Holistic Nursing in Practice: Mindfulness-Based Yoga as an Intervention to Manage Stress and Burnout

Theory of Environmental Adaptation to Include the Holistic Nurse

Considering the five philosophical principles that comprise the framework in holistic nursing, this study focused on self-reflection and self-care.

From a holistic perspective, nurses are considered part of the physical environment for the healing of their patients (Mariano, 2013). This premise highlights the duty to practice self-care as part of a nurse’s responsibility to provide holistic patient care and should not be regarded as solely a personal practice. In Figure 1 (Mariano, 2013), the circle represents the physical environment for optimal healing. Within the circle are several suggested healing properties of the physical environment as suggested by Florence Nightingale (1860; Mariano, 2013) such as cleanliness, fresh air, order, nutrition, light and sunlight, warmth, writing letters for patients, being present, and attending to patient needs. In this approach, which represents the theory of environmental adaption (Mariano, 2013), the holistic nurse is viewed as a healing property of the physical environment (Sher & Akhtar, 2018). Therefore, the action of a holistic nurse to self-reflect and practice self-care, is a proactive measure of being able to attend to the physical environment for optimal healing of the patient.

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Figure 1.

The Holistic Nurse’s Role in the Holistic Representation of the Physical Environment for Optimal Healing

Stress in the Health Care Environment and How it Can be Measured

Since the turn of the 20th century, different methods have been proposed to measure stress. These measures are divided into two distinct approaches: perceived measures of stress and biological markers for stress.

Perceived measures of stress are subjective and rely on feedback using methods of data collection such as interviews or questionnaires. According to King and Hegadoren (2002), perceived stress is the self-reported degree to which situations in an individual’s life are judged as stressful. A standardized tool for measuring perceived stress is the Perceived Stress Scale (PSS; Roberti et al., 2006). Prolonged exposure to stress on the job such as patient suffering, heavy assignments, staffing shortage, and unchecked workplace conflict can eventually lead to the well documented phenomenon of burnout (Boyle, 2015; Mathieu, 2014).

Burnout has been described as a “syndrome of emotional exhaustion, depersonalization (cynicism and lack of empathy), and lack of a sense of personal accomplishment” (Cohen-Katz et al., 2005, p. 26). It is, however, the response to stressful situations that is key to understanding the effects of stress and subsequent progression to burnout. Burnout has been shown to negatively impact job satisfaction, personal health and well-being, patient care, and patient satisfaction (Grønkjær, 2013; Weinberg & Creed, 2000). For example, “an increase of one patient per nurse assignment to a hospital’s staffing level increased burnout by 23%” (Botha et al., 2015, p. 22). A reliable and validated tool for the measurement of burnout is the Maslach Burnout Inventory (MBI; Kalliath et al., 2000; Maslach & Jackson, 1981; Poghosyan et al., 2009).

Vitality is related to the energy levels and fatigue of an individual (L. F. Brown et al., 2011). It can be measured using the Vitality Scale (L. F. Brown et al., 2011; Ware & Sherbourne, 1992). The term “vitality,” which has also been referred to as “the energy available to the self, is a salient and functionally significant indicator of health and motivation” (Ryan & Deci, 2008, p. 702). Hevezi (2016) further validates the role of fatigue, or poor vitality, in nursing, by stating, “the physical, mental, and psychological effects of compassion fatigue and burnout adversely affect nurse satisfaction and quality care” (p. 343).

Sleep quality also plays an integral role in how an individual deals with stress and it affects overall well-being and energy levels (Buysse et al., 1989; Fang & Li, 2015). A single item, Global Sleep Quality, drawn from the Pittsburgh Sleep Quality Index (Buysse et al., 1989) can be used to assess the quality of sleep.

Biomarkers are defined by the National Institutes of Health as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological responses to a therapeutic intervention” (Zhang et al., 2001, p. 2136). Biomarkers that indicate levels of stress in the human body can be assessed by examining the concentration of specific hormones: cortisol, serotonin, epinephrine, and dopamine (Steckl & Ray, 2018). Of these biomarkers, cortisol is most often used in research as an indicator of stress (also referred to as the stress hormone) and was examined in this study. Cortisol is a hormone that is released into the bloodstream in response to stress and is often used as a biomarker to indicate the degree of short- versus long-term stress associated with exhaustion of the hypothalamic–pituitary–adrenal axis and subsequent poor sleep and fatigue (Buckley & Schatzberg, 2005).

