Sage Journals: Discover world-class research

Abstract

The purpose of the study was to evaluate the effects of a modified mindfulness-based stress reduction (MBSR) program on the levels of stress, affect, and resilience among nurses in general hospitals in mainland China. In addition, the study attempted to determine the impact of the program on job satisfaction. A total of 110 nurses were randomly assigned to the intervention versus control groups. The intervention group participated in a modified 8-week MBSR program. All participants were evaluated with questionnaires at baseline, immediately after the intervention, and 3 months later. The intervention group showed decreases in stress and negative affect and increases in positive affect and resilience after the intervention. No improvement in job satisfaction was observed, but the trends of the data were in the hypothesized direction that job satisfaction would improve. The modified MBSR program is an effective approach for nurses to decrease stress and negative affect and improve positive affect and resilience. In addition, the program has the potential to improve job satisfaction.

Keywords

mindfulness stress affect resilience job satisfaction nurses

Nursing professionals face extraordinary stressors in the medical environment. The main sources of stress for nurses are workload, the emotional cost of caring, lack of reward and shift rotation, complex interpersonal relationships, and the increased need for knowledge of ever-changing technology (Botha, Gwin, & Purpora, 2015; Guillaumie, Boiral, & Champagne, 2017). Persistent high stress has a negative impact not only on the physical and mental health of nurses but also on work activities and performance, leading to burnout, compassion fatigue, lower job satisfaction, high workplace turnover, and poor quality of care for patients (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Howlett et al., 2015; Leiter & Maslach, 2009; McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011). Aiken et al. (2011), in a study of nurses from nine countries, reported that high nurse burnout was found in hospitals in all countries except Germany and ranged from roughly one third of nurses to approximately 60% of nurses in South Korea and Japan. Job dissatisfaction among nurses was close to 20% in most countries and as high as 60% in Japan. With regard to quality of care, half or more of the nurses surveyed, regardless of country, lacked confidence that their patients could care for themselves following discharge.

China is contending with a very serious nursing shortage compared with many other countries (Yun, Jie, & Anli, 2010). By the end of 2016, China reached a total of 3.5 million registered nurses (National Health and Family Planning Commission of the People’s Republic of China, 2016), but the increase in trained nurses was much lower than the increase in outpatient visits and inpatient numbers (Gu, 2011). Furthermore, nurses in China have frequently suffered from occupational stress owing to the speed of economic development and the new medical reform program, which have led to a higher demand for better medical services and a more complex nurse–patient relationship (Wu et al., 2011; Zhang et al., 2014).

The negative consequences of work-related stress among Chinese nurses are well characterized in the literature. Dong, Zhang, Sun, Sang, and Xu (2017) recently reported that the overall prevalence of sleep disturbances among clinical nurses in general hospitals in mainland China is 63.9%, which is higher than that in the general population (Chung & Tang, 2006; Gu, Xu, & Yin, 2015; Guo et al., 2005; Soldatos, Allaert, Ohta, & Dikeos, 2005; Wong & Fielding, 2011). According to a large study (n = 1,807) of Chinese nurses working in public hospitals, the prevalence rates of anxiety and depressive symptoms were 43.4% and 61.7%, respectively (Gao et al., 2012a, 2012b). In a separate study of 9,698 nurses from 181 hospitals in China, nearly 20% of the nurses reported high levels of burnout in the three dimensions of emotional exhaustion, depersonalization, and reduced personal accomplishment (Zhang et al., 2014). In addition, 54% of the nurses were dissatisfied with their current job, and 5% reported their intention to leave. These findings suggest that Chinese nurses have poor health prospects that may affect the quality and safety of nursing services, which ultimately influences the health of the population at large.

Mindfulness-Based Interventions (MBIs)

Mindfulness can be defined as the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally (Kabat-Zinn, 2003). The practice of mindfulness was originally developed in an Asian culture that emphasized the value of being, nonstriving, and acceptance of experience (Dundas, Thorsheim, Hjeltnes, & Binder, 2016). In the 1970s and 1980s, mindfulness was introduced to Western countries and gradually evolved into one of the most important concepts and techniques in contemporary psychotherapy (Hayes, Follette, & Linehan, 2004). In recent years, mindfulness practice, an effective way to reduce stress and improve health, has been widely applied in both clinical and nonclinical populations (Fjorback, Arendt, Ørnbøl, Fink, & Walach, 2011). The most widely known structured program for mindfulness practice is Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney, 1985), which has inspired the development of several MBIs (Kabat-Zinn, 2003) worldwide, including Mindfulness-Based Cognitive Therapy (MBCT; Teasdale et al., 2000).

An increasing number of reports in the literature discuss the use of MBIs for health care professionals, especially nurses, who are an indispensable resource in patient care and are particularly vulnerable to work-related stress and burnout (Sillero & Zabalegui, 2018; Xie, Wang, & Chen, 2011; Zhang et al., 2014). In a recent mixed-methods systematic review (Guillaumie et al., 2017), the meta-analysis suggested that MBIs may be effective in significantly reducing anxiety and depression among nurses, and qualitative studies and uncontrolled studies have provided insight into the benefits overlooked in randomized controlled trials (RCTs), including improvements in the well-being of individuals and improved performance at work. A review (Hunter, 2016) using critical interpretative synthesis of five studies examining the impact of MBIs on nursing and midwifery practice indicated that mindfulness training enabled nurses and midwives to gain some control over their thoughts and stress levels, thereby creating a quiet mental space to give them perspective which led to improved care, including a more patient-centered focus, increased presence, and listening. Another literature review (Smith, 2014) outlined evidence to support that mindfulness training may be a promising intervention to decrease stress, anxiety, and burnout and improve focus, empathy, self-care, and mood. In addition, given the demanding nature and busy schedule of nurses’ work, a few studies have analyzed the effects of adapted MBSR, which was divided into three categories: modified traditional MBSR, abbreviated MBSR, and nontraditional mindfulness training (Luken & Sammons, 2016). For example, Mackenzie, Poulin, and Seidman-Carlson (2006) found significant improvements in burnout symptoms, relaxation, and life satisfaction among nurses and nurse aides after a brief 4-week mindfulness intervention. Similarly, Duchemin, Steinberg, Marks, Vanover, and Klatt (2015) found that a workplace-modified MBI for surgical intensive care unit workers (nurses represented 69% of the participants) was positively associated with reductions in indicators of stress and burnout. Furthermore, a study by Wylde, Mahrer, Meyer, and Gold (2017) delivered MBIs through smartphone applications to a group of novice nurses. This nontraditional mindfulness training showed promise in equipping nurses with important coping skills to manage stress.

