COUNS-EDU The International Journal of Counseling and Education Vol.3, No.1, 2018, pp. 1-13 | p-ISSN: 2548-348X- e-ISSN: 2548-3498 http://journal.konselor.or.id/index.php/counsedu DOI: https://doi.org/10.23916/0020170211740 Received on 08/26/2017; Revised on 10/24/2017; Accepted on 12/30/2017; Published on: 05/23/2018 1 A review on mindfulness and nursing stress among nurses Zaini Said *)1 , Goh Lei Kheng 2 12 Universiti Kebangsaan Malaysia * ) Corresponding author, e-mail: zainisaid@ukm.edu.my Abstract Previous research has been done on mindfulness and nursing stress but no review has been done to highlight the most up-to-date findings, to justify the recommendation of mindfulness training for the nursing field. The present paper aims to review the relevant studies, derive conclusions, and discuss future direction of research in this field.A total of 19 research papers were reviewed. The majority was intervention studies on the effects of mindfulness-training programs on nursing stress. Higher mindfulness is correlated with lower nursing stress. Mindfulness-based training programs were found to have significant positive effects on nursing stress and psychological well-being. The studies were found to have non-standardized intervention methods, inadequate research designs, small sample size, and lack of systematic follow-up on the sustainability of treatment effects, limiting the generalizability of the results. There is also a lack of research investigation into the underlying mechanism of action of mindfulness on nursing stress. Future research that addresses these limitations is indicated. Keywords: mindfulness, nurse, nursing stress How to Cite: Said, Z., Kheng, GL. (2018). A review on mindfulness and nursing stress among nurses. Couns-Edu: International Journal of Counseling and Education, 3(1): pp. 1-13. DOI: https://doi.org/10.23916/0020170211740 This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©2017 by author and Indonesian Counselor Association (IKI). Introduction The nature of the nurses’ job is widely recognized as stressful. They have heavy workload juggling between clinical contacts and administrative tasks, time constraint, insufficient number of colleagues to share the work burden, strained relationship with other healthcare providers, role conflicts, and challenges in dealing with the patients and the families’ expectations and sufferings (American Holistic Nurses Association 2012). Nurses in Malaysia also face the similar stressors (IntanNazni&Asri 2003). However, research focusing on the nurses’ stress levels in Malaysia had contradictory outcomes on whether the prevalence of stress was high (Emilia & Noor Hassim 2007) or moderate (Lua &Imilia 2011; Sharifah Zainiyah et al. 2011). In fact, the participants in each study reported various levels of stress. This suggests that given similar external stressors, individual nurses’ differential experiences of stress can be explained by their personal appraisals and coping strategies. The use of self-blame and emotional ventilation among the nurses predicted a higher level of stress (Emilia & Noor Hassim 2007; Wan Salwina, Raynuha, Ainsyah et al. 2009). The issue of nursing stress concerns the society because the nurses play an important role within the healthcare settings. Ongoing experience of high stress levels contributes to a higher likelihood of burnout, psychological distress, and physical health but diminished job satisfaction among the nurses (Michie& Williams 2003; Wan Salwina et al. 2009) http://dx.doi.org/10.23916/0020170211740 COUNS-EDU  Vol.3, No.1, 2018 Available online: http://journal.konselor.or.id/index.php/counsedu Said, Z., Kheng, GL A review on mindfulness and nursing stress among nurses | 2 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 This contributed to a high turnover rate among the nurses (O’Henley et al. 1997) that would worsen the problem with lack of manpower within the field. It also impeded healthcare outcomes and patients’ satisfaction (Brady, O’Connor, Burgermeister et al. 2011; Larrabee, Ostrow, Withrow et al. 2004). Without the use of adaptive coping, combined with the alarming negative impacts of nursing stress, necessitate the implementation of stress-management program as part of the nurses’ training so that they can learn to cope with stress more effectively. In recent years, there is an escalating amount of research attention focusing on the effectiveness of mindfulness training programs which include mindfulness-based stress reduction (MBSR; Kabat- Zinn1990) and mindfulness-based cognitive therapy (MBCT; Segal, Williams & Teasdale, 2002)developed