FEATURES The Effects of Mindfulness-based Stress Reduction on Nurse Stress and Burnout A Qualitative and Quantitative Study, Part III • Joanne Cohen-Katz, PhD • Susan Wiley, MD • Terry Capuano, MSN, MBA • Debra M. Baker, MA • Lynn Deitrick, PhD U Shauna Shapiro, PhD Part III of the study on mindfulness-based stress reduotion (MBSR) describes qualitative data and discusses the implications of the findings. Study analysis revealed that nurses found MBSR helpful. Greater relaxation and self-care and improvement in work and family relationships were among reported benefits. Challenges included restlessness, physical pain, and dealing with difficult emotions. KEYWORDS: meditation, mindfuhess, nurse, stress, stress tvanagement Holist Nurs Pract 2005,\9{2):lH-S6 An 8-week mindfulness-based stress reduction (MBSR) program, based on the University of Massachusetts Medical Center program created by Jon Kabat-Zinn,' was offered to nurse professionals at Lehigh Valley Hospital and Health Network (LVHHN). The effects of MBSR on nurse stress and burnout were studied and presented in a 3-part series. Part I reported on the rationale for offering MBSR to nurses and the process of developing and implementing a program within the LVHHN system.^ Part II of the series presented the quantitative data analysis, reporting the effects of MBSR on burnout, psychological distress, and mindfulness.-' This article, Part III, highlights qualitative data analysis. Qualitative methodology was chosen for data collection and analysis in this phase of the project for several reasons. First, the number of participants on From the Lehigh Valley Hospital and Health Network, Allentown, Pa (Drs Cohen-Katz, Wiley, and Deitrick, and Mss Capuano and Baker); and the Santa Clara University, Calif (Dr Shapiro). Corresponding author: Joanne Cohen-Katz, PhD, Lehigh Valley Hospital, Department of Family Medicine, 17th & Chew Sts, Allentown, PA 18105 (e-mail: [email protected]). Clarification: The authors of "The Effects of Mindfulness-based Stress Re- duction on Nurse Stress and Burnout, Part II: A Quantitative and Qualitative Study," Holist Nurs Pract, 2005;19(l):26-35 were listed incorrectly. The correct authors are as follows: Joanne Cohen-Katz, PhD, Susan Wiley, MD, Terry Capuano, MSN, MBA, Debra M. Baker, MA, Sharon Kimmel, MHA, PhD, and Shauna Shapiro, PhD. whom we collected quantitative data was small (Â — 25), suggesting that these measures should be interpreted with caution and supplemented with other types of analysis. Second, because almost no data exist examining the impact of MBSR on nurse burnout and stress, qualitative data allowed us to explore issues in a more open-ended way and helped uncover areas to be explored in future studies. Third, literature on the nurse as healer, explored in Part I,̂ suggested that many aspects of becoming a healer are difficult to capture through existing quantitative measures; for example, self-care, self-awareness (wounded hea.

1. FEATURES
The Effects of Mindfulness-based
Stress Reduction on Nurse Stress
and Burnout
A Qualitative and Quantitative Study, Part III
• Joanne Cohen-Katz, PhD • Susan Wiley, MD • Terry Capuano,
MSN, MBA
• Debra M. Baker, MA • Lynn Deitrick, PhD U Shauna Shapiro,
PhD
Part III of the study on mindfulness-based stress reduotion
(MBSR) describes qualitative data and discusses the
implications of the findings. Study analysis revealed that nurses
found MBSR helpful. Greater relaxation and
self-care and improvement in work and family relationships
were among reported benefits. Challenges included
restlessness, physical pain, and dealing with difficult emotions.
KEYWORDS: meditation, mindfuhess, nurse, stress,
stress tvanagement Holist Nurs Pract 2005,9{2):lH-S6
An 8-week mindfulness-based stress reduction
(MBSR) program, based on the University of
Massachusetts Medical Center program created by
Jon Kabat-Zinn,' was offered to nurse professionals at
Lehigh Valley Hospital and Health Network
(LVHHN). The effects of MBSR on nurse stress and

2. burnout were studied and presented in a 3-part
series. Part I reported on the rationale for offering
MBSR to nurses and the process of developing and
implementing a program within the LVHHN
system.^ Part II of the series presented the quantitative
data analysis, reporting the effects of MBSR on
burnout, psychological distress, and mindfulness.-'
This article, Part III, highlights qualitative data
analysis.
Qualitative methodology was chosen for data
collection and analysis in this phase of the project for
several reasons. First, the number of participants on
From the Lehigh Valley Hospital and Health Network,
Allentown, Pa (Drs
Cohen-Katz, Wiley, and Deitrick, and Mss Capuano and Baker);
and the
Santa Clara University, Calif (Dr Shapiro).
Corresponding author: Joanne Cohen-Katz, PhD, Lehigh Valley
Hospital,
Department of Family Medicine, 17th & Chew Sts, Allentown,
PA 18105
(e-mail: [email protected]).
Clarification: The authors of "The Effects of Mindfulness-based
Stress Re-
duction on Nurse Stress and Burnout, Part II: A Quantitative
and Qualitative
Study," Holist Nurs Pract, 2005;19(l):26-35 were listed
incorrectly. The
correct authors are as follows: Joanne Cohen-Katz, PhD, Susan
Wiley, MD,
Terry Capuano, MSN, MBA, Debra M. Baker, MA, Sharon
Kimmel, MHA,

