2. Quantitative studies There were seven quantitative studies. The first study by [3] was a randomized controlled trial that sought to determine the effect of massage therapy in reducing stress in nurses working at hospitals. This study had a sample of 60 nurses with the group being divided into an experimental group and a control group. The experimental group received massage therapy while the control group did not receive any intervention. Outcomes measured stress finding that there was a decrease (P ¼ .006) in stress for the experimental group. The study identified providing therapy at a reduced cost as a facilitator. The researchers acknowledged a need for additional evidence. The second quantitative study which was conducted by [4] determined if computer guided meditation helped nurses reduce stress. The study had 11 participants, all of whom were nurses. These nurses were involved in a program that used computer sessions to reinforce training. This study measured stress, anxiety and quality of life and found that improvements in stress and anxiety were statistically significant: STAI (p ¼ .03), LASA stress (p ¼ .01) and LASA anxiety (p ¼ .01). Also, the nurses were satisfied with the program. Barriers that were encountered by the practitioners included high work demands, time constraints and also, overwhelming personal and professional challenges. [5] et al. evaluated the effectiveness of an abbreviated mind-body therapy. The study had a sample of 30 with the participants belonging to different healthcare specialties from family medicine, internal medicine and pediatrics. These participants did receive a modified MBSR program that included guided sitting, and walking mindfulness practices. After the interventions, the participants responded to four surveys, at different times through emails. The outcome of the study showed that an abbreviated mindfulness intervention improved accomplishment (p ¼ .001), decreased stress (p ¼ .002), depression (p ¼ .001), burnout (p ¼ .009) and anxiety levels (p ¼ .006). A facilitator in this study was an affordable and timeefficient intervention can increase usage. Ref. [12] conducted a cross sectional on-line survey study that sought to understand factors that influenced the form of training that nurses chose to receive mind-body interventions. The method of this study was a cross-sectional on-line survey of nurses in different specialty areas through email. The study had a sample of 342 nurses that was diverse in race, gender and level of education. Information obtained in the survey included health conditions, stress levels, experiences with mind-body practices and expected health benefits. Outcome measured many factors and found that time whether in completing training (58%) or daily practice (60%) and self-guidance (58%) affected the choice of mind-body therapy that nurses used. Facilitators that were somewhat important in this study included knowing the instructor and their professional qualifications. Another quantitative study in this literature review was done by [13]. This study focused on finding effective ways for nurses to decrease stress. This study which was a controlled, randomized pilot study found that mind-body interventions helped decrease emotional exhaustion while at the same time increasing job-related accomplishment and general wellbeing. There were 30 participants in this study comprised of nurses and nurse aides. The study found that there was a positive influence on personal accomplishment (p ¼ .06), improvement in perceived sense of coherence (effect size ¼ .09) and a statistically significant improvement in job-related accomplishments (p ¼ .04). A barrier to clinicians self-use of mindbody therapies included time restraint and intensity of the intervention. A facilitator was the use of a shortened MBSR that is suitable for the hectic schedule of healthcare providers. The next
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Table 1 Results of electronic search for facilitators/barriers of mind-body therapies. Author Mind body (Date) intervention Quantitative studies [3] Back massage
[4]
[5].
[12]
[13]
[14]
Sample size, design and settings
Purpose/aims
Data collection outcome Method/Jadad measures score
“Investigate the effectiveness of massage therapy in reducing physiological and psychological indicators of stress in nurses employed in an acute care hospital”
Randomized State-Trait Anxiety Control Trial Inventory (STAI), life 4 event questionnaire, urinary cortisol and blood pressure readings Outcome measures: physiologic stress, psychological stress
Major findings/factors
Facilitators/barriers to practice
P-value for State-STAI is Facilitators: .006 and Trait-STAI is “Interventions that .008. reduce stress at individual and organizational level.” Frequent massages at a reduced price. Barriers: More evidence required Facilitators: Pre and Post Study SF-36 (p ¼ .04). STAI Linear Analogue Self“To assess whether a Sample Biofeedback (p ¼ .03). LASA stress (Healing Rhythms number ¼ 11 self-directed, computer- Assessment [LASA], State Design None (p ¼ .01), LASA Anxiety Barriers: Trait Anxiety Inventory 1 guided meditation St Marys meditation (p ¼ .01). Nurses were [STAI], Short-Form 36 training program is Hospital program) High work demands and satisfied with the [SF-36] questionnaires useful for stress time constraints program, rating it 8.6 out Dropouts felt Outcome measures: reduction in hospital of 10. “self-directed, stress, anxiety, quality of nurses.” overwhelmed by computer-guided” life. personal and program is effective in professional challenges. reducing stress. Facilitators: Single sample pre Increased “Investigating whether Maslach Burnout Guided sitting and Sample accomplishment scores “Low cost, collegial, and post design. Inventory, Depression number ¼ 30 an abbreviated walking (p < .001). 