from MBSR in stress reduction and well-being enhancement(Baer 2003; Grossman, Niemann, Schmidt et al. 2004)across different populationincluding people with cancer, depression, heart disease and healthcare providers (Beddoe& Murphy 2004; Bruce & Davies 2005; Gazella 2005; Smith, Richardson, Hoffman, & Pilkington 2005; Tacon et al. 2003 as cited in Praissman 2008).Mindfulness is the receptive awareness and attention to the present events and experiences which encompass observing, describing, acting with awareness, non-judging, and non-reactivity to private experiences (Baer, Smith, Hopkins et al. 2006; Brown & Ryan 2003). Mindfulness can be a psychological trait, a state with high awareness of the present or as a result of meditational practices that cultivate mindfulness (Germer, Siegel &Fullton 2005). The origin of mindfulness can be traced back to the ancient Buddhist tradition of contemplation. However, it is now widely applied within the secular context without the need of spirituality support because it depends on universal humans’ ability to be attentive to the present (Coffey & Hartman 2008). As there is a rise in the number of research investigations on the relationships between mindfulness and nursing stress, it is important to conduct a literature review to highlight the most up-to-date research findings and justify the need to introduce mindfulness training to the profession. To date, only one review has been done by Smith (2014) on the studies that investigated the specific effects of MBSR on healthcare providers’ ability to cope with work-related stress. However, no systematic literature review has been doneon the relationship between mindfulness and nursing stress. The present paper serves to fill in the gap by reviewing the relevant studies to date to draw conclusions and identify future research directions. Method Studies mindfulness and nursing stress were identified after a comprehensive search using three electronic databases: EBSCO (1997-present), Pro-Quest Health and Medical Complete (1994-present), PubMed (1999-present), and SCOPUS (2001-present). Google Scholar was used to search for unpublished dissertations. The inclusion criteria are research studies that investigate the effects of training programs that incorporate mindfulness on nursing stress. The exclusion criteria are research studies that investigate the effects of other stress management programs on other population’s stress. Keywords used to search for the articles include “mindfulness,” “nurse,” and “nursing.” The generic keywords were used to identify as many studies as possible. Filters such as “English language” and “peer-reviewed” were used to refine search. 14 full articles, three unpublished dissertations, noted with an asterisk (*), one abstractof a review paper, and one abstract of a research whereby the manuscript was under corrected prooffrom the abovementioned databases were identified and included in this review (Figure 1). COUNS-EDU  The International Journal of Counseling and Education Vol.3, No.1, 2018 A review on mindfulness and nursing stress among nurses | 3 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 Figure 1: Flowchart of the reviewing process Table 1 presents the studies on mindfulness training programs for nursing stress and their relevant important features (a) authors, (b) participants, (c) location, (d) research design, (e) program, (f) measures of stress-related outcome, (g) measures of well-being related outcome, and (h) treatment outcomes with significant improvement. Results and Discussion A total of 19research papers from the year 1994 till present fulfilled the inclusion criteria to be reviewed in the present paper (see Table 1 and Table 2). 17 of the research papers are intervention studies on the effects of mindfulness training programs on nursing stress and other well-being measure, one is survey study, and another one is a review paper. 18.75% of the intervention studies were randomized controlled pre-post studies, 37.5% were nonrandomized controlled, another 37.5% were quasi- experiments, and the remaining one study was qualitative. There were ten studies that involved only nurses, three that included other healthcare professionals besides nurses, and four that recruited nursing students as participants. The study by Horner, Piercy, Eure& Woodard (2013) is under corrected proof thus only the abstract with limited details is made available. Excluding Horner at al.’s (2013) study, there were a total number of 1460nurses and 197 nursing students that were being studied. Most of the studies were conducted in U.S. (64.7%), two in South