Cortisol may be measured in a person’s blood, urine, or saliva (El-Farhan et al., 2017). Salivary cortisol is routinely examined as a biomarker for psychological stress as it is quick, noninvasive, and the least expensive (Hellhammer et al., 2009). Diurnal salivary cortisol is a measurement of cortisol sampled over the course of a day to examine diurnal patterns. A “normal” diurnal curve is considered to be an awakening increase followed by a gradual and steady decline during the day, reaching the lowest point before bedtime and remaining low during the night. Among healthy adults and stressed adults, overall levels and diurnal patterns of cortisol may be remarkably different. This makes it difficult to use as a way to compare between individuals as an indicator of stress (Kurina et al., 2004). It is more useful to evaluate either overall levels of cortisol or diurnal patterns represented by area under the curve (AUC) (with more slope represented in a greater AUC considered to be less stressed) assessed in the context of changes in an individual’s AUC over time compared to their own baseline in response to stress or in response to stress reduction interventions (Pascoe et al., 2017; Vizcaino et al., 2018). Flatter slopes that are low are indicators of longer term experiences of stress to the point of hypothalamic–pituitary–adrenal axis exhaustion while flat slopes that are high are more indicative of shorter-term stress conditions (Young et al., 2019).

BP has also been associated with stress in several studies, where the higher the BP, the higher the stress levels of an individual (Ho et al., 2013; Mucci et al., 2016; Spruill, 2010).

Health and Well-Being in the Health Care Environment and How It Can Be Measured

Health and well-being, specifically in holistic nursing, acknowledges serenity as a “dimension of spirituality that is secular and distinct from religious orientation or religiosity, shows promise as a tool that could be used to measure outcomes of nursing interventions that improve health and well-being” (Kreitzer et al., 2009, p. 7). The Brief Serenity Scale was developed for nurses to assess their peaceful and serene state of mind (Kreitzer et al., 2009).

There has been increasing interest in “mindfulness as an approach to reduce cognitive vulnerability to stress and emotional distress in recent years” (Bishop et al., 2004, p. 230). Mindfulness has been described as a process of bringing focused attention to a moment-by-moment experience (Kabat-Zinn, 1990). A tool used to measure mindfulness, is the Mindful Attention Awareness Scale, which can be used to determine an individual’s receptive state of mind to their environment (Carlson & Brown, 2005). This tool has the potential to measure mindfulness before and after a MB intervention.

Benefits of Mindfulness and Yoga

MB interventions have been shown to decrease the response to stress and symptoms of burnout in a variety of populations (Botha et al., 2015; Kabat-Zinn, 1990). Yoga is considered among a number of practices to be a “meditative movement,” facilitating practices that incorporate body postures and/or movement along with a focus on the breath and a mindful or meditative state to produce the relaxation response (Larkey et al., 2009). Thus, the MB yoga intervention used for this study included these elements, and, based on research, was expected to reduce stress and associated mind–body states.

The popularity of yoga for decreasing perceptions of stress and increasing physical fitness has doubled in the United States since the year 2000 (Hartfiel et al., 2010). Many mindfulness and spirituality-based programs report a decrease in levels of perceived stress among nurses (K. W. Brown & Ryan, 2003; Davies, 2008; Jackson, 2004) and HCPs (Atanes et al., 2015; Yang et al., 2017). Practice of various styles of yoga have also shown a reduction in stress and improved sleep (Chen et al., 2009). More specifically, “regular yoga can improve sleep quality and reduce work stress in staff nurses” (Fang & Li, 2015, p. 3374).

MB yoga includes mind–body awareness through various methods such as using easy-to-practice postures, breathing techniques, and mindful practices that can be successfully completed by nearly everyone. Herrick and Ainsworth (2000) discuss how the effects of MB yoga practices have been shown to achieve physiological, psychoemotional, and spiritual benefits, including reduction of stress, increased energy, and dramatic improvements in overall sense of well-being among nurses. Mindfulness expert Jon Kabat-Zinn describes the practice of mindful yoga as a “specific attitude and attentional stance that is brought to practice, both on the mat and in daily life: namely, a refined moment-to-moment nonjudgmental, nonstriving attending to the entire range of our experience” (Kabat-Zinn, 2005, p. 3). This may be helpful in stressful hospital environments where nurses and HCPs have constant external demands.

According to Kabat-Zinn (2003), in addition to stress reduction, practicing MB interventions during stressful times, nurses and HCPs can become more aware that they have the choice to respond with unattached observance to a stressful situation rather than reacting. This “moment-to-moment” awareness can be helpful in high stress work environments by decreasing instances of feeling overwhelmed (Kabat-Zinn, 1990).