1 Anxiety Stress Scales, mindfulness UW Health mindfulness time-efficient way to Improvements in stress improve well-being and Perceived Stress Scale, Mindfulness. intervention could practices. (p ¼ .002), depression increase job satisfaction, Resilience Scale, the manage burnout (p ¼ .001), burnout Santa Clara Brief quality of life, and symptoms among (p ¼ .009), anxiety Compassion Scale. compassion among primary care clinicians” (p ¼ .006). primary care clinicians.” Outcome measures: Barriers: burnout, anxiety, stress, None resilience, compassion, job satisfaction Facilitators: Time wither in Cross Sectional Outcome measures: Sample Understanding Healing touch, completing training health conditions, stress email online therapeutic touch, number ¼ 342 “participants' baseline Scientific findings, (58%), daily practice (60), knowing the instructor levels, experiences with survey experience, prayer, meditation, and self-guidance 0 mind-body practices, expectations, or hypnosis, yoga and their reputation/ affected (58%) choice of credentials preferences for training. expected health benefits, intervention. 90% were Barriers: training preferences, To better plan interested in mind-body Study require access to willingness to participate participant-centered training. mind-body intervention technology trials for nurses to reduce occupational stress.” Facilitators: Reduced emotional Controlled Maslach Burnout Effective ways to Mindful stretching, Sample exhaustion (effect randomized pre Inventory, Smith number ¼ 30 decrease stress among None mindful eating, size ¼ .16), increases job- Barriers: Relaxation Dispositions and post Pilot nurses. large urban body scan related accomplishments Time restraint. Inventory, the Intrinsic Study geriatric (p ¼ .04). Job Satisfaction subscale 3 teaching “The intensity of this Positive influence on from the Job Satisfaction hospital intervention is likely to personal Scale, Satisfaction With be aversive to many accomplishment Life Scale, 13-item individuals who work (p ¼ .06). version of Antonovsky's and live under high Improvement on sense of levels of stress; it also (1987) Orientation to Life coherence (effect Questionnaire. limits opportunities to size ¼ .09), general well- offer on-the-job being and life satisfaction mindfulness training, (effect size ¼ .21). especially in shiftwork occupations.” “Several exceptions were made to accommodate participants' vacation schedules.” “Shortened MBSR program is easier to add to nurses schedule”, “the full MBSR program might not fit into the demanding schedule of nurses and nurse aides” Facilitators: SemiReduce ruminations “How Mindfulness SCL 90-R inventory, Mindfulness-based Sample experimental (Cohen's d of .53), facilitates a distress Survey of Recent Life number stress reduction Instructors experience, distress (p ¼ .16), Experiences (SRLE, N ¼ 29 (MBSR) course is accredited, Sample size ¼ 60 Acute care hospital in Queensland
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Table 1 (continued ) Author Mind body (Date) intervention
Sample size, design and settings
Purpose/aims
reduction in a group of Palma de Mallorca's IB- health professionals” Health
[17]
Mindfulness-based Sample number ¼ 33 stress reduction healthcare (MBSR) system in the southwest United States
Author/ Mind body date Qualitative studies [7] -Based Stress Reduction (MBSR)
“Evaluate a brief stress management intervention for nurse leaders.”
Data collection outcome Method/Jadad measures score Perceived Stress Scale, Positive and Negative Affect Scale (PANAS) Outcome measures: stress, negative affect Symptom Checklist 90Revised (SCL-90-R) “explore the lived experience of nurses who practice Reiki for self-care.”, Positive Symptom Distress Index (PSDI), Positive Symptom Total, Positive Symptom Total. Outcome measures: stress, depression, anxiety, caring efficacy
study. 1
Randomized control trial. 4
Major findings/factors
negative affects (Cohen's financial compensation. d of .78) Barriers: Barrier is adhering to MBSR outside of work. Facilitators are Facilitators: Improvement in depression (p ¼ . 05), MBSR is effective for anxiety (p ¼ .04), and nursing leaders and symptom improvement groups. (p ¼ .009). Caring “Exerting leadership improved however it influence to create was not statistically organizational significant (p ¼ .99). environments All p values are Raw P. supporting healthy stress management” Barriers: Reason for dropping out: “personal time management reasons.” Major findings/factors Facilitators/barriers to practice
Design and sample size
Purpose/aims
Data collection/outcome Quality score measures
Sample number ¼ 20 large tertiary care center in the Midwest Sample number ¼ 21 University of Lethbridge
“Describe the perceived effects of a MindfulnessBased Stress Reduction (MBSR) Program on stress and quality of life of women in midlife.” “To gain an understanding of students' experiences related to all aspects of the course content and process”
Guidelines by Strauss and Corbin and Tesch. Outcome measures: stress, coping, quality of life
Author/ Mind body date Quantitative and qualitative [6]. Mindfulness Based Stress Reduction MBSR program
Design and Sample size studies Sample number ¼ 40 Two metropolitan teaching hospitals in NSW
Purpose/aims
Data collection/outcome Quality score measures
“Pilot the effectiveness of an adapted mindfulnessbased stress reduction intervention on the psychological wellbeing of nurses and midwives.”