3. PhD, and Shauna Shapiro, PhD.
whom we collected quantitative data was small
(Â — 25), suggesting that these measures should be
interpreted with caution and supplemented with other
types of analysis. Second, because almost no data
exist examining the impact of MBSR on nurse burnout
and stress, qualitative data allowed us to explore issues
in a more open-ended way and helped uncover areas to
be explored in future studies.
Third, literature on the nurse as healer, explored in
Part I,̂ suggested that many aspects of becoming a
healer are difficult to capture through existing
quantitative measures; for example, self-care,
self-awareness (wounded healer), and therapeutic
presence. MBSR potentially affects all of these areas,
and they are all closely related to our quantitative
outcome measures of burnout and stress. By asking
the nurses more open-ended questions, both during
and after the program's completion, we heard more of
their stories relating to these issues. In this way,
unexpected data emerged, and we had a better
understanding of the process.
Finally, as the program was taught, we were struck
by how much new, unanticipated qualitative data
emerged. To illustrate, the first 2 authors, who taught
the program, received unsolicited e-mails throughout
the course of the program, each containing stories,
poetry, or journal entries about the participant's
reactions to the experience. We believe these
communications contained rich data that added to our
78

4. Mindfulness-based Stress Reduction 79
understanding of how MBSR may be a useful tool for
reducing nurse burnout and stress.
METHODS
Procedures
In January 2004, nurses at LVHHN were recruited to
attend a 1-hour information session regarding an
8-week stress management program.^ Using various
marketing strategies, it was explained that the program
cost would be covered by a combination of each
nurse's employee wellness dollars and funds
contributed by LVHHN's Senior Vice President for
Clinical Services (the third author). Inclusion criteria
included being employed at Lehigh Valley Hospital,
holding a current position with regular patient contact,
speaking and reading English, and being at least
18 years old. Exclusion criteria included being
actively suicidal or currently abusing substances.
At the information session, participants were given
an overview of the intervention, as well as the
opportunity to sign up for the study. Those choosing to
participate were randomly assigned to the treatment
group or wait-list control group. For both groups, the
intervention consisted of an 8-week MBSR group,
modeled closely after Kabat-Zinn's MBSR program'
and run by the first 2 authors of this study.
Using identical procedures, a third cohort was
recruited in Fall 2004. Although we initially planned

5. to replicate the experimental design described earlier,
we were unable to divide the group into 2 cohorts
because of inadequate enrollment. The third cohort
received the 8-week MBSR program, which was
taught by the first author and a nurse colleague, who
recently received MBSR instructor training.
Qualitative data sources
Forty-six documents were analyzed for the qualitative
phase of the study, all generated from participants in
the 3 cohorts. The documents included "Getting to
Know You" forms, weekly evaluation forms, final
evaluation forms, e-mails, interviews, and a focus
group. Although all cohorts filled out the Getting to
Know You form (Table 1), these forms were only
available for analysis from the third cohort.
Participants filled out the weekly evaluation forms as
they were participating in the program, with final
evaluation forms filled out on the last night of the
program. The open-ended questions included on these
forms are shown in Table 2. In addition, 16 unsolicited
TABLE 1. Getting to know you
1. Tell us about any challenges or stressors that you face
related to your family and your work. A brief summary
is fine.
2. How do you relax? Please include the role alcohol
and/or drug use plays in your relaxation.
3. Please list any medical problems you may have.
Are you currently receiving medical treatment?
What medications do you take?
Do you have any physical limitations that we should

6. know about?
4. Are you experiencing behavioral, emotional, or mental
problems? Are you receiving treatment?
5. Have you experienced any abuse (physical, sexual, or
emotional)? If yes, feel free to tell us anything you think
might be relevant.
e-mails were received from 7 participants of the first 2
cohorts, during the program and several months
postgraduation.
There were 2 types of depth interviews. First, a
hospital newsletter journalist interviewed 4 graduates
of the first cohort for the purpose of writing an article
to be used to market the program. The hospital
TABLE 2. Weekly and final evaluation forms*
Weekly evaluation form
General comments:
Class practice:
I learned tonight:
I am challenged tonight by:
What would "improve" my experience is:
Final evaluation form
Do you get something of lasting value or importance
from MBSR?
yes no
If yes, please state what you got from MBSR:
Have you made any lifestyle changes as a result