A study conducted by Ceravolo and Raines (2019), focused specifically on the impact of a mindfulness intervention for nurse managers. Their findings emphasized that not only do mindfulness practices need to be taught to nurse managers, but these practices need to be reinforced to ensure regular practice in order to be most effective (Ceravolo & Raines, 2019).

Hypotheses

Design

This was a single-blinded randomized controlled trial designed to study the effects of a MB yoga intervention in a sample of nurses and HCPs on perceived stress, burnout, vitality, sleep quality, serenity, mindfulness, BP, and a biomarker of stress, diurnal salivary cortisol, compared with the control group.

Setting

This study was conducted at a community-based hospital system in the southwestern United States as well as in the private homes of selected participants per the instructions provided by the primary investigator (PI).

Sample

Eligibility criteria included employees who provided direct patient care (including but not limited to nurses, nursing assistants, therapists, physicians, and social workers), older than 18 years. Exclusion criteria were the presence of joint or muscle problems that limited mobility (e.g., advanced arthritis, herniated disk, or past injuries that prevent painless or safe movement), having routinely practiced yoga or any other MB intervention in the past 6 months, or currently on medication that might interact with the results of salivary cortisol measures, including prednisone, cortisone, or steroid-based medicine.

Procedure

This study was approved prior to implementation by the Institutional Review Board. IRB Information: Scottsdale Healthcare Institutional Review Board SHC IRB number: 2010-117. Once approved, invitations were sent to all direct care hospital employees via email and print. Efforts were made to recruit both male and female participants. Interested participants contacted the PI to schedule an eligibility screening assessment. Once identified as eligible, participants signed consent, completed subjective assessments, and were randomly assigned to the intervention or control group using a computerized randomization tool. Program staff who collected, entered, and analyzed data were blinded to study group assignment.

All participants (n = 80) completed baseline measurements of perceived stress, burnout, vitality, sleep quality, serenity, mindfulness, diurnal salivary cortisol, and BP. Those participants who experienced the intervention (n = 41) participated in group MB yoga instruction sessions, which took place weekly over a period of 6 weeks. Class attendance was kept. Weekly logs were also completed by MB yoga participants. They journaled the number of minutes per week they completed home yoga practice and any personal observations that resulted from practicing yoga as part of their self-care and self-reflective practice. The control group (n = 39) did not receive the intervention between the pre- and postassessments. No adverse events were reported throughout the program duration.

Following the 6-week intervention, both groups completed post measurements of perceived stress, burnout, vitality, sleep quality, serenity, mindfulness, diurnal salivary cortisol, and BP.

Measurement Instruments

Both perceived measures of stress and biomarkers of stress were collected. Measurements of perceived stress, burnout, vitality, sleep quality, serenity, and mindfulness were assessed at pre- and postintervention periods for both groups. To ensure validity well-known validated instruments were used:

The PSS is a validated 10-item tool using a 5-point Likert-type scale of “how often you feel stress” where 0 is never, and 4 is everyday, with higher scores indicating more stress. The PSS has high internal consistency (0.89; Roberti et al., 2006).

The MBI is a 22-item scale to evaluate burnout and has been validated with nurses and HCPs. This instrument has a Cronbach’s alpha ranging from .80 to .93. A subscale was selected to assess emotional burnout (nine-item subscale) that is scored on a 7-point rating scale of “how often you feel” each item, where 0 is never, and 6 is everyday (Kalliath et al., 2000; Maslach & Jackson, 1981; and Poghosyan et al., 2009). High scores indicate higher emotional exhaustion.

The Vitality Scale is a four-item subscale of the Medical Outcomes Short Form–36 with higher scores indicating greater vitality, energy and less fatigue (L. F. Brown et al., 2011; Ware & Sherbourne, 1992). This tool’s internal consistency is demonstrated with a Cronbach alpha of .86. Lower scores indicate more vitality, higher scores more fatigue.

A single item, Global Sleep Quality, drawn from the Pittsburgh Sleep Quality Index (Buysse et al., 1989) was used to assess sleep quality. This single-item indicator of overall sleep quality has been shown to be highly correlated with the total computed Pittsburgh Sleep Quality Index score (Carpenter & Andrykowski, 1998) and thus was selected to assess sleep quality while reducing measurement burden. The question used was “During the past month, how would you rate your overall sleep quality?” This one item is rated on a 4-point scale, where 0 is very good and 3 is very bad, thus, higher scores are less favorable, indicating sleep problems.