Pilot study pre and Lots of participants General health quotes about questionnaire (GHQ-12), posttest. effectiveness. sense of coherence (SOC) 0 Improvements in e orientation to life, the relaxation, calm, more depression, anxiety and focused, importance of stress scale (DASS). “me time”, awareness of other, receiving help early on, better control of thoughts and stress. Improved health GHQ-12 p ¼ .11,.031. SOC-Orientation to life p ¼ .009. DASS-Stress p ¼ .004
[18]
Sample number ¼ 84 University of Maryland
To evaluate the effect of a Outcome measures: coping with life, life holistic program stressors, and adverse (Healing Pathway) in events.
[10].
Many different forms of complementary and alternative therapies were offered however the interventions were not listed.
Reiki, guided imagery, yoga, toning, meditation, intuitive scanning,
Qualitative evaluation with experimental and comparison group. 0
Exploratory and Journals, student narratives, projects, class descriptive qualitative study. presentation and 0 scholarly paper
Systematic qualitative and qualitative
Facilitators/barriers to practice
“Strengthened communication through support, Increased awareness and better handling of stress, “living life in the balance” Five concepts that emerged were: engaging, opening, hesitating, understanding, and knowing. Increased personal growth.
Major findings/factors
Facilitators: None Barriers: High demand on time led to less time spent on selfcare Facilitators: None Barriers: Most learners were unprepared to accept evidence that was not concrete in nature although their willingness to learn was evident. Students questioned their perceptions of, and responses to, their experiences as they tried to find an explanation for the “phenomena.” Challenge of adding opportunities into nursing education curriculum Facilitators/barriers to practice
Facilitators: Support of manager. Coworker encouragements Barriers: Taking timeout at work to do the intervention, time constraints, and scheduling conflict related to unit staffing needs. Assimilating mindfulness into work environment. Working night shift was a barrier as participants wanted to rest during the day rather than do the intervention Improvements in stress, Facilitators: self-efficacy, positive Interventions should be comments throughout offered earlier on in the the article from curriculum as a “health
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Table 1 (continued ) Sample size, design and settings
Purpose/aims
creative expression, mentorship
Medical Center
dealing with stress in Data Collection: healthcare practitioners Perceived Stress Scale (PSS), Coping SelfEfficacy Scale
Signature cell healing and reconnection healing, balancing heart energy therapy, acupressure, Reiki, integrative energy, healing touch
Sample number ¼ 11 Proximity to Florida Atlantic University
“Explore the lived experience of nurses who practice Reiki for self-care.”
Author Mind body (Date) intervention
[19]
Data collection outcome Method/Jadad measures score
Interview colaizzi method
quantitative study was conducted by [14]. The objective of this study was to determine how MBSR program enabled healthcare providers to deal with stress. This study had a sample of 29 participants with healthcare professionals taking an 8 week class. The study was a semi-experimental study performed at Palma de Mallorca's IBHealth. Of the outcomes measured, negative affect and stress, there was a decrease in distress level (p ¼ .16) and negative affect (Cohen's d of .78). A barrier that participants encountered was that it was difficult to adhere to the program outside of work. Facilitators include instructors experience, course accreditation and financial compensation.
evaluation 0
Major findings/factors
respondents, transferring learned skill to work was a challenging: support and mentoring resolved this. 81% reported frequent Descriptive phenomenological use of Reiki. 72% practiced other forms of approach. energy based therapies. 0 8 major themes emerged about the benefit of Reiki
Facilitators/barriers to practice promotion tool.” Barriers: None
Facilitator: None Barriers: Lacked appropriate place and environment to practice: “bathroom or office space, places where it is not seen or valued.”