Although an increasing number of studies have demonstrated that MBIs can reduce stress and improve health and work performance among nurse professionals, there is still a paucity of rigorous studies exploring the effectiveness of MBIs in Chinese nurses. The aim of this study was to evaluate the effects of a modified MBSR program on levels of stress, affect, and resilience among nurses in general hospitals in mainland China. In addition, the study attempted to determine the impact on nurses’ job satisfaction. We hypothesized that, compared with a wait-list comparison group, participants receiving mindfulness training would experience (a) decreased perceived stress, (b) decreased negative affect, (c) increased positive affect, (d) increased resilience, and (e) increased job satisfaction.

Method

This study utilized a randomized controlled design. Eligible participants were randomized 1:1 using a computer-generated random number table to the intervention group or the wait-list control group. The intervention group was given a modified 8-week MBSR program, and the control group was not given an intervention, but was offered the option to participate in the same program immediately after the study. Assessments were performed for all participants of both groups at baseline, immediately after the intervention, and again at the 3-month follow-up.

Setting and Sample

Two hospitals were selected from seven tertiary-level general hospitals by convenience sampling in Dongguan, South China. In mainland China, hospitals are divided into three levels based on their staffing, function, and technology. A third-level hospital is considered a general and sophisticated hospital, providing high-quality service and a high level of education and research across regions. Once the hospitals were selected, a notice was issued through the hospital mobile platform to invite nurses for voluntary participation in the study, and the subjects were screened after the Ethical Committee of Xiangya Nursing School granted approval (approval number 2015078).

The inclusion criteria included being employed as a full-time nurse. The exclusion criteria were as follows: (a) being a student nurse, (b) suffering from serious somatic disease, (c) taking mood-regulating drugs, (d) having suffered a major traumatic event in the past 6 months, and (e) having participated in mindfulness training previously. Ultimately, 110 nurses provided informed consent, enrolled in the training program, and were randomly divided into the intervention group (n = 55) and the control group (n = 55).

Intervention

The program was an 8-week mindfulness-based group intervention generally based on the principles and exercises of MBSR (Kabat-Zinn, 1990) and MBCT (Teasdale et al., 2000). Although MBCT is derived from MBSR, it incorporates some elements of cognitive-behavioral therapy and places greater emphasis on promoting enhanced awareness of one’s relationship with thoughts and feelings, which facilitates coping with a painful affect and challenging circumstances (Sipe & Eisendrath, 2012). A traditional MBSR program developed by Kabat-Zinn consists of eight weekly group sessions lasting for 2.5 hours, 45 minutes of home-based practice daily, and one half-day retreat (6 hours of formal mindfulness training) between the sixth and seventh weeks. To address the time constraints of nurses, we modified the length of the weekly group sessions and the daily home-based practice and did not include a half-day retreat. Therefore, the final manualized intervention consisted of eight 2-hour weekly group sessions and 20 minutes of formal mindfulness practice at home daily for 6 days a week for 8 weeks. The weekly group sessions were facilitated by an MBSR instructor and included guided practice, education, and dialogues around participants’ observations of their feelings, thoughts, and body sensations during practice. The specific content of program is shown in Table 1. In addition, we set up a network Chatgroup through WeChat (Tencent Inc., China) on mobile phones, sending session PowerPoint slides and audio recordings of guided mindfulness exercises, which helped the participants to share their practice experience or to ask the MBSR instructor questions.

Table 1.

Overview of the MBSR Program

Week	Theme	Session content	In-class exercises	Homework
Week 1	First experience of mindfulness	1. Introduce to each other;2. Introduce mindfulness and mindfulness training;3. Introduce this program;4. Practice and discussion;5. Assignment of homework	Mindful eating (raisin exercises); mindful breathing (awareness of breath)	1. Formal training: Mindful breathing (10 minutes) at least twice a day, 6 days a week;2. Informal training: Mindful eating at least once a week
Week 2	Concentration: The beginning of mindfulness	1. Discuss the stress response and the mechanism of MBSR;2. Introduce recent research on mindfulness;3. Practice and discussion; 4. Assignment of homework	Mindful breathing; mindful walking	1. Formal training: Mindful breathing (10 minutes) at least twice a day, 6 days a week;2. Informal training: Mindful walking at least once a week
Week 3	Pay attention to your body	Introduce and teach the body scan technique	Mindful breathing; mindful walking; body scan	1. Formal training: Body scan (20 minutes) at least once a day, 6 days a week;2. Informal training: Self-selection
Week 4	Awareness in sports	1. Introduce the origin and characteristics of mindfulness yoga;2. Practice and discussion;3. Assignment of homework	Body scan; mindfulness standing yoga	1. Formal training: Body scan (20 minutes) at least once a day, 3 days a week; standing yoga (20 minutes) at least once a day, 3 days a week;2. Informal training: Self-selection
Week 5	Thought is not reality	1. Discuss the importance and truth of thought;2. Practice and discussion;3. Assignment of homework	Mindfulness meditation (mindful sitting with choiceless awareness); standing yoga	1. Formal training: Mindfulness meditation (20 minutes) at least once a day, 3 days a week; standing yoga (20 minutes) at least once a day, 3 days a week;2. Informal training: Self-selection
Week 6	Emotional management by mindfulness	1. Listen to your emotions;2. Understand the relationship between the body and emotions;3. Introduce RAIN^a;4. Practice and discussion;5. Assignment of homework	Mindfulness meditation (mindful sitting with choiceless awareness); reclining yoga	1. Formal training: Mindfulness meditation (20 minutes) at least once a day, 3 days a week; reclining yoga (20 minutes) at least once a day, 3 days a week;2. Informal training: Self-selection
Week 7	Love yourself, love others	1. Discuss interpersonal communication skills;2. Games (seeing the good in people);3. Practice and discussion;4. Assignment of homework	Transposition exercise; mindful communication; love-kindness mediation	1. Formal training: Participant’s choice of practice (20 minutes) and love-kindness mediation at least once a day, 6 days a week;2. Informal training: Self-selection
Week 8	New mindful life	1. Retrospective practice;2. Introduce and teach 3-minute breathing space;3. Encouragement to continue practicing mindfulness in daily life	Mindfulness meditation; mindfulness yoga; body scan; 3-minute breathing space	Participant’s choice of practice

Note. MBSR = modified mindfulness based stress reduction.