The Brief Serenity Scale (Kreitzer et al., 2009) was developed for a highly stressed clinical population, with a single subscale, “Inner Haven,” selected to assess predicted increases for a more general (less clinically oriented) construct describing a peaceful, serene state of mind (nine items).

The Mindful Attention Awareness Scale was used to measure mindfulness. This scale has 15 items and scores are summed. Higher scores indicate higher levels of mindfulness (K. W. Brown & Ryan, 2003).

Biomarkers of salivary cortisol samples were obtained before and after the 6-week intervention. Saliva samples were collected three times per day over two days (Sample 1: awakening, Sample 2: 45 minutes after awakening, Sample 3: 12-14 hours postawakening) based on a protocol for detecting changes in diurnal slope (Kraemer et al., 2006). The series of samples was collected within 5 days of the class commencement and after the intervention period. BP was assessed using standard procedures during in-person data collection pre- and postintervention.

MB Yoga Intervention

The intervention was custom designed by the PI of this study. It is principally based on a combination of Hatha and Raja Yoga practices (Hilcove, 2011). The MB yoga intervention was a beginner level program, starting with seated centering, brief teaching about yoga (e.g., what the word yoga means), focused attention on the breath, and yogic breath practice (complete yogic breath and alternate nostril breathing). Participants were invited to scan their bodies from head to toe and to observe how they felt before and after each class, facilitating increased self-awareness and self-reflection. These were followed by several minutes of guided, gentle stretching (neck, waist, side stretching), a series of traditional Hatha Yoga movements (e.g., Cat and Cow), and postures selected for ease and continued mindfulness focus (e.g., Downward Facing Dog, Forward Fold, Half Sun Salutations, Warrior II, Child’s Pose, and ended with Corpse Pose).

After each pose, participants were invited to close their eyes and pay attention to the sensations felt in their bodies, reinforcing the practice of self-awareness. This practice draws from the mental and spiritual disciplines of Raja Yoga, where inwardly focused attention and meditative awareness can be used when on the yoga mat and applied in everyday life. Each participant was provided with a DVD and CD of the yoga routine and breathing exercises for guided home practice to be completed three to five times each week. Participants were encouraged to journal and log their weekly yoga practice as personal accountability tools, which were submitted weekly.

Data Collection

All participants completed baseline measurements 2 weeks prior to the intervention. In addition to the measures described above, data were gathered at baseline for demographic information including age, gender, ethnicity, and job title. Following the 6-week MB yoga intervention, all measurements were repeated for both the intervention and control group.

Data Analysis

The power analysis software G*Power 3 (Faul et al., 2007) was used to determine the appropriate sample size. With a planned sample size of 60 participants (n = 30/group), the power to detect a significant change over time between the intervention and control group was 0.87 (α = .05) given a within subjects difference of 0 for the control group and 0.5 standard deviations for the intervention group based on previous research (Raghavendra et al., 2009). The reason for selecting 80 subjects was to account for possible attrition which was minimal for this study (2.5%).

Data were entered into SPSS version 18 and analyzed using PASW version 20. Descriptive statistics were examined at baseline for equivalence of group values in the levels of perceived stress, burnout, vitality, sleep quality, serenity, and mindfulness between the intervention and control group mean scores. A qualitative analysis of the journal entries was not conducted, as these were meant to enhance personal self-awareness among participants. However, selected excerpts from participants’ journals are reported in the discussion to further support study results.

To examine the effects of the intervention, a one-way analysis of variance (ANOVA) was conducted to test for significant differences in changes between the intervention and control groups. Salivary cortisol values were tested for increased slope (AUC) for MB yoga participants compared to control using ANOVA and Wilcoxon rank–sum test.

Hypothesis 1

There was a statistically significant improvement in stress and burnout in the individuals participating in the 6-week MB yoga interventions compared with the control group (p < .01) (see Table 3).

Hypothesis 2

There was a statistically significant improvement in the participants in the MB yoga group in vitality, sleep quality, serenity and mindfulness, compared to the control group (p < .01; see Table 3).

Hypothesis 3

Of the 78 participants, 19 were missing sufficient cortisol values. The AUC was calculated using the trapezoid rule for each day individually (2 predays and 2 postdays). Average values of the 2 pre- and 2 postdays were computed if there were 2 days available. If only a single day was available, it was used. The mean baseline AUC values were 3.35 (SD = 1.77) and 2.58 (SD = 1.08), for MB yoga and control groups respectively with post intervention means at 3.34 (SD = 2.40) and 3.07 (SD = 1.91; see Table 4). Therefore, there was no statistically significant difference in the change in the mean cortisol AUC values between the two groups using either a two-sample independent t test (p = .21) or a Wilcoxon rank–sum test (p = .27) for nonnormally distributed values within groups.