Korea, and the others wereeach carried out in Australia, Canada, China, Japan, and Malaysia. Of all the intervention studies, eight studies (47%) investigated on the effects of MBSR in alleviating stress experienced by the nurses.MBSR was developed by Jon Kabat-Zinn from the University of Massachusetts Medical Center based on the concept of being entirely present to one’s personal experience without resisting or attaching any judgment termed mindfulness. The program was detailed in Kabat- Zinn’s (1990) textbook entitled “Full Catastrophe Living: Using the Wisdom of YourBody and Mind to Face Stress, Pain, and Illness.” The original MBSR spans across eight weeks, with at least 2.5 hours of weekly group sessions for formal didactic instruction on topics such as communication skills, stress reactivity, and self-compassion and experiential exercises and a 6-hour daylong retreat during the 6th or 7th week. The participants would also be instructed to actively practice mindfulness meditation for 6 days per week facilitated by the audiotaped instructions. They would also be expected to integrate the mindfulness skills and concepts into daily routine.Beddoe and Murphy (2004), Beth Elsa et al. (2007), and Articles searched from EBSCO, Pro-Quest Health and Medical Complete, PubMed, and SCOPUS with the keywords of mindfulness, nursing, and nurse 148 citations in EBSCHO, 145 in Pro-Quest Health and Medical Complete, 59 in PubMed, and 57 in SCOPUS 14 articles and 2 abstracts from all the selected databases were included Combined with 3 unpublished dissertations found using Google Scholar yielded a total of 19 studies for review COUNS-EDU  Vol.xx, No.x, Month 201x Available online: http://journal.konselor.or.id/index.php/counsedu Said, Z., Kheng, GL A review on mindfulness and nursing stress among nurses | 4 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 Cohenz-Katz,Wiley, Capuano, Baker, and Shapiro’s (2005) studies were based on the traditional Kabat- Zinn’s (1990) version of MBSR. Other researchers modified the traditional format and/or contentbut found similar improvement. Bazarko, Cate, Azocar, and Kreitzer (2013) named the modified MBSR as telephonic MBSR (tMBSR) by replacing the group meeting sessions with 6 scheduled weekly 1.5-hour group teleconference calls, an additional in-person retreat day at the beginning of the program, email discussion with the instructor in between sessions, and access to personalized instructions and supports. Brady, O’Connor, Burgermeister and Hanson (2011) and Mackenzi, Poulin and Sigmund-Carlson’s (2006) adapted the duration to 4 weeks to cater to the nurses’ heavy job demands. There were weekly 1-hour group sessions focusing on formal meditation and attention to breath, mindfulness in daily activities, total body relaxation, and mindfulness at workplace and the requirement to practice meditation and mindfulness in daily activities at least 30 minutes daily. On the other hand, Foureur, Besley, Burton, Yu and Crisp (2013) modified the contentinto only a 1-day workshop to psychoeducate the nurses’ on the relationships among body, mind, emotion, and behavior and strategies for moment-to-moment mindfulness and the assignment to meditate daily for 8 weeks. Hee, Subramaniam, Rahmat andPhang (2014) devised a 5-week program constituting 2-hour weekly sessions and daily mindfulness practice, named brief-MBCT by integrating MBSR and MBCT approaches.b-MBCT seeks to train the participants in cultivating meta-mindfulness so that by being more aware of their private experiences, they assume a detached perspective to defuse from the negative internal events (Phang&Ooi 2012; Segal et al. 2002).b-MBCT also consists of the elements of compassion and gratitude in addition to mindfulness. In O’Brien et al.’s (2013) study where exposure to humor was incorporated to 7-minute daily meditation for 4 weeks, there was also significant improvement in terms of the nursing students’ anxiety and well-being. There were four intervention studies that concluded the positive effects of mere daily mindfulness meditation practice across a variety of duration on nursing stress and well-being. The participants in Kang, Choi and Ryu’s (2009) 8-week mindfulness meditation program learned and practiced walking mindfully and body scan and breathing meditation as daily routine. On the other hand, in Pipe, Bortz, Dueck et al.’s (2009) study, the participants underwent a 4-week daily meditation program. Ando, Natsume, Kukihara, Shibata and Ito (2011) investigated on 2-week daily 30-to-60 minute cyclic meditation whereby the participants moved their hands or legs while