RAIN: R (recognize), A (allow), I (investigate), N (nonidentify).

Procedures

The modified program used in this study was conducted by a researcher who has been practicing mindfulness for 2 years and attended several MBSR courses, retreats, and other training activities related to mindfulness and meditation. Pretest, posttest, and tracking measurements were performed by research assistants who were trained in program management procedures and methods and in the measurements. Prior to the intervention, strong support was received from the nursing department of each hospital, and the session calendar was released to nurses in advance to facilitate the nurses’ scheduling.

The group intervention occurred for 8 weeks from April 25, 2017 to June 16, 2017. As the intervention group included 55 nurses, it was divided into two groups. Group 1 included 30 nurses who attended sessions at 15:00 to 17:00 every Tuesday afternoon, and Group 2 included 25 nurses who attended sessions at 15:00 to 17:00 every Friday afternoon. The participants in both Group 1 and Group 2 were guided by the same instructor, and the content and length of the sessions were identical. During the 8-week sessions, research assistants recorded the attendance of the members of the intervention group. If a participant was absent more than two times, the participant was classified as a dropout from the intervention. In addition, through the WeChat group, we urged the nurses to attend their sessions on time, to complete home-based practice, and to fill out the questionnaires, but home-based practice was not mandatory and was not assessed. The control group also had a WeChat group for connection and to send questionnaires. Upon completion of the program, the participants were incentivized with continuing education (CE) credits if they attended at least 50% of the group sessions.

Data Collection

Social demographic data were collected at baseline, including age, gender, education, professional title, marital status, duration of employment, and work during the night shift or not. In addition, a battery of questionnaires was used for the evaluations at baseline (T₀), immediately after the intervention (T₁), and at the 3-month follow-up (T₂). Researchers sent a link to the online questionnaires through the WeChat group. Before completing the questionnaires, the participants were informed of the purpose of the study, the scoring methods, and matters needing attention. The participants completed and submitted the questionnaires on the day they were issued, and the researchers checked the quality of the submitted questionnaires, verifying them immediately if there was any doubt.

Effectiveness of the intervention was measured via data collection at the three specific time periods, which pertained to the worker’s perceived stress, positive and negative affect, resilience, and job satisfaction. The following is a description of the specific scales used.

Perceived Stress Scale (PSS)

The PSS (Cohen, Kamarck, & Mermelstein, 1983) is a 14-item self-report tool that provides a global measure of perceived stress. This study adopts the Chinese version revised by Prof. Yang Tingzhong, which has good reliability and validity (Yang & Huang, 2003). The scale consists of 14 items reflecting stress and loss of control, and responses range on a 5-point scale from never to very often. A higher score indicates greater stress. The internal consistency (Cronbach’s alpha) of the PSS was .802 in this study.

Positive and Negative Affect Schedule (PANAS)

Watson, Clark, and Tellegen (1988) developed the PANAS, and Huang, Yang, & Li (2003) established a Chinese version with satisfactory validity and reliability. The PANAS is a self-report instrument that measures positive and negative affect. The instrument consists of a list of 20 adjectives, 10 per subscale, to be rated on a 5-point scale within the time constraints established by the researcher. In this study, the Cronbach’s alphas were .861 for the positive affect subscale and .834 for the negative affect subscale.

Connor–Davidson Resilience Scale (CD-RISC)

The CD-RISC (Connor & Davidson, 2003) was developed in the United States to measure individuals’ ability to cope effectively when faced with adversity. The present study adopted the Chinese version revised by Yu and Zhang (2007), which has good reliability and validity. The revised scale includes 25 items and three dimensions (tenacity, strength, and optimism). Each item is rated on a Likert-type scale ranging from 0 (not at all) to 4 (almost always). The range of possible total scores is 0 to 100, with higher scores indicating higher levels of resilience. In this study, the Cronbach’s alpha of the CD-RISC was .895.

The McCloskey/Mueller Satisfaction Scale (MMSS)

Mueller and McCloskey (1990) developed the MMSS, and He, Zhang, and Bai (2008) established a Chinese version with satisfactory validity and reliability. The MMSS is a 31-item scale that measures hospital nurses’ job satisfaction. The scale measures eight types of satisfaction: extrinsic rewards, scheduling, family and work balance, coworkers, interactions, professional opportunities, praise and recognition, and control and responsibility. Responses were coded on a Likert-type scale ranging from 1 (very dissatisfied) to 5 (very satisfied). The possible range of total scores is 31 to 155, with higher scores indicating greater job satisfaction. In this study, the Cronbach’s alpha of the MMSS was .934.

Data Analysis

A data analysis was performed using SPSS 22.0 (IBM Corp., Armonk, NY, USA). All statistical tests were two-tailed, and the significance level was set at p < .05. The demographic data of the two groups were compared by Student’s t test or the chi-square test. The effects of the intervention as indicated by changes in the outcome variables (perceived stress, positive affect, negative affect, resilience, and job satisfaction) were analyzed using 2 (groups) × 3 (times) repeated-measures ANOVA. When the data did not satisfy the hypothesis of spherical symmetry, the F values from the ANOVA were corrected by the Greenhouse–Geisser method. If no significant group effect but a significant effect of the Group × Time interaction was observed, then a simple effects analysis was performed. First, an independent-sample t test was used to compare the two groups within each time point. Second, one-way ANOVA was used to compare the three time points within each group, and the least significant difference (LSD) method was used for multiple comparisons.

Results

In the intervention group, 11 participants missed the weekly sessions more than twice. In the control group, six participants did not complete the questionnaire, and three participants submitted invalid questionnaires. Therefore, the effective sample size was 90, including 44 in the intervention group and 46 in the control group. No significant differences were observed between the two groups for any of the demographic characteristics (see Table 2).