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Table 4.

Comparison of Cortisol Area Under the Curve Values Across Groups ^a

Group	n	Pre			Post			Difference = post – pre
		M	SD	Mdn	M	SD	Mdn	M	SD	Mdn
Mindfulness-based yoga	29	3.35	1.77	3.02	3.34	2.40	2.70	–0.01	1.31	–0.01
Control	30	2.58	1.01	2.44	3.07	1.91	2.83	0.49	1.69	0.22

a

The formula for computing the area under the curve (AUC) using the trapezoid rule for concentrations C₀, C_0.75, and C₁₂ at times 0, 0.75, and 12 is: AUC = 0.75 ∗ (C₀ + C_0.75)/2 + 11.25(C_0.75 + C₁₂)/2. This can be interpreted as the sum of the average of the two concentrations for each trapezoid multiplied by the elapsed time between them.

BP values at baseline indicated very similar means (in mmHg) for both groups for systolic (128.78 and 125.10, MB yoga and control, respectively), and diastolic pressure (89.29 and 78.29, respectively). Postintervention values were also similar across both groups, with very little change from preintervention values (122.56 and 121.25, for systolic and 78.44 and 74.5, diastolic respectively for MB yoga and control). These values represent very small reductions in BP values, resulting in no significant change over time between groups.

Limitations

All assessment measures in this study were self-report tools. Although these tools were validated and shown to be sensitive to changes in response to mind–body practices they are still reflective of individual perceptions rather than objective measures. Thus, reports of changes may be influenced by participation in a yoga class—an unavoidable circumstance of this popular practice with a known reputation for increased relaxation and stress reduction. Findings for diurnal cortisol slopes and BP, the only objective measures, did not reveal any significant changes or improvements over time for either group, and no significant differences between groups. The baseline cortisol patterns were within normal ranges and showed healthy slopes (increasing after the morning wake up and sloping downward through the day) suggesting this was not a chronically stressed group of participants. Similarly, mean BP readings were within normal ranges, indicating an overall healthy group. It is not remarkable that BP did not significantly change over time for either group. This, and the lack of significant improvement in slope for the cortisol values, suggest that consideration of a measure of chronic stress and/or biomarkers associated with longer term stress responses should be included as an inclusion criterion so that change in stress biomarkers might be detected.

Additionally, the study was designed to focus on the short-term effects of a MB yoga program with a specific population of health care providers. The results therefore cannot be generalized to the greater population.

Implications for Holistic Nursing Practice and Future Research

MB yoga has been demonstrated as an effective intervention to manage perceived stress and burnout among nurses and HCPs. It is highly recommended that this intervention is included as an option in workplace training as a part of employee wellness opportunities. Additionally, this self-care modality could be included in holistic nursing curricula to emphasize the importance of self-care through a meditative movement approach. As noted by Aiken et al. (2002), stress and burnout have a significant impact on patient care and turnover. Therefore, it is recommended that employers provide stress reduction modalities in the workplace. This recommendation supports Raingruber and Robinson’s (2007) statement that “hospitals willing to invest in self-care options for nurses can anticipate patient and work-related benefits” (p. 1141). It also reinforces the importance of nurses playing a vital role in the physical environment for optimal healing, which emphasizes the importance of self-care as a holistic approach to the health and well-being of the patient.

There are many areas for future study regarding stress reduction modalities. This was a short-term intervention of 6 weeks; however, longer term effects of MB yoga using these or similar variables should be examined in several sites across various states for more detailed analyses and comparison. Future studies could benefit from adding measures of behavioral outcomes known to be associated with stress (e.g., job performance or error rates). Additionally, a separate study focused on male nurses and HCPs could be conducted and compared for noticeable gender differences in the study outcomes. Similarly, this study could be duplicated with different ethnic or socioeconomic groups to determine if these variables have any effect on study outcomes.

In addition, the incorporation of technology, based on mindfulness practices could be provided by hospital management for their nurses and HCPs to assist with stress alleviation and reminders for their own self-care. Such examples might be apps such as Headspace: Meditation and Sleep; Calm for Meditation, Sleep and Relaxation; The Mindfulness App: Relax, Calm, Focus and Sleep; and Mindfulness Coach. Furthermore, comprehensive online courses could also be provided, where nurses and HCPs receive further in-depth training in self-care via a MB modality accompanied by movement such as yoga or tai chi.