meditating to focus their attention on mind and body. The program with the shortest duration is Chen, Yang, Wang and Zhang’s (2013) that involved nursing students to meditate for 30 minutes daily for only a week. There were two other intervention studies that had also shown positive effects of spirituality program that incorporated important elements of mindfulness on nurses’ stress and well-being. Borrman, Becker, Gershwin et al. (2006) and Yong, Kim, Park, Sweo and Swinton’s (2013) 5-week, 90-minute weekly sessions of spirituality program was based on The Mantram Handbook (Easwaran 1998), that includes practicing Mantram as a form of meditation,cultivating one-pointed attention, slowing down, and repeating mantram during daily activities. There is only one qualitative study (Beth Elisa et al. 2007) and two quantitative studies that had included some qualitative findings (Cohen-Katz et al. 2005; Foureur et al. 2013). The participants reported that they found the program helpful in managing stress and instilling calmness but having difficulty in following routine meditation and doubted the feasibility of such program to be conducted in the hectic settings. Twelve intervention studies (70.5%) measured both nursing stress-related and well-being outcomes. Three (17.6%) measured only stress-related findings whereas two (11.7%) measured only psychological well-being at post intervention. To measure stress-related outcomes including perceived stress, burnout symptoms, emotional distress, and job satisfaction, different instruments were used across studies. Three studies used Perceived Stress Scale (PSS) (Bazarko et al. 2013; Borrman et al. 2006; Hee et al. 2014), one study used Derogatis Stress Profile (DSP) (Beddoe& Murphy 2004) and Mental Health Professionals Stress Scale (MHPSS) (Brady et al. 2011).Five studies used Maslach Burnout Inventory (MBI) (Brady et al. 2011; Cohen-Katz et al. 2005; Mackenzi et al. 2006; Penque et al. 2009; Yong et al.2011) and one used Copenhagen Burnout Inventory (CBI) (Bazarko et al. 2013) to measure their burnout symptoms. Certain studies also measured depression, anxiety, stress, and anger using respective questionnaires such as Depression Anxiety Stress Scale (DASS) (Fourer at al. 2013), State/Trait Anxiety Anger Inventory COUNS-EDU  The International Journal of Counseling and Education Vol.3, No.1, 2018 A review on mindfulness and nursing stress among nurses | 5 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 (STAA) (Borrman et al. 2006), Beck Depression Inventory (BDI) (Kang et al. 2009). Chen at al. (2013) adopted Self-rated Anxiety and Depression Scale and physiological measures. Other instruments used were Brief Symptom Inventory (BSI) and Emotional Exhaustion Subscale (EES) (Cohen-Katz et al. 2005). The studies that include work satisfaction measures used Index of Work Satisfaction (Penque et al. 2009) and Job Satisfaction Scale (Yong et al. 2011). In line with the review done by Smith (2014) which concluded that the healthcare providers including the nurses’ ability to cope with job stress was improved after the MBSR, all the nurses or nursing students who had undergone the mindfulness training program regardless format and content differences, experienced significant reduction in terms of stress-related symptoms including perceived stress, burnout symptoms, anxiety, and anger. The only exception is that Brady et al. (2013) did not find significant improvement in the participants’ burnout symptoms despite the significant improvement in stress levels with MBSR. Also, mindfulness training programs were found to have no impact on depressive symptoms (Chen et al. 2013; Fourer et al. 2013; Kang et al. 2009). In terms of job satisfaction, the findings by two studies were contradictory whereby the nurses in Penque et al. (2009) but not Yong et al.’s (2011) reported higher job satisfaction at post-intervention. This might be due to other individual and environmental differences in addition to stress that also affect to what extent that they could derive contentment from their job. Besides stress-related outcomes, most intervention studies also assess the effects of mindfulness training programs on different well-being related outcomes, including mindfulness, sense of coherence, sense of self, quality of life, spiritual well-being, empathy, self-compassion, happiness, and satisfaction with life. 66.7% studies included a combination of different measures in attempt to capture the totality of psychological well-being. This is in line with the general consensusthat the definition of well-being is multifaceted (Ryff& Keyes 1995). The