Table 2.

Demographic Characteristics of Study Participants (N = 90)

Variables	Category	Intervention group (n = 44)	Control group (n = 46)	Statistics	p
Age in years (M ± SD)		32.86 ± 7.49	30.20 ± 6.09	1.86^a	.07
Sex, n (%)	Male	1 (2.3)	5 (10.9)	1.47^b	.23
Sex, n (%)	Female	43 (97.7)	41 (89.1)
Duration of employment (M ± SD)		11.77 ± 7.53	9.26 ± 5.60	1.80^a	.08
Professional title, n (%)	Assistant nurse	1 (2.3)	1 (2.2)		.17^c
	Nurse	9 (20.5)	18 (39.1)
	Senior nurse	13 (29.5)	16 (34.8)
	Supervisor nurse	17 (38.6)	10 (21.7)
	Associate chief nurse or higher	4 (9.1)	1 (2.2)
Education, n (%)	Technical secondary school	1 (2.3)	3 (6.5)		.44^c
	Junior college	15 (34.1)	19 (41.3)
	Bachelor’s degree	27 (61.4)	24 (52.2)
	Master’s degree or higher	1 (2.3)	0 (0)
Marital status, n (%)	Single	16 (36.4)	10 (21.7)		.16^c
	Married	28 (63.6)	35 (76.1)
	Divorced	0 (0)	1 (2.2)
Night shift, n (%)	Yes	30 (68.2)	37 (80.4)	1.78^b	.18
Night shift, n (%)	No	14 (31.8)	9 (19.6)	1.78^b	.18

t-value.

χ² value.

Probability according to Fisher’s exact test.

Repeated-measures ANOVA showed that the group effect was not significant (p > .05), but statistically significant effects of time and the Group × Time interaction on perceived stress, positive affect, and negative affect were observed between the two groups at baseline (T₀), immediately after the intervention (T₁), and at the 3-month follow-up (T₂; p < .05; Table 3). No significant effect of group or time on resilience was identified between the two groups (p > .05), but the effect of the Group × Time interaction on resilience was statistically significant (p < .05). No significant effect of group or time or the Group × Time interaction on job satisfaction was identified between the two groups (p > .05), but the trends of the data were in the hypothesized direction.

Table 3.

Comparisons of Outcomes Between Nurses That Received the MBSR Intervention and the Control Group Over Three Time Periods (n = 90)

Outcomes	Group	Baseline (M ± SD)	Postintervention (M ± SD)	3-month follow-up (M ± SD)	Time (F)	Group (F)	Time × Group interaction (F)
Perceived stress	Intervention group	40.91 ± 6.44	37.39 ± 5.97	36.68 ± 6.79	11.631***	2.709	13.488***
Perceived stress	Control group	39. 91 ± 4.90	40. 76 ± 5.01	39.67 ± 5.24	11.631***	2.709	13.488***
t		0.82	−2.91**	−2.33*
Positive emotion/affect	Intervention group	28.52 ± 6.50	32.02 ± 6.45	33.21 ± 7.38	9.129***	2.024	6.620**
Positive emotion/affect	Control group	28.74 ±5.05	29.00 ± 5.51	29.00 ± 5.62	9.129***	2.024	6.620**
t		−0.18	2.39*	1.59*
Negative emotion/affect	Intervention group	23.82 ± 5.45	20.80 ± 4.72	20.84 ± 5.09	3.125*	0.662	13.805***
Negative emotion/affect	Control group	21.78 ± 5.04	23.61 ± 5.17	24.37 ± 5.62	3.125*	0.662	13.805***
t		1.84	−2.69**	−1.35*
Resilience	Intervention group	54.43 ± 11.46	57.98 ± 11.58	59.70 ± 11.87	1.954	1.252	4.587*
Resilience	Control group	55.17 ± 11.85	55.11 ± 12.80	53.85 ± 16.21	1.954	1.252	4.587*
t		−0.30	1.11	1.95*
Job satisfaction	Intervention group	98.23 ± 11.87	102.27 ± 14.44	102.14 ± 15.55	2.716	1.957	2.234
Job satisfaction	Control group	96.17 ± 16.21	96.17 ± 18.05	96.59 ± 19.25	2.716	1.957	2.234
t		0.59	1.87	1.50

p < .05. **p < .01. ***p < .001.

MBSR = Modified Mindfulness-Based Stress Reduction.

The results of the simple effects analysis (independent-samples t tests and one-way ANOVA) were as follows: First, when the time points were fixed, no significant differences in perceived stress, positive affect, negative affect, or resilience were noted between the two groups at baseline (p > .05), but significant differences were found in perceived stress, positive affect, and negative affect between the two groups immediately after the intervention and at the 3-month follow-up (p < .05), and significant differences in resilience were found between the two groups at the 3-month follow-up (p < .05; see Table 3). When the groups were fixed, no significant differences were found in perceived stress, positive affect, negative affect, or resilience across different time points in the control group (p > .05; Table 4); when different time points were compared in the intervention group, the levels of perceived stress, positive affect, and negative affect were significantly different between T₀ and both T₁ and T₂ (p < .05), and the levels of resilience were significantly different between T₀ and T₂ (p < .05).

Table 4.

The Examination of the Effects of MBSR Within Groups: Intervention and Control (N = 90)

Outcomes	Group	Baseline (T₀)(M ± SD)	Immediately after intervention (T₁)(M ± SD)	3-month follow-up (T₂)(M ± SD)
Perceived stress	Intervention group	40.91 ± 6.44	37.39 ± 5.97**	36.68 ± 6.79**
Perceived stress	Control group	39.91 ± 4.90	40.76 ± 5.01	39.67 ± 5.24
Positive emotion/affect	Intervention group	28.52 ± 6.50	32.02 ± 6.45*	33.21 ± 7.38*
Positive emotion/affect	Control group	28.74 ± 5.05	29.00 ± 5.51	29.00 ± 5.62
Negative emotion/affect	Intervention group	23.82 ± 5.45	20.80 ± 4.72**	20.84 ± 5.09**
Negative emotion/affect	Control group	21.78 ± 5.04	23.61 ± 5.17	24.37 ± 5.62
Resilience	Intervention group	54.43 ± 11.46	57.98 ± 11.58	59.70 ± 11.87*
Resilience	Control group	55.17 ± 11.85	55.11 ± 12.80	53.85 ± 16.21
Job satisfaction	Intervention group	98.23 ± 11.87	102.27 ± 14.44	102.14 ± 15.55
Job satisfaction	Control group	96.17 ± 16.21	96.17 ± 18.05	96.59 ± 19.25

p < .05. **p < .01, compared with T₀.

