The PICO question guiding this paper is; in nurses working 12-hour shifts, do strategies to control stress, compared with doing nothing, reduce nurse errors, and improve patient outcomes, in a period of one year? The paper is a critique of a quantitative study examining effective interventions for stress reduction in nurses to improve patient safety and outcomes.
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Background of Study
The clinical problem that led to the quantitative study by Duarte and Pinto-Gouveia (2016) is the high rate of “burnout, compassion fatigue, and stress” in oncology nurses – estimated to be over 40% (p. 98). Stressed nurses suffer physical and psychological issues, including depression, which increases the medical error risk. Mindfulness-based interventions (MBIs) have been applied to teach stress-coping strategies in different professionals, but not nurses. This study fills this gap in research by using MBIs with oncology nurses to reduce stress/fatigue.
The significance of the study is well established through the statistics on the high prevalence of stress/burnout in oncology nursing (>40%). Further, the authors note that besides its direct impacts on the wellbeing of nurses and patients, stress/burnout is very costly to health organizations. They estimate the economic costs of stressed and depressed nurses to be 46% and 147%, respectively (Duarte & Pinto-Gouveia, 2016).
The study’s purpose, as described in its aims, is to explore the efficacy of on-site MBI on the wellbeing of oncology nurses (Duarte & Pinto-Gouveia, 2016). The specific health outcomes explored include a reduction in stress/anxiety and improved job satisfaction. The study involved a comparison of the intervention group and the wait-list group.
The research questions guiding the study are not explicitly stated. However, from the answers and study hypotheses, we can infer two research questions: (1) do subjects receiving MBI, report reduced stress/burnout symptoms and improved satisfaction compared to the controls? And (2) does MBI enhance mindfulness, reflection, and stressor avoidance by nurses? The purpose and research questions are tied to the study problem of a high prevalence of stress/burnout in nursing.
Methods of Study
The identified benefits of participation included the award of the certificate on completing the program and convenience due to on-site intervention. No intervention risks are identified. The unnamed benefits include training on mindfulness techniques and meditation exercises by an experienced clinical psychologist.
Written informed consent was obtained from the participants before participation. This implies that the participants were informed about the potential risks of the study to minimize harm (Gelling, 2015). It seems that participation in this study was voluntary. The reason for this conclusion is that no monetary compensation was given for participation. However, participants who completed 50% of the program were awarded a certificate of attendance (Duarte & Pinto-Gouveia, 2016).
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An institutional review board approval was obtained before conducting the study. The ethics committees/boards of the two Portuguese oncology hospitals (study sites) approved the research protocol. The authors identify and define the major variables – independent and dependent – of the study. The identified independent variable is a mindfulness-based intervention, while the dependent variables (six) include “compassion satisfaction, burnout, compassion fatigue, psychological symptoms, and satisfaction with life (outcomes) and psychological mechanisms” (Duarte & Pinto-Gouveia, 2016, p. 102).
Data collection involved questionnaires with validated scales to measure the variables. The questionnaires were administered before and after the 6-week MBI program. Additionally, 3-month follow-up questionnaires were administered to the intervention group (n=29). The authors have not given a rationale for using questionnaires as the data collection method in this study. However, the structured questionnaires involved closed questions (discrete measures) that yield numerical data for quantitative analysis (Esperon, 2017). Data collection was done throughout the six weeks of the MBI intervention in 2015. Additional data were collected from the experimental group three months after the intervention.
The data collection procedure involved obtaining baseline data – gender, age, marital status, and weekly work hours – from the participants (n=48) a week before the intervention. Post-intervention data were collected from the treatment group (n=29) immediately after the 6-week MBI program using questionnaires based on validated scales, e.g., self-compassion scale. Follow-up data were also collected three months after the intervention. The data management and analysis involved two-way ANOVA to determine the relationships between the program and intervention outcomes and ANCOVA to compare post-treatment scores between the intervention group and the control group. Demographic differences between the two groups were determined by Chi-square tests.
Research rigor was assured through priori power analyses, which indicated that the sample size (n=29) could give 80% power to “detect interaction effects of condition and time” (Duarte & Pinto-Gouveia, 2016, p. 102). The author does not describe maintaining a paper trail of critical decisions related to data analysis. To enhance the accuracy of the analysis, all statistical procedures were done using statistical software, IBM SPSS (v. 20). It is not indicated if the two researchers did the data analysis independently to minimize researcher bias.
Results of Study
Based on the results, nurses who received MBI training reported significantly lower levels of compassion fatigue and burnout/stress and increases in stressor avoidance and mindfulness compared to those who did not. The researchers’ interpretation of these results is that MBI can enhance the quality of life and performance of nurses in the oncology departments (Duarte & Pinto-Gouveia, 2016). Overall, the findings are valid due to the research rigor and procedures followed. Therefore, I have absolute confidence in the findings.
One of the identified limitations of the study includes the use of a small sample size with more females than male subjects – may have affected its representativeness. Other limitations include non-random assignment of subjects, reliance on self-report measures, and high attrition rate (50%). The presentation of the findings followed a coherent and logical pattern. It entailed a discussion of each outcome variable in the context of the hypotheses and relevant past studies. The findings have significant implications for nursing practice. MBI training may be effective in decreasing “burnout, compassion fatigue, and stress levels” and improving the wellbeing of oncology nurses, translating into improved quality of patient care (Duarte & Pinto-Gouveia, 2016, p. 106). Further studies should explore the impacts of MBI for nurses on patient outcomes and organizational variables. The studies should include in-depth interviews to give deeper insights into the efficacy of MBI.
The Institutional Review Boards of two hospitals approved the study protocol before being conducted. Patient privacy protection involved anonymous completion and returning of enclosed questionnaires to the training office. Therefore, the data collection procedures were consistent with the principle of anonymity and confidentiality. The ethical considerations related to the treatment of participants included obtaining written informed consent, absence of monetary compensation to induce participation, and voluntary participation – subjects could withdraw at any point during the study.
The outcome of the research critique is consistent with the paper’s thesis that stress-reduction strategies could be effective interventions in reducing nurse errors and improving patient outcomes. Through this appraisal, MBI has been shown to reduce compassion fatigue and stress in nurses, resulting in improved quality of nursing care. Therefore, the MBI training of nurses can help control work stress, reduce the risk of sentinel events, and achieve optimal patient care within a year.
Duarte, J., & Pinto-Gouveia, J. (2016). Effectiveness of a mindfulness-based intervention on oncology nurses’ burnout and compassion fatigue symptoms: A non-randomized study. International Journal of Nursing Studies, 64, 98–107.
Esperon, J. M. T. (2017). Quantitative research in nursing science. Escola Anna Nery, 21(1), 1-4. doi:10.5935/1414-8145.20170027
Gelling, L. (2015). Stages in the research process. Nursing Standard, 29(27), 44-49.