most widely used instrument is Mindfulness Attention Awareness Scale (MAAS) (Beth Elisa at a., 2007; Cohen-Katz et al. 2005, Hee et al. 2014; O’Brien et al. 2013), followed by General Health Questionnaire (GHQ-12) (Ando et al. 2011; Foureur et al.2013), Sense of Coherence Scale (SOC) (Ando et al. 2011; Foureur et al. 2013), and Interpersonal Reactivity Index (Beddoe& Murphy 2004; Penque et al. 2009). Others are listed in Table 1. In the studies that also measured the treatment outcomes at 1, 2, 3, and 4 months respectively after post-intervention, the positive effects of mindfulness training programs on nursing stress and psychological well-being sustained overtime (Bazarko et al. 2013; Beth Elisa et al. 2007; Cohen-Katz et al. 2005; Mackenzi et al. 2006; Penque et al. 2009). The survey study done by Heard (2010) showed that the nurses who reported higher level of dispositional mindfulness also had lower propensity to burn out. This implied that without mindfulness training program, individuals’ trait mindfulness is also likely to buffer against stress.Based on Taylor, White andMuncer’s (1999) findings, facing with the challenge of consistently inadequate number of colleagues to share the workload, the working nurses perceived a lack of resources and support that negatively affected their self-efficacy in managing the job demands. Therefore, trait mindfulness or mindfulness cultivated via training programs assist the nurses to focus while fulfilling their roles, without attaching negative judgment on personal capability and the inevitable stressful job demands. While the training programs also engaged them to develop the habit of being mindful in daily activities, it also improved their general well-being. COUNS-EDU  Vol.xx, No.x, Month 201x Available online: http://journal.konselor.or.id/index.php/counsedu Said, Z., Kheng, GL A review on mindfulness and nursing stress among nurses | 6 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 Table 1: Studies of mindfulness training programs on nursing stress Study Participan ts Location Design Program Measures of stress- related outcome Measures of well-being related outcome Significant improveme nt Ando et al. (2011) N=28 nurses Treatment- 15; Control-13 Elderly ward, Japan Nonrandomiz ed controlled pre-post intervention study 2-week of daily cyclic meditation for 30-to-60 minutes N/A General Health Questionnaire (GHQ-12), Sense of Coherence (SOC), Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp) GHQ-12, SOC Bazarkoe t al. (2013) N=36 29 clinical nurses, 7 staff nurses Midwest & Southwes t Healthcar e Company , U.S. Quasi- experimental, single group, pre-post intervention study 8-week tMBSR with additional 1 retreat day at the beginning, 2 and 4-month follow- up Perceived Stress Scale (PSS), Copenhage n Burnout Inventory (CBI) Brief Serenity Scale, SF-12v2 Health Survey,Self- Compassion Scale, Jefferson Scale of Physician Empathy All Beddoe& Murphy (2004) 23 nursing students U.S. Quasi- experimental, single group, pre-post intervention study 8-week MBSR Derogatis Stress Profile (DSP) Interpersonal Reactivity Index (IRI) All Beth Elisa et al. (2007) 4 nurses Wisconsi n, U.S. Qualitative 8-week MBSR, 3-month follow‑up N/A Self‑developme nt, Mindfulness Attention Awareness Scale (MAAS) MAAS Brady et al. (2011) N=16 7 psychiatric nurses Inpatient behaviora l health unit in Midwest hospital, Quasi- experimental, single group, pre-post intervention 4-week brief MBSR, 1-hour weekly sessions, without retreat day Mental Health Professiona ls Stress Scale (MHPSS), Sense of Self Scale, the Toronto Mindfulness Scale All except burnout COUNS-EDU  The International Journal of Counseling and Education Vol.3, No.1, 2018 A review on mindfulness and nursing stress among nurses | 7 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 U.S. study Maslach Burnout Inventory (MBI) Borrman et al. (2006) N=62 31 nurses 31 staffs Veterans Affairs San Diego Healthcar e System, U.S. Quasi- experimental, single group, pre-post intervention study 5-week Mantramrepetiti on PSS, Spielberger State/Trait Anxiety Inventory (STAI) and Anger Inventory (STAA) Endicott’s Quality of Life Enjoyment and Satisfaction Short Form, Spiritual Well- being Scale All Table 1: Continued Study Participa nts Location Design Program Measur es of stress- related outcom e Measures of well-being related outcome Significant improvemen t Chen et al. (2013) N=60 nursing students Treatmen t – 30; Control - 30 Medical Universit y in Guangzh ou, China Randomized controlled pre-post intervention study 1-week of daily 30- minute mindfulness meditation Self- rated Anxiety