MBSR = Modified Mindfulness-Based Stress Reduction.

Discussion

To the best of our knowledge, this is the first study to investigate the effectiveness of a modified MBSR program with respect to the stress, affect, resilience, and job satisfaction of nurses in general hospitals in mainland China. There was a significant improvement in perceived stress, negative affect, and positive affect immediately after the intervention and at the 3-month follow-up. The results were consistent with those of similar previous studies. For example, studies with mixed samples of health care staff reported improvements in stress reduction (Fortney, Luchterhand, Zakletskaia, Zgierska, & Rakel, 2013; Goldhagen, Kingsolver, Stinnett, & Rosdahl, 2015). Studies with nurses have also found that participating in an MBI leads to decreases in perceived stress (Bazarko, Cate, Azocar, & Kreitzer, 2013; Dos Santos et al., 2016; Spadaro & Hunker, 2016) and negative affect (Craigie et al., 2016) and increases in positive affect (Demarzo et al., 2017). Mindfulness emphasizes continuous, nonjudgmental attention to the internal and external stimuli present at the moment, which helps nurses enhance their experience, cultivate self-compassion, and avoid becoming trapped in a negative affect or preoccupied by thoughts caused by stress (Hunter, 2016; Kabat-Zinn, 1990). When negative affect or thoughts appear, mindfulness enables one to observe and describe them with an accepting attitude, allowing them to fade away gradually. Thus, mindfulness helps nurses to cope with stress in healthier and adaptive ways rather than through habitual and often maladaptive reactions. Several studies (Davidson & McEwen, 2012; Flook, Goldberg, Pinger, Bonus, & Davidson, 2013; Lutz, Slagter, Dunne, & Davidson, 2008) have also suggested that mindfulness has a positive effect on brain areas associated with attention regulation and emotional adaptation and that this is the physiological and neuroscientific basis of stress reduction associated with MBIs.

Changes in resilience did not offer significant results immediately after the intervention, but the changes were statistically significant at the 3-month follow-up. The results were similar to those of Pidgeon, Ford, and Klaassen (2014), who used an RCT to evaluate the effects of a retreat-based Mindfulness with Metta Training Program on human service professionals’ mindfulness, self-compassion, and resilience. The study found no significant difference in resilience between the intervention and control groups immediately after the intervention, but significant improvement was observed at the 4-month follow-up. Resilience, defined as competency to cope and adapt in the face of adversity, is considered a significant protective factor against the negative effects of job stress (Hart, Brannan, & De Chesnay, 2014). An individual’s power of resilience is not fixed but is very complicated and related to a large number of influences, including demographic features, personal traits, and environmental factors (Guo et al., 2017). MBIs are based primarily on strengthening intrapersonal factors to enhance resilience (Grafton, Gillespie, & Henderson, 2010), which is a gradual and complex process that needs to be founded on changes in related factors such as mindfulness (Pidgeon et al., 2014), self-compassion (Pidgeon et al., 2014), and positive affect (Lord, Rumburg, & Jaser, 2015). Therefore, the development of resilience requires time and it is difficult to observe positive changes immediately after an intervention, which has also been confirmed by two other studies (Craigie et al., 2016; Demarzo et al., 2017).

Regarding job satisfaction, we found no significant improvement either immediately after the intervention or at the 3-month follow-up, but the trends of the data were in the hypothesized direction. This result is not surprising to us because job satisfaction is a very complex and multifactorial construct (Silva, Velasque, & Tonini, 2017) that a modified MBSR program might not sufficiently improve in a short period of time. A mixed-methods systematic review (Guillaumie et al., 2017) indicated that only a few studies have explored the effect of mindfulness on organizational changes (e.g., patient satisfaction, job satisfaction, turnover, and absenteeism) at nurses’ work, and the meta-analysis revealed no significant impact on job satisfaction, which is similar to our findings. Future research should focus on organization-related variables and further explore the long-term impacts of MBIs on nurses’ job satisfaction.

Overall, these results suggest that the modified MBSR program may help nurses manage stress and improve their affect, resilience, and job satisfaction in Chinese hospital settings.

Strengths and Limitations

This study has several strengths. First, there is still a paucity of studies exploring the use of MBIs for Chinese nurses and the associated effects on stress, affect, resilience, and job satisfaction, and this study therefore addresses a major scarcity in the field. Second, this study assessed the effectiveness of a modified MBSR that may be more adaptive to busy professionals working in stressful conditions such as nurses. The program combined elements of MBSR and MBCT, not only teaching and practicing basic skills such as mindful breathing, yoga, meditation, body scan, and 3-minute breathing space but also discussing self-care and mindful communication as well as exploring the relationship between an individual and his or her own thoughts and affect, which helps nurses cope more effectively with stress and negative affect in their work. Third, although the modified version of the program was 8 weeks long, paralleling the traditional MBSR, the weekly group sessions and daily home-based practice were shorter and a half-day retreat was not included, allowing the intervention to more easily fit into the schedules of hospital nurses. Finally, a WeChat group on mobile phones was established to facilitate communication between instructors and trainees after group sessions, which is a very flexible, convenient, and time-efficient strategy to supplement the main interventions.

