Exploring the value of mindfulness for Saudi Arabian women mental health nurses

Introduction

Mindfulness, according to Moscardo,^[1] stems from the improved understanding of a situation obtained by maintaining an open mind to other categories and alternatives. Additionally, mindfulness makes people sensitive to their immediate environment, supports better behaviour and thoughts and improves decision-making.^[2],[3]

Mindfulness implies maintaining awareness of the surrounding environment without interpreting events in a judgemental way. Applying this method of thinking is instrumental in reducing psychic stress during events by preventing emotional value from being attached to them.^[4] Therefore, events are not designated ‘terrible’ or ‘awful’ but are evaluated for the real impact they have in the setting in which they occur. The Merriam-Webster Dictionary reiterates this definition, calling mindfulness a ‘non-judgmental state of heightened and complete awareness of one’s thoughts, emotions, and experiences on a moment-to-moment basis’.^[5]

White,^[6] using Rodgers’ evolutionary method of concept analysis, conducted a systematic review of 59 English language theoretical and research-based articles that examined the concept of mindfulness. Attributes, antecedents, consequences, references and related terms as they appeared in nursing literature were analysed. The results identified attributes of mindfulness as the experience of being present, acceptance, attention and awareness.

The practice of mindfulness aims at enhancing the ability of individuals to focus on the present moment by helping them separate distracting feelings and thoughts from the immediate situation. Learning to practice mindfulness-based interventions in their caring activities was found to assist healthcare practitioners in mediating otherwise stressful situations, as indicated by a systematic review of 19 studies of 1815 participants which reported decreased stress, anxiety, improved mood, higher self-efficacy and empathy among caregivers.^[7]

Guillaumie et al.^[8] noted that a few studies have explored the relationship between nurse behaviour towards patients and colleagues and mindfulness. A systematic review of 32 studies was conducted on this topic. Although there were no significant differences between participants and non-participants in mindfulness-based stress reduction training, quantitative studies found a trend of reduced anxiety and depression. Qualitative data revealed trends that were missed by focusing on quantitative outcomes via questionnaire-based studies. These emerging trends were increased calmness, awareness and enthusiasm; improved work performance; better communication with colleagues and patients; greater sensitivity to patient needs; clearer analysis and emotional regulation in complex or stressful situations.

These findings were supplemented by data from a systematic review of 24 articles observing the effects of mindfulness-based stress reduction. Reduced levels of emotional exhaustion, stress, psychological distress, depression, anxiety and occupational stress were observed, as well as improved mindfulness skills, feelings of personal accomplishment, self-compassion, quality of sleep and relaxation,^[9] although Gu et al.^[10] found insufficient evidence of increased self-compassion.

Moreover, when mindfulness is being considered as a coping mechanism, a frequent reason for its implementation is the presence of stress. The Psychology Dictionary (2013) describes this state as a ‘response to internal or external stressors’. The American Psychological Association (2018)^[11] found one-third of working Americans reported experiencing chronic stress at work and suggested that uncontrolled stress may lead to hypertension, anxiety, insomnia, depression and a weakened immune system.

Al-Omar^[12] conducted a cross-sectional study of 414 hospital staff at the Ministry of Health Hospitals in Riyadh, Saudi Arabia, using self-administered questionnaires. The sources of stress identified by staff were insufficient technical facilities, lack of appreciation, long working hours, younger age, shorter length of employment and short breaks. Each of these stressors reached statistical significance (p≤0.05) in stepwise multiple regression analysis. Saudi staff noted statistically significantly more stress overall than foreign staff (p≤0.028).

On the other hand, the concept of burnout was repeatedly mentioned by participants. This concept was first discussed by Herbert Freudenberger as a complex of factors. Healthcare workers and others responsible for welfare of others are vulnerable to emotional stress. When this occurs during the performance of work tasks, it is labelled burnout syndrome (BOS).^[13] BOS has been defined by Al-Turki pertaining to the Saudi context as ‘primarily exhaustion in response to prolonged emotional and interpersonal stress at work, leading to depersonalization’.^[14]

A variety of manifestations of this phenomenon have been described. A cross-sectional study conducted at King Fahad National Guard Hospital applied the Maslach Burnout Inventory to measure burnout incidence in 348 physicians. Back pain, sleep deprivation and negative effects on family life were associated with BOS in the final multivariate model.^[13]

Cross-sectional studies using the Maslach Burnout Inventory questionnaire in a variety of countries have independently produced a group of emotional states shared by Indian, Brazilian, Chinese and Jordanian nurses, who identified emotional exhaustion, depersonalization and a diminished feeling of accomplishment as major concerns.^{[15],[16],[17],[18]}

Theoretical basis

The theoretical support for mindfulness in the context of this study is rooted in the Social Ecological Model, a component of Social Cognitive Theory. This model emphasizes the importance of personal, social and physical environments in shaping the patterns of disease, health and injury and our responses to them.^[19]

Data related to the practice of mindfulness among nursing professionals in Saudi Arabia or the Arabian Gulf or Middle East (MENA) were not found. Due to the dearth of information available pertaining to the practice of mindfulness among mental health nurses, particularly those practising in the MENA area, it seems important to enquire into the use of this technique and its perceived benefits by practising nurses.

Research question

How do mental health nurses in Saudi Arabia perceive the benefits of mindfulness training?

Methods

The above research question was investigated using a qualitative approach. Data were collected using focus group discussions, which are considered an excellent technique for obtaining views on specific topics and the underlying reasons for people’s opinions.^[20]

Setting

This study was conducted at the Nursing College of King Saud University in Riyadh, Saudi Arabia. Focus group discussions of approximately 1 hour in length were conducted at the university.

Sample

The study involved 18 women aged 27–31 years pursuing a graduate mental health nursing programme. All participants had previous experience in mental healthcare work in a variety of settings.

Data collection

Semi-structured interviews had open-ended questions on problems encountered in mental health nursing practice and the impact of mindfulness training and practice on the students’ perceptions of their ability to address stress and BOS.

The Institutional Review Board of King Saud University approved the protocol. Written and verbal informed consents were obtained from all participants. Group discussions were digitally recorded and transcribed. These documents were stored in a locked location. The participants were assured that their contribution was confidential and would not prejudice course grades.^[21]

Each statement made by the participants was considered important and treated as relevant. In the focus group discussions, the researcher planned each session so that each participant had sufficient time to think and reflect upon her experiences. To enhance credibility, member checking was employed at the termination of each focus group meeting and at the beginning of new sessions as a method of establishing directions for theoretical sampling in subsequent sessions to assist in exploring emerging themes.

Tabulation and analysis of data

Data were analysed by the researchers, and inductive concepts were recorded. NVivo10.1 software was used to extract codes and emerging themes from inductive codes (Silver and Lewins, 2014). These codes were further refined by the researchers who were assisted in reflexivity by employment of peer-checking to assist in trustworthiness. Researchers focused on practising self-awareness and emotional detachment during final formulation of the core and main themes.

Results

Analysis of data obtained from the focus group revealed a core theme: ‘Compassion, integrity and survival’. This main cluster includes views of the participants on using mindfulness to address the stress encountered in their mental health caring. The main themes that emerged from the data were: (i) positive techniques; (ii) recognized stress; (iii) managing stress; (iv) acceptance; (v) psychological reaction; and (vi) physical responses.

These themes are explored through a thorough description and discussion of the results.

Theme one: Positive techniques

Participants indicated their ability to consciously adapt to changes occurring in various moments in their lives and stated that mindfulness training has enhanced their work, especially their tolerance to stress. The effect of mindfulness practice on stress levels of participants was discussed.

One of the students noted the effect of mindfulness in her life when she said: ‘It gives me the power of focus and thinking particularly about my life.'

Another participant reported ‘I believe I’m improving at letting go of thinking negatively about my memories, and this knowledge is not easy to apply, but it can be learned gradually in each related event in our lives.' Yet another participant said, ‘I have become less of a worrier and a ruminator. '

One participant stated, ‘Now, understanding of mindfulness is helpful to be able to say to myself now, I’m not going to think about that (a negative memory), I am going to look at the scenery while I am working, or focus on my breathing, or something along these lines.'

She went on to express: '…relieves me of the guilt…the feeling that I should always be thinking about solving my problems or other people’s problems. I’m proud that I have learned this.' This statement implies she has learnt to treat these feelings as thoughts and is therefore able to let them go by separating them from what is happening now.

With mindfulness training, another student felt she was better able to let go of distressing thoughts, ‘I can tell you that with the mindfulness understanding I felt I was becoming more able to let go of the distressing thoughts.'

Another student added, ‘And accepting the stress allowed me to choose how to react to it or not react to it.'

Recognized stress

With mindfulness training, participants indicated that they were more aware of their stress: ‘With the mindfulness training, I was more aware of the stress…' and ‘I noticed this semester that I could identify stress well before it overwhelms me.' Another participant said, ' I remember when I had high levels of stress, I felt high levels of anxiety in the stomach, tension in my neck, and more pains and aches.'