Scale, Self- rated Depress ion Scale, heart rate, blood pressure N/A anxiety, systolic blood pressure Cohen -Katz et al. (2005) N=25 nurses Treatmen t-12; Control- 13 Lehigh Valley Hospital & Health Network, U.S. Randomized controlled pre-post intervention study 8-week MBSR, 3-month follow-up MBI, Brief Sympto m Invento ry (BSI), Emotio nal Exhaust ion Subscal MAAS All COUNS-EDU  Vol.xx, No.x, Month 201x Available online: http://journal.konselor.or.id/index.php/counsedu Said, Z., Kheng, GL A review on mindfulness and nursing stress among nurses | 8 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 e (EES) Foure uret al. (2013) N=40 20 nurses, 20 midwives 2 teaching hospitals in New South Wales, Australia Nonrandomi zed controlled pre-post intervention study Modified 8- week MBSR: 1-day workshop, without retreat day Depress ion, Anxiety and Stress Scale (DASS) GHQ-12, SOC All Hee et al. (2014) N=37 critical care nurses Hospital Serdang, Malaysia Quasi- experimental , single group, pre- post intervention study 5-week brief MBCT, 2 hours/week DASS, PSS MAAS, Subjective Happiness Scale (SHS) All Horne r et al. (2013) In press, corrected proof U.S. Nonrandomi zed controlled pre-post intervention study 10-week mindfulness training program - - All: stress, burnout, mindfulness, compassion Kang et al. (2009) N=41 nursing students Treatmen t- 20; Control- 21 South Korea Nonrandomi zed controlled pre-post intervention study 8-week mindfulness meditation stress coping program Psychos ocial Well- being Index- Short Form (PWI- SF), STAI, Beck Depress ion Invento ry N/A Stress, anxiety COUNS-EDU  The International Journal of Counseling and Education Vol.3, No.1, 2018 A review on mindfulness and nursing stress among nurses | 9 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 Table 1: Continued Study Participant s Location Design Program Measures of stress- related outcome Measures of well-being related outcome Significant improvemen t Mackenz i et al. (2006) N=30 nurses and nurse-aides Treatment- 16; Control- 14 Canada Nonrandomize d controlled pre-post intervention study 4-week MBSR, 1 month follow-up MBI Satisfaction With Life Scale (SWLS) burnout symptoms, relaxation, and life satisfaction O’Brien et al. (2013)* N=73 Junior and Senior nursing students Treatment- 36; Control-37 Capella University, U.S. Nonrandomize d controlled pre-post intervention study 4-week daily 7- minute guided mindfulnes s meditation + humor STAI MAAS STAI, MAAS Penque et al. (2009)* N=61 nurses Abbott Northwester n Hospital in Minnesota, U.S. Quasi- experimental, single group, pre-post intervention study 8-week MBSR, 3 months follow-up MBI, Index of Work Satisfactio n Brief Freiburg Mindfulness Inventory (BFMI), Self‑Compassio n Scale, BSS, IRI MAAS, self- compassion, serenity, work satisfaction, job burnout Pipe et al. (2009) N=33 nurse leaders U.S. Randomized controlled pre- post intervention study 4-week brief mindfulnes s meditation course Symptom Checklist 90- Revised N/A Stress Yong et al. (2013) N=51 manager nurses Treatment- 24; Control-27 Hospital in Seoul, South Korea Nonrandomize d controlled pre-post intervention study 5-week spirituality program MBI, Job Satisfactio n Scale Spiritual Well- being, Spiritual Integrity Burnout, spiritual well-being, integrity, leadership practice Table 2: Other non-intervention studies paper COUNS-EDU  Vol.3, No.1, 2018 Available online: http://journal.konselor.or.id/index.php/counsedu Said, Z., Kheng, GL A review on mindfulness and nursing stress among nurses | 10 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 It is indicated from this review that research on mindfulness and nursing stress is limited in the aspects of research design, research participants, generalizability of results, measures of treatment outcomes,intervention content and dosage, comparisons with other stress-buffering factors, and the underlying explanation of the positive effects of mindfulness on nursing stress. In terms of research design, there are only a limited number of randomized controlled trials (RCTs) for the intervention studies, though RCT is widely recognized as the gold standard in evaluating the efficacy and effectiveness of a treatment (Akobeng 2005). For the single-group pre-post intervention studies where there is no controlled or comparison group, it is difficult to determine the validity of the significance of improvement. Out of 17 intervention studies, 12 did not assess the long term effects of mindfulness training program, thus weakening the justification to incorporate mindfulness training in the nursing field. Moreover, there is no standardized