The study is not without limitations. The hospitals in this study are third-level general hospitals in the city and were selected by convenience sampling, which affected the representativeness of the sample to a certain extent. In addition, the sample size was relatively small (n = 90), warranting a larger randomized control trial to confirm the results. In addition, the modified program was evaluated in this study primarily using quantitative methods by self-reported questionnaires. Although we collected some qualitative data, including the participants’ WeChat sharing records and reports of learning experiences at the end of the intervention, no qualitative interviews and no in-depth analyses of the data were carried out. Because qualitative research is the best way to unpack the mechanisms of MBI benefit on nurses’ work performance, enabling an open and inductive inquiry (Hunter, 2016), future research should combine quantitative and qualitative methods to explore the effect of MBIs in a more comprehensive and deeper way. Moreover, although the training program has been simplified from traditional MBSR, 20% of the intervention group (n = 11) did not complete the weekly sessions, and most of them did not finish the homework as required owing to a lack of time (according to reports of learning experiences); this noncompliance reduces the effectiveness of the intervention to a certain extent. Some attempts have been made to increase the feasibility and accessibility of MBIs while maintaining their efficacy, adapting them to specific target populations and contexts. However, many questions remain unanswered, such as the minimum number and length of sessions and daily practice required to maintain effectiveness and the types and order of the therapeutic components and mindfulness exercises to be included (Demarzo et al., 2017). Therefore, future work should focus on identifying the above factors to develop the shortest and most effective program available and to improve the accessibility of such programs to a larger number of health care professionals with high levels of job stress.

Implications for Practice

In this study, an RCT combining within-group and between-group comparisons was used to evaluate the effects of the modified MBSR program. The results showed that this program was an effective approach to improving the levels of stress, affect, and resilience among nurses in Chinese hospital settings. In addition, the program has the potential to improve nurses’ job satisfaction. Although further research is necessary, the results have some implications for nursing practice and education. First, as an effective strategy to reduce stress and improve health, the modified MBSR program or other MBIs can be integrated into short-term or long-term health promotion plans for nurses. Second, nursing educators should recognize the importance of mindfulness and incorporate it into the nursing curriculum, which can help improve resilience among nursing students when they enter the clinical environment.

Applying Research to Practice

This randomized clinical trial provides evidence that a modified MBSR program is a promising approach for nurses to improve stress, affect, resilience, and job satisfaction. Although further research is necessary, the results have some implications for nursing practice and education. First, as an effective strategy to reduce stress and improve health, the modified MBSR program or other MBIs can be integrated into short-term or long-term health promotion plans for nurses. Second, nursing educators should recognize the importance of mindfulness and incorporate it into the nursing curriculum, which can help improve resilience among nursing students when they enter the clinical environment.

Footnotes

Acknowledgements

We thank the nurse executives and staff nurses of the study hospitals for their participation in our study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from the General Program of Science and Technology Plan for Health Care in Dongguan City of Guangdong Province (2016105101286). The funder played no role in the study design, data collection, data analysis, manuscript preparation, or decision to publish the report.

Author Biographies

Lin Lin is a PhD student in Xiangya Nursing School of Central South University and a Lecturer in the Nursing School of Guangdong Medical University.

Guoping He is a professor and doctoral supervisor in the Xiangya Nursing School of Central South University.

Jin Yan is a clinical nursing specialist and works as Director of Nursing Department in The Third Xiangya Hospital of Central South University.

Can Gu is an associate professor in the Xiangya Nursing School of Central South University, Her research interests in cancer care and long-term care.

Jianfei Xie is a clinical nursing specialist and works as ICU head nurse in The Third Xiangya Hospital of Central South University.

References

Aiken

L. H.

Clarke

S. P.

Sloane

D. M.

Sochalski

Silber

J. H.

(2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, 1987-1993. doi:10.1001/jama.288.16.1987

Aiken

L. H.

Sloane

D. M.

Clarke

Poghosyan

Cho

You

. . . Aungsuroch

(2011). Importance of work environments on hospital outcomes in nine countries. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care, 23, 357-364. doi:10.1093/intqhc/mzr022

Bazarko

Cate

R. A.

Azocar

Kreitzer

M. J.

(2013). The impact of an innovative mindfulness-based stress reduction program on the health and well-being of nurses employed in a corporate setting. Journal of Workplace Behavioral Health, 28, 107-133. doi:10.1080/15555240.2013.779518

Botha

Gwin

Purpora

(2015). The effectiveness of mindfulness based programs in reducing stress experienced by nurses in adult hospital settings: A systematic review of quantitative evidence protocol. JBI Database of Systematic Reviews and Implementation Reports, 13(10), 21-29. doi:10.11124/jbisrir-2015-2380

Chung

K. F.

Tang

M. K.

(2006). Subjective sleep disturbance and its correlates in middle-aged Hong Kong Chinese women. Maturitas, 53, 396-404. doi:10.1016/j.maturitas.2005.07.001

Cohen

Kamarck

Mermelstein

(1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385-396. doi:10.2307/2136404

Connor

K. M.

Davidson

J. R. T.

(2003). Development of a new resilience scale: The Connor–Davidson Resilience Scale (CD-RISC). Depression and Anxiety, 18, 76-82. doi:10.1002/da.10113

Craigie

Slatyer

Hegney

Osseiran-Moisson

Gentry

Davis

. . . Rees

(2016). A pilot evaluation of a mindful self-care and resiliency (MSCR) intervention for nurses. Mindfulness, 7, 764-774. doi:10.1007/s12671-016-0516-x

Davidson

R. J.

McEwen

B. S.

(2012). Social influences on neuroplasticity: Stress and interventions to promote well-being. Nature Neuroscience, 15, 689-695. doi:10.1038/nn.3093

10.

Demarzo

Montero-Marin

Puebla-Guedea

Navarro-Gil

Herrera-Mercadal

Moreno-González

. . . Garcia-Campayo

(2017). Efficacy of 8- and 4-session mindfulness-based interventions in a non-clinical population: A controlled study. Frontiers in Psychology, 8, 1343. doi:10.3389/fpsyg.2017.01343

11.

Dong

Zhang

Sun

Sang

(2017). Sleep disturbances among Chinese clinical nurses in general hospitals and its influencing factors. BMC Psychiatry, 17(1), 241. doi:10.1186/s12888-017-1402-3

12.

Dos Santos

T. M.

Kozasa

E. H.

Carmagnani

I. S.

Tanaka

L. H.

Lacerda

S. S.

Nogueira-Martins

L. A

. (2016). Positive effects of a stress reduction program based on mindfulness meditation in Brazilian nursing professionals: Qualitative and quantitative evaluation. Explore, 12, 90-99. doi:10.1016/j.explore.2015.12.005

13.