7. of MBSR?
yes no
If yes, please state what they are:
As a result of greater awareness developed through
meditation, has your relationship to your thoughts and
feelings and your reactions to them changed?
yes no
If yes, please state how:
General comments:
Please rate the overall value of the MBSR program.
On a scale of 1 to 10, please rate how important
MBSR has been for you (1 means not at all important
and 10 means very important):
•MBSR indicates mindfulness-based stress reduction.
80 HOLISTIC NURSING PRACTICE • MARCH/APRIL 2005
marketing department solicited the interviewees by
generating e-mails to all members of the first cohort,
asking for volunteers to be interviewed. Of the 8
graduates who volunteered, 4 were chosen on the basis
of ease of scheduling.
Second, the first author conducted 2 interviews with
the fourth author, the Vice President for Clinical
Services, about her view of the program. Both
interviews were held after the completion of the first 2

8. cohorts. The intention of the first interview was to
learn more about the Vice President's motivation for
supporting the MBSR program; the second interview
was designed to learn her impression of program
results, based on nurse employee contact. In addition,
the first author interviewed the nurse
participant/observer at the completion of the second
cohort's MBSR group to determine her impressions of
the program and its impact on her nurse colleagues.
The questions used in the depth interviews are
represented in Table 3.
The focus group was conducted with 7 of 25 MBSR
graduates from the first 2 cohorts. The moderator, a
family physician, had completed MBSR training, as
well as professional MBSR teacher training with Drs
Kabat-Zinn and Santorelli. Participants were invited
(via e-mail) to attend a graduates' gathering, which
would include a 1-hour refresher course and a 1-hour
focus group. Owing to scheduling and other
difficulties, of the 16 who wanted to attend, only 7
actually attended. The focus group moderator's guide
is shown in Table 4.
Data analysis
To guide thematic analysis of project documents, a
32-item codebook was developed as a collaborative
effort by the research team. The codebook was tested
using a random sample of 5 interview documents.
Transcripts were read for content and theme by the
project principal investigator, as well as by a research
assistant and hospital ethnographer. Each member
independently coded the 5 transcripts by hand, using
the preliminary 32-item codebook. At this time, the

9. analysis team compared coding results and agreed that
the codebook was cumbersome and that not all codes
were necessary.
TABLE 3. Interview questions
MBSR graduates:
1. What type of work do you do?
2. Why did you decide to take this seminar?
3. What did you learn?
4. No longer going to the training, how do you keep in touch on
a daiiy basis?
5. What does it mean to be mindful, specifically in your work?
6. What changes do you notice in your work now? Do you do
anything differently?
7. Has this training affected your personal life?
8. Would you recommend this class to others?
Nurse observer (MBSR trainee):
1. Please share some stories that have been shared with you by
MBSR graduates who are practicing nurses about fhe impact
of MBSR training on their lives.
2. What was your experience of watching the nurses go through
the MBSR program?
3. Did anything about watching the nurses surprise you?
4. Is watching a patients' group different from watching a
nurses' group?
Vice president of clinical services (regarding motivation to
support program):

10. 1. How many nurses are in the LVHHN system?
2. What sparked your interest in supporting the MBSR program?
3. You stated that recently you hear a lot about stress from the
nursing staff. Were you aware of that before?
4. What other programs have been offered to help nurse
retention?
5. Does your data show that retention has changed?
6. Are you Interested in measuring any other variable other than
burnout, psychological distress, self-compassion, mindfulness,
and iife-satisfaction?
Vice president of clinical services (regarding impression of
program results)
1. Do you have a sense of how many nurses have given you
feedback regarding the MBSR program?
2, What was the nature of the feedback?
•MBSR indicates mindfulness-based stress reduction; LVHHN,
Lehigh valley Hospital and Health Network.
Mindfulness-based Stress Reduction 81
TABLE 4. Focus group questions
1. What changes occurred in the way you think about
taking care of yourself, if any?
2. What changes occurred in the way you perceive and
react to stressful events, if any?
3. How has practicing mindfulness changed your

11. perception of your daily life?
4. How did you choose to be mindful in your daily life?
How did that work out? Are you still using these
mindfulness reminders?
5. What did you notice about your energy or interest
levels during or after mindfulness groups? Before the
series, compared with the end of the series?
6. Have you changed how you interact with your
supervisor or colleagues?
7. Have you changed how you interact with your
partner, children, or parents?
8. Have you changed how you interact with the "rest of
the world"?
9. Have you changed your perception of how any of
these people interact with you?
10, Mindfulness groups are a journey into the self. What
did you learn about you during this journey?
11, What are you doing to keep mindfulness alive within
you? How can we help support and nurture your
continued mindfulness?
number of children living at home was 1 (range —
0-3). The average employment in the healthcare field
was 21 years (range = 2^1) , with an average of
13 years' employment at LVHHN (range = 25-30)
and 7 years' employment in their current position
(range = 25-25). The majority (90%) were nurses, but
the sample also included persons employed in pastoral

12. care, respiratory therapy, and social work. The
participants were employed in various departments
throughout the hospital, including Behavioral
Health, Cancer Center, Cardiac Catheterization Lab,
Diabetes Center, Labor and Delivery, and the Float
Pool.
The mean age of the third cohort was 47 years
(range = 30-64). The participants were all white
females (100%) and the majority (81%) reported
being married. The mean of