treatment component except daily meditation that is required in all programs. Across studies, the participants self-monitored and self-reported on their assignments to carry out daily meditation; thus, without an objective monitoring method, it is uncertain whether they actually perform the assignments. The duration of different adaptations of the programs ranges from 1-to-10 week. The method of delivery such as classroom or telecommunication-based and content such as didactic presentations, group sharing sessions, retreat day, and self-directed meditative practices also vary by studies. There is no specific research to determine which treatment components have the largest positive effects (Penque et al. 2009). There is also no investigation to determine the format and dosage that is the most cost and time effective. Although there are many other stress-reduction programs such as relaxation therapy, assertiveness training, and peer support groups (Lee & Ellis 1990) that were found to be effective, to date, there is no study that compares mindfulness training programs against other stress-management programs for nurses to determine the best intervention option. There is a wide range of measures of treatment outcome which makes comparisons among studies difficult. In fact, nursing stress was not assessed directly and specifically using work-stress instruments. Although it is shown that mindfulness training programs effectively reduce stress, it is necessary to pinpoint whether the reduced stress is pertaining to the job demands in order to further justify the need to incorporate mindfulness training in the field. The generalizability of the findings is limited because of the intervention studies that involved small sample size (Cohen-Katz et al. 2005; Mackenzie et al. 2006; Yong et al. 2011) making it difficult to obtain conclusive findings. Brady et al. (2013) explained that small sample size might have resulted in insignificant improvement in the participants’ burnout symptoms. There is also a lack of investigation on Study Participants Design Program Measures of stress-related outcome Measures of well-being related outcome Heard (2010) * N=1186 registered nurses from 4 hospitals in South Mississippi, U.S. Survey N/A MBI, Index of Work Satisfaction, Nurse Comfort Questionnaire MAAS, Langer Mindfulness scale, Mindfulness-Based Self Efficacy Scale, Smith (2014) - Review paper MBSR - - COUNS-EDU  The International Journal of Counseling and Education Vol.3, No.1, 2018 A review on mindfulness and nursing stress among nurses | 11 Indonesian Counselor Association (IKI) | DOI: https://doi.org/10.23916/0020170211740 the impact of gender. Among the participating nurses across studies, there was only three male nurses were involved in the Penque et al.’s (2009) study. However, this is inevitable as it is in line with the fact that male is always the underrepresented group within the nursing field (Penn State School of Nursing, 2007). Mindfulness has been proven effective as a mean by which nurses can empower themselves to combat various stressors and comfort themselves through mindfulness meditation. However, there is no research in the underlying mechanism of the positive effects. These limitations of current studies done on mindfulness training programs and nursing stress inform the direction of future research. Future studies are needed to compare mindfulness training programs against controlled and comparisons group using other stress management programs using RCT. The sustainability of positive effects needs to be accessed via long term follow-ups. It is also important to devise the program so that the participants’ daily meditation can be measured objectively. The investigations should also aim to produce a manualized protocol that details standardized format, content, and dosage that is deemed most cost and time effective, in order to cater to the nurses’ busy schedule. This can be done by researching on specific efficacy and effectiveness of the therapeutic components. The measure of stress can be specified to be job-related. To improve the generalizability of the findings, the sample size needs to be larger and the sample should be representative of nurses across departments, genders, and other cultural groups. Further research is indicated to explore the mechanism of action underlying the positive effects mindfulness has on the nursing stress by using mediator or path analysis studies. Conclusions Mindfulness has been proven to be effective in reducing nursing stress and improving psychological well-being. 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