Duchemin

A. M.

Steinberg

B. A.

Marks

D. R.

Vanover

Klatt

(2015). A small randomized pilot study of a workplace mindfulness-based intervention for surgical intensive care unit personnel: Effects on salivary α-amylase levels. Journal of Occupational and Environmental Medicine, 57, 393-399. doi:10.1097/JOM.0000000000000371

14.

Dundas

Thorsheim

Hjeltnes

Binder

P. E.

(2016). Mindfulness based stress reduction for academic evaluation anxiety: A naturalistic longitudinal study. Journal of College Student Psychotherapy, 30, 114-131. doi:10.1080/87568225.2016.1140988

15.

Fjorback

L. O.

Arendt

Ørnbøl

Fink

Walach

(2011). Mindfulness-based stress reduction and mindfulness-based cognitive therapy: A systematic review of randomized controlled trials. Acta Psychiatrica Scandinavica, 124, 102-119. doi:10.1111/j.1600-0447.2011.01704.x

16.

Flook

Goldberg

S. B.

Pinger

Bonus

Davidson

R. J.

(2013). Mindfulness for teachers: A pilot study to assess effects on stress, burnout and teaching efficacy. Mind, Brain, and Education: The Official Journal of the International Mind, Brain, and Education Society, 7, 182-195. doi:10.1111/mbe.12026

17.

Fortney

Luchterhand

Zakletskaia

Zgierska

Rakel

(2013). Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: A pilot study. Annals of Family Medicine, 11, 412-420. doi:10.1370/afm.1511

18.

Gao

Y. Q.

Pan

B. C.

Sun

Wang

J. N.

Wang

(2012a). Anxiety symptoms among Chinese nurses and the associated factors: A cross sectional study. BMC Psychiatry, 12(1), 141. doi:10.1186/1471-244X-12-141

19.

Gao

Y. Q.

Pan

B. C.

Sun

Wang

J. N.

Wang

(2012b). Depressive symptoms among Chinese nurses: Prevalence and the associated factors. Journal of Advanced Nursing, 68, 1166-1175. doi:10.1111/j.1365-2648.2011.05832.x

20.

Goldhagen

B. E.

Kingsolver

Stinnett

S. S.

Rosdahl

J. A.

(2015). Stress and burnout in residents: Impact of mindfulness-based resilience training. Advances in Medical Education and Practice, 6, 525-532. doi:10.2147/AMEP.S88580

21.

Grafton

Gillespie

Henderson

(2010). Resilience: The power within. Oncology Nursing Forum, 37, 698-705. doi:10.1188/10.ONF.698-705

22.

(2011). The human resource crisis in the field of Chinese medicine. Journal of China National School of Administration, 6, 17-22. doi:10.3969/j.issn.1008-9314.2011.06.004

23.

G. M.

Yin

H. F.

(2015). Epidemiologic study on sleep quality of community population aged 18 years or over in Tianjin. Chinese Mental Health Journal, 29, 114-131 doi:10.3969/j.issn.1000-6729.2015.03.008.

24.

Guillaumie

Boiral

Champagne

(2017). A mixed-methods systematic review of the effects of mindfulness on nurses. Journal of Advanced Nursing, 73, 1017-1034. doi:10.1111/jan.13176

25.

Guo

Deng

Huang

. . . Lu

(2005). Prevalence and correlates of sleep disturbance and depressive symptoms among Chinese adolescents: A cross-sectional survey study. BMJ Open, 4(7), e005517. doi:10.1136/bmjopen-2014-005517.

26.

Guo

Y. F.

Cross

Plummer

Lam

Luo

Y. H.

Zhang

J. P.

(2017). Exploring resilience in Chinese nurses: A cross-sectional study. Journal of Nursing Management, 25, 223-230. doi:10.1111/jonm.12457

27.

Hart

P. L.

Brannan

J. D.

De Chesnay

(2014). Resilience in nurses: An integrative review. Journal of Nursing Management, 22, 720-734. doi:10.1111/j.1365-2834.2012.01485.x

28.

Hayes

S. C.

Follette

V. M.

Linehan

(2004). Mindfulness and acceptance: Expanding the cognitive-behavioral tradition. New York, NY: Guilford Press.

29.

Zhang

Bai

(2008). Introduction of MMSS scale. Chinese Nursing Research, 22, 1063. doi:10.3969/j.issn.1009-6493.2008.12.045

30.

Howlett

Doody

Murray

LeBlanc-Duchin

Fraser

Atkinson

P. R.

(2015). Burnout in emergency department healthcare professionals is associated with coping style: A cross-sectional survey. Emergency Medicine Journal, 32, 722-727. doi:10.1136/emermed-2014-203750

31.

Huang

Yang

(2003). Applicability of the positive and negative affect scale in Chinese. Chinese Mental Health Journal, 17, 54-56. doi:10.3321/j.issn:1000-6729.2003.01.018

32.

Hunter

(2016). Making time and space: The impact of mindfulness training on nursing and midwifery practice. A critical interpretative synthesis. Journal of Clinical Nursing, 25, 918-929. doi:10.1111/jocn.13164

33.

Kabat-Zinn

(1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33-47. doi:10.1016/0163-8343(82)90026-3

34.

Kabat-Zinn

(1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Dell.

35.

Kabat-Zinn

(2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144-156. doi:10.1093/clipsy.bpg016

36.

Kabat-Zinn

Lipworth

Burney

(1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8, 163-190. doi:10.1007/BF00845519

37.

Leiter

M. P.

Maslach

(2009). Nurse turnover: The mediating role of burnout. Journal of Nursing Management, 17, 331-339. doi:10.1111/j.1365-2834.2009.01004.x

38.

Lord

J. H.

Rumburg

T. M.

Jaser

S. S.

(2015). Staying positive: Positive affect as a predictor of resilience in adolescents with type 1 diabetes. Journal of Pediatric Psychology, 40, 968-977. doi:10.1093/jpepsy/jsv042

39.

Luken

Sammons

(2016). Systematic review of mindfulness practice for reducing job burnout. American Journal of Occupational Therapy, 70, 7002250020p1-7002250020p10. doi:10.5014/ajot.2016.016956

40.