The final quantitative study of this literature review was conducted by [17]. This study was a randomized control study that evaluated the effect of MBSR on nurse leaders. The study had a sample of 33 participants all of whom were nurse leaders. These leaders took a mindfulness course and self-reported their stress level at the beginning and at the end of the study. The effect of MBSR was evident with statistically significant reductions in both depression (p ¼ .05) and anxiety (p ¼ .04). The primary barrier to the mind-body intervention in this study was the lack of time. Facilitators include having an organizational environment that supports the intervention.
Fig. 1. Flow chart of article selection.
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2.3. Qualitative studies There were two qualitative studies. The first study which was performed by [7] focused on the effectiveness of MBSR on stress and quality of life in healthcare providers. This study had a sample of 20 all of whom were nurses. The study was a qualitative evaluation of these healthcare providers after taking a MBSR course at a large tertiary care center in the Midwest. Outcomes measured stress, coping and quality of life. The participants in this study reported an increase in the management of stress, and having a wellbalanced life. A barrier that was noted was that due to high demand on participants' time, they were not able to spend much time on their self-care. The final qualitative study is by [10]. The study had 21 participants who were students from different professions: nursing, education, social work, kinesiology, recreation and prepharmacy. The aim of this study was to obtain students' perspective of a mind-body course. Results were obtained from students’ assignments such as journals, narratives, projects, class presentation and scholarly papers. There were five themes that emerged for the students: engaging, opening, hesitating, understanding, and knowing. Barriers that the students encountered include, lack of concrete evidence, lack of an explanation for what they were perceiving and experiencing and finally, the challenge of including these interventions in the educational curriculum. 2.4. Quantitative and qualitative studies There were three quantitative and qualitative studies. The first study is by [6]. This study determined the effectiveness of a modified MBSR program on nurse's health. The study had a sample of 40 participants 20 of whom were midwives while the other 20 were nurses. This study was a pilot study with a pre and posttest with some participants being interviewed. Outcomes measured anxiety, stress, and orientation to life. Participants reported an improvement in stress (p ¼ .004), and other aspect of life: awareness of others, more positive thoughts, and much more. Barriers noted relates to time constraints and time at which intervention was scheduled was not ideal for participants who worked the night shift. Facilitators included coworker encouragement and leaders support. The second study is by [18]. This study focused on the effect of a holistic program on reducing stress in healthcare providers. The study had 82 participants and these participants were nurses or nurse practitioners, massage therapists, social workers and physical therapists. These participants were enrolled in a program called Healing Pathways and they self-reported on stress, coping and much more. The study found that there was an improvement in stress (5.7 less in 8 weeks and 2.5 less in 12 months) and self-efficacy (36.6 points more in 8 weeks and 33.6 more after 12 months). Facilitator of mind-body intervention was to introduce the intervention early in the curriculum as a form of a “health promotion tool” [18]. Ref. [19] focused on nurses' self-care use of Reiki. The study concluded that there was a frequent use of mind-body therapies and that there were eight themes that emerged: “infinite connection and divine guidance, journeying to the centered self, calming oasis for the workday, relationship between relaxation and clarity, awareness of self-healing transformation, personal space of oneness, providing self-Reiki care, relationship between reverence, caring and nursing [19]. A barrier for practitioners in this study was that they did not have a place to practice at the work. A facilitator is to include the intervention into the philosophy of the healthcare system. 2.5. Study quality The quality of the studies varied, with scores ranging from 0 to 4. Of the 12 articles, two obtained a score of four [3,17]. One of the
studies received a score of three [13]. Three articles received a score of one [4,5,14]. Six of the 12 received a score of zero because these studies were not randomized, controlled, or blinded and did not provide a description about withdrawals or dropouts [6,7,10,12,18,19]. 3. Discussion The main aim of each of the included articles was to provide findings about the effectiveness of mind-body therapies. As such, there was not much emphasis on the barriers that the healthcare providers encountered. However, there were some overall themes about barriers that emerged when the articles were analyzed. Of these themes, one barrier identified in relation to clinician self-use of mind-body therapy was time. Clinicians had difficulty scheduling time off to partake in a particular study or just had an increasing demand on their time [6,7]. Another barrier was the high work demand of healthcare providers [4]. Some of the high work demand included participants changing their schedule to assist their unit with staffing. In some cases, the time for the intervention to be delivered was changed promptly to accommodate the schedule of the participants [6]. In terms of facilitators of mind-body therapies, these also were briefly addressed in the 12 articles. One facilitator identified to increase the use of mind-body therapies was supportive evidence [3,10]. Some students found it hard to grasp the phenomenological concept of mind-body therapies given that it is less concrete in its nature [10]. As such, more evidence might yield an increase in the use of mind-body therapies. Another reoccurring facilitator noted was support, either financially or encouragement from leaders. If healthcare providers receive financial assistance in pursuing a mind-body therapy [5,14], which reduces concerns about the financial cost of such therapies, then they may be more likely to engage and adhere to these therapies. 4. Conclusion Work-related issues that have an impact on healthcare providers' abilities to care for themselves have been a topic of interest for numerous years. Some of these issues, which are attributable to healthcare provider shortages, have resulted in emotional exhaustion, a decreased sense of well-being, poor quality of care and depersonalization [3,13]. With these negative outcomes being severe, interventions such as mind-body therapies are being used to address this issue. Mind-body therapies encompass a large group of interventions with underlying mechanisms involving the brain [1,16]. The effectiveness of these therapies in helping to alleviate work-related psychological issues has been documented in numerous studies; however, there is the issue of adherence. Many articles addressed the issue of mind-body therapies in relation to healthcare providers self-use; however, most were excluded based on the predefined inclusion and exclusion criteria (Fig. 1). 12 articles provided brief information relating to facilitators and barriers of mind-body use by healthcare providers to care for themselves. The quality of the articles was assessed using the modified Jadad score with scores ranging from 0 to 4. Some of the facilitators found in the articles included mind-body interventions that fit into the healthcare providers’ schedules and provision of financial assistance [13,14]. Examples of barriers that healthcare providers encountered included high work demand and time [6,7,13]. The primary aim of these articles focused on the effectiveness of mind-body therapies. As such, there is limited data which addresses the primary aim of this systematic review. Even though mind-body therapies are effective, the usage by the healthcare provider is likely to be limited if these barriers and
Please cite this article in press as: Mensah SB, Anderson JG, Barriers and facilitators of the use of mind-body therapies by healthcare providers and clinicians to care for themselves, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.01.004
S.B. Mensah, J.G. Anderson / Complementary Therapies in Clinical Practice xxx (2015) 1e7
facilitators are not addressed. Hence, more research about facilitators and barriers is needed. 5. Distinguished majors project The purpose of this research project was to analyze facilitators of and barriers to healthcare provider/clinicians’ use of mind-body therapies. This systematic review will assist in the experimental aspect of this project in numerous ways including knowledge about effectiveness, questions to place on the survey, ways that barriers and facilitators can be addressed and many more. Nurses will be invited, through emails, posters and word of mouth, to partake in a survey that will analyze barriers and facilitators to their use of mind-body therapies for self-care. Conflict of interest statement The authors have no conflicts of interest to declare. References [1] Anderson JG, Taylor AG. The metabolic syndrome and mind-body therapies: a systematic review of clinical trials. J Nutr Metabol 2011;2011:8. http://dx.doi. org/10.1155/2011/276419. [2] Beddoe AE, Murphy SO. Does mindfulness decrease stress and foster empathy among nursing students? J Nurs Educ 2004;43(7):305e12. Retrieved from: http://ovidsp.ovid.com.proxy.its.virginia.edu/ovidweb.cgi? T¼JS&CSC¼Y&NEWS¼N&PAGE¼fulltext&D¼med5&AN¼15303583. [3] Bost N, Wallis M. The effectiveness of a 15 minute weekly massage in reducing physical and psychological stress in nurses. Aust J Adv Nurs 2006;23(4): 28e33. Retrieved from: http://ovidsp.ovid.com/ovidweb.cgi? T¼JS&CSC¼Y&NEWS¼N&PAGE¼fulltext&D¼med5&AN¼16800217. [4] Cutshall SM, Wentworth LJ, Wahner-Roedler DL, Vincent A, Schmidt JE, Loehrer LL, et al. Evaluation of a biofeedback-assisted meditation program as a stress management tool for hospital nurses: a pilot study. Explore J Sci Heal 2011;7(2):110e2. http://dx.doi.org/10.1016/j.explore.2010.12.004. [5] Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med 2013;11(5):412e20. http://dx.doi.org/10.1370/afm.1511. [6] Foureur M, Besley K, Burton G, Yu N, Crisp J. Enhancing the resilience of nurses and midwives: pilot of a mindfulness-based program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemp Nurse 2013;45(1):114e25. http://dx.doi.org/10.5172/conu.2013.45.1.114.
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Please cite this article in press as: Mensah SB, Anderson JG, Barriers and facilitators of the use of mind-body therapies by healthcare providers and clinicians to care for themselves, Complementary Therapies in Clinical Practice (2015), http://dx.doi.org/10.1016/j.ctcp.2015.01.004