For this particular participant, her new awareness allowed her to identify her stress limits by reading signals from her body. By recognizing these limits, she noted that she could recognize her anxiety without becoming overwhelmed: ' Now I feel that I can recognize my anxiety without getting overwhelmed by it…I can see the red flags of stress and therefore am able to initiate control mechanisms before it takes a toll on me.'

Several other students described their ability to gauge the level of stress that they were experiencing and detect when the stress level was becoming critical.

One student stated: ' Wow, I thought in the past my thinking managed stress very well, the completion of several meditations made me realize that my practice was associated with higher stress and therefore the training has improved my awareness of stress and therefore I am able to manage stress better before it spirals out of control. '

Managing stress

Mindfulness training helped improve management of a stressful environment: ' With mindfulness I became aware of my stress cycles and learned effective management of stress by being present with it, talking about it, and being able to let it go. '

However, this student described letting it go as a challenge. Yoga sometimes helped, but not enough, and the stress usually returned. Nonetheless, the student has become more aware of this pattern and is therefore more able to manage stress by developing better stress management skills: ‘Now and for tomorrow letting it go will be a challenge but sometimes yoga or disciplined regular prayer and exercise helps me some though not that much as the stress usually comes back.'

Participants also claimed that they could perceive stress through bodily states. One student noted that ‘The mind–body class reflected on me by enhancing the ability of my body to be more responsive to the escalation of stress. '

Another student indicated she accepts stress instead of being ashamed of it. This student noted that unlike before, she considers stress to be part of her life and therefore does not consider it as problematic as before, when she ignored it or tried to develop strategies to overcome it: ‘As of now I can accept stress more as opposed to being ashamed of it and I feel that it can to tolerated, faced, and solved. Now I can accept the stress and don’t ignore it as I used to do previously and see stress as an indicator that I need to do something to address it as opposed to having it.'

Acceptance

On the value of accepting stress, another student reflected after attending a practical session of the course and said, ‘Everyone felt exhausted and stressed, but for the first time I allowed all the exhaustion and stress to take control of me and did not struggle with it.'

This participant also observed, ' The struggle with stress and exhaustion requires a lot of energy as opposed to letting it go, and sinking into a difficult feeling rather than fighting it made it easier for it to pass.'

The participants in the study also developed higher levels of acceptance of themselves than in the past. One participant noted: ‘In the past I used to worry over the same thing for a long time but after applying what I understand from the mindfulness meaning and techniques, I find it easy to accept that there are things that I don’t have control over and therefore I leave them to sort out themselves naturally, and this has helped me in reducing the levels of stress. '

Another student reported, ‘Through this class I feel acceptance reflected on me positively and I started living more in this moment and present with a lot of experience that’s helping me’.

She also said: ‘Now that I understand what mindfulness means, I can focus on what can be done in the present moment to accomplish what I need to accomplish at that moment.' In describing her experiences, this participant’s description was characterized by cognitive restructuring.

Psychological reaction

We also found that students were now better able to accept and therefore endure difficult thoughts and feelings by regulating their emotional states. One of the participants indicated that she could recognize negative and disruptive thoughts, and observed ' Definitely, now I can say that I am able to recognize disturbing thoughts and consider them to be thoughts only and therefore let them go…but I remember that I was concerned with how people’s stories kept popping up in my mind when I was not at work and it made me worry about burnout and any stress that happened to me. '

In addition, other students indicated the important effects of understanding mindfulness and how to be more aware of their psychological state: ‘According to me, for sure this course and learning and understanding mindfulness has allowed me to be more effective in how to treat them as only thoughts and therefore let them go by separating them from what is happening at the moment.'

Another student participant was better able to modulate her emotions and recognize initial reactions to stress and therefore develop mechanisms to cool herself down: ' I was more able to modulate my emotions as my awareness is raised to recognize the signs. This has improved me by realizing initial reactions to stress…Now I can develop mechanisms to cool myself down, really I’m happy to feel that. '

Another student said that in addition to accepting complex emotional states caused by stressful conditions, she was experiencing emotions in a new way. ' I experienced emotions in addition to accepting complex emotional states that result in stressful conditions. Actually, I had a difficult time dealing with stress and the accompanying emotions and was overwhelmed and paralysed by stress, which led me to depression at times…but with the understanding and application of mindfulness, I now feel confident with being more aware of the stressful emotions and can acknowledge such feelings, validate them, and let them go directly. '

This student further noted a difference when compared to her own past self, ‘For me, frankly, compared to the situation before, now I feel more at peace and more comfortable with experiencing sadness or anger and allowing myself to feel them without judging or trying to bury them.’

She also said: ' Now I can say that accepting the stress allowed me to release the stress, that happened with gaining an understanding of mindfulness and absorbing the ideas related to it. I definitely will work positively in the future.'

Physical response

In describing this new found ability to cope with stress, this student noted that stress can have adverse effects on the body. She noted that she has discovered a deep connection between stress and her body and that holding stress in her body made her concentrate so much on the sensations in her body that she lost sight of the task at hand: ' When the stress affected my body, that led me to concentrate a lot on the body while losing focus on the important issues such as my studies, work or family.'

Furthermore, another participant observed the effect of stress on her body and said how mindfulness helped her escape the vicious cycle of stress, ‘I can say a high level of stress affects my body and makes me become critical of the appearance and functioning of my body, reduces my self-esteem, and causes the level of total stress to go up…the truth is, understanding and training on mindfulness has become a source of this awareness and happiness. '

Discussion

We attempted to highlight the positive effects that mindfulness had on students involved in a programme designed to enhance their knowledge and abilities of coping with stress. The self-evaluations and self-reflections provided by the students indicate the importance of mindfulness in enhancing the self-knowledge and understanding of others. The study examined perceptions of mindfulness held by students pursuing graduate study in mental health nursing, including a 16-week mindfulness course. The benefits of mindfulness as a prophylactic for stress and burnout among mental health nurses were examined. In a qualitative analysis, themes related to stress management and burnout in the nurses’ professional and personal lives emerged. Across the semester, there was a notable shift in the conceptual understanding of stress as the students reflected on their experiences of using mindfulness to cope with stress. This shift indicated the students’ improved ability to cope with stress more effectively by gaining new skills or enhancing their strategies for combating stress and burnout. The changes that occurred across the various themes suggest that a course on mindfulness has a positive impact on nursing practice and personal lives of these professionals.

The ability of a clinician to differentiate herself from a patient is defined as emotional separation and was found by Harr^[22] to be key in preventing burnout and compassion fatigue. The participants in the study were found to have enhanced ability to regulate their awareness of and reactions to stress. In their post-semester responses, the students noted that they experienced less judgement of and attachment to their own thoughts and feelings. This new found capacity confirms the results of a review article on the history, aspects and benefits of mindfulness performed by Davis and Hayes.^[23] They further noted that mindfulness training enhanced their ability to manage and mediate BOS and stress by cultivating their ability to observe or consider their thoughts and feelings as temporary events in their minds rather than reflections of themselves.

Our study may support the incorporation of a mindfulness course into training provided to mental health professionals and perhaps those in other fields aimed at helping to decrease the levels of stress, BOS and compassion fatigue that they may experience.

Schwarzer and Hallum^[24] found that perceived coping ability mediates the development of BOS and compassion fatigue. Participants in this study felt improved confidence in addressing stress and BOS due to improved self-care strategies such as mindfulness, prayer and yoga, noting that these strategies are key in helping them prevent stress and burnout. Students also indicated that their new found confidence made them more aware of and less worried about BOS and attributed this to their increased ability to accept and become more aware of the things happening around them. This acceptance and awareness have both been cited as outcomes of successful mindfulness practice in the related literature.

Compassion plays a critical role in the work of healthcare professionals, as it forms the basis for connecting with patients. Our study suggests that the students’ capacity for self-reflection improved. It also supports the growing body of evidence suggesting that mindfulness training is key in fostering mental health and is therefore an important aspect of training healthcare professionals. By prioritizing mindfulness training in curricula aimed at training healthcare professionals, institutions and accreditation organizations may play a considerable role in promoting staff satisfaction, longevity in the workplace and enhanced patient care.

Mindfulness meditation, according to Kabat-Zinn,^[25] is the energy of being awake and aware of the present moment. This is operationalized as ‘paying attention in a particular way, on purpose, in the present moment and non-judgmentally’. Mindfulness can be practised by anyone at any time and in any place because it does not require equipment or a facility and is universally accessible. The only restriction on refinement of this practice is self-discipline cultivated by frequent practice. Many other professionals beyond healthcare practitioners may experience increased quality of life for themselves and those they serve through increased wholeness, compassion, empathy and integrity.

Limitations

Mature graduate mental healthcare nurses enrolled at King Saud University participated in a focus group convened for the purpose of examining stress and BOS in their practice as mental health nurses and role of mindfulness in that work. Group members were committed to explaining their experiences of perceived benefits of mindfulness practice. Because men were not recruited, they may have different sources of stress and BOS. Healthcare practitioners representing other populations may have different needs, and results may therefore need modification or interpretation in the practical application of outcomes of this study.

Conflicts of interest. None declared