Lutz

Slagter

H. A.

Dunne

J. D.

Davidson

R. J.

(2008). Attention regulation and monitoring in meditation. Trends in Cognitive Sciences, 12, 163-169. doi:10.1016/j.tics.2008.01.005

41.

Mackenzie

C. S.

Poulin

P. A.

Seidman-Carlson

(2006). A brief mindfulness-based stress reduction intervention for nurses and nurse aides. Applied Nursing Research, 19, 105-109. doi:10.1016/j.apnr.2005.08.002

42.

McHugh

M. D.

Kutney-Lee

Cimiotti

J. P.

Sloane

D. M.

Aiken

L. H.

(2011). Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30, 202-210. doi:10.1377/hlthaff.2010.0100

43.

Mueller

C. W.

McCloskey

J. C.

(1990). Nurses’ job satisfaction: A proposed measure. Nursing Research, 39, 113-117. doi:10.1097/00006199-199003000-00014

44.

National Health and Family Planning Commission of the People’s Republic of China. (2016). Statistical bulletin development of health and family planning in China [EB/OL]. Retrieved from http://www.nhfpc.gov.cn/guihuaxxs/s10748/201708/d82fa7141696407abb4ef764f3edf095.shtml

45.

Pidgeon

A. M.

Ford

Klaassen

(2014). Evaluating the effectiveness of enhancing resilience in human service professionals using a retreat-based mindfulness with Metta training program: A randomised control trial. Psychology, Health & Medicine, 19, 355-364. doi:10.1080/13548506.2013.806815

46.

Sillero

Zabalegui

(2018). Organizational factors and burnout of perioperative nurses. Clinical Practice and Epidemiology in Mental Health, 14, 132-142. doi:10.2174/1745017901814010132

47.

Silva

V. R. D.

Velasque

L. S.

Tonini

(2017). Job satisfaction in an oncology nursing team. Revista Brasileira de Enfermagem, 70, 988-995. doi:10.1590/0034-7167-2016-0422

48.

Sipe

W. E. B.

Eisendrath

S. J.

(2012). Mindfulness-based cognitive therapy: Theory and practice. Canadian Journal of Psychiatry/Revue Canadienne de Psychiatrie, 57, 63-69. doi:10.1177/070674371205700202

49.

Smith

S. A.

(2014). Mindfulness-based stress reduction: An intervention to enhance the effectiveness of nurses’ coping with work-related stress. International Journal of Nursing Knowledge, 25, 119-130. doi:10.1111/2047-3095.12025

50.

Soldatos

C. R.

Allaert

F. A.

Ohta

Dikeos

D. G.

(2005). How do individuals sleep around the world? Results from a single-day survey in ten countries. Sleep Medicine, 6, 5-13. doi:10.1016/j.sleep.2004.10.006

51.

Spadaro

K. C.

Hunker

D. F.

(2016). Exploring the effects of an online asynchronous mindfulness meditation intervention with nursing students on stress, mood, and cognition: A descriptive study. Nurse Education Today, 39, 163-169. doi:10.1016/j.nedt.2016.02.006

52.

Teasdale

J. D.

Segal

Z. V.

Williams

J. M. G.

Ridgeway

V. A.

Soulsby

J. M.

Lau

M. A.

(2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615-623. doi:10.1037/0022-006X.68.4.615

53.

Watson

Clark

L. A.

Tellegen

(1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063-1070. doi:10.1037/0022-3514.54.6.1063

54.

Wong

W. S.

Fielding

(2011). Prevalence of insomnia among Chinese adults in Hong Kong: A population-based study. Journal of Sleep Research, 20(1, Pt. 1), 117-126. doi:10.1111/j.1365-2869.2010.00822.x

55.

S. Y.

H. Y.

Tian

Zhu

Wang

X. R.

(2011). Health-related quality of life and its main related factors among nurses in China. Industrial Health, 49, 158-165. doi:10.2486/indhealth.MS1160

56.

Wylde

C. M.

Mahrer

N. E.

Meyer

R. M. L.

Gold

J. I.

(2017). Mindfulness for novice pediatric nurses: Smartphone application versus traditional intervention. Journal of Pediatric Nursing, 36, 205-212. doi:10.1016/j.pedn.2017.06.008

57.

Xie

Wang

Chen

(2011). Nurse burnout and its association with occupational stress in a cross-sectional study in Shanghai. Journal of Advanced Nursing, 67, 1537-1546. doi:10.1111/j.1365-2648.2010.05576.x

58.

Yang

T. Z.

Huang

H. T.

(2003). An epidemiological study on stress among urban residents in social transition period. Chinese Journal of Epidemiology, 24(9), 760-764. doi:10.3760/j.issn: 0254-6450.2003.09.004

59.

Zhang

(2007). Factor analysis and psychometric evaluation of the Connor–Davidson Resilience Scale (CD-RISC) with Chinese people. Social Behavior and Personality: An International Journal, 35, 19-30. doi:10.2224/sbp.2007.35.1.19

60.

Yun

Jie

Anli

(2010). Nursing shortage in China: State, causes, and strategy. Nursing Outlook, 58, 122-128. doi:10.1016/j.outlook.2009.12.002

61.

Zhang

L. F.

You

L. M.

Liu

Zheng

Fang

J. B.

M. M.

. . . Bu

X. Q.

(2014). The association of Chinese hospital work environment with nurse burnout, job satisfaction, and intention to leave. Nursing Outlook, 62, 128-137. doi:10.1016/j.outlook.2013.10.010

The Effects of a Modified Mindfulness-Based Stress Reduction Program for Nurses: A Randomized Controlled Trial

Abstract

Keywords

Mindfulness-Based Interventions (MBIs)

Method

Setting and Sample

Intervention

Procedures

Data Collection

Perceived Stress Scale (PSS)

Positive and Negative Affect Schedule (PANAS)

Connor–Davidson Resilience Scale (CD-RISC)

The McCloskey/Mueller Satisfaction Scale (MMSS)

Data Analysis

Results

Discussion

Strengths and Limitations

Implications for Practice

Applying Research to Practice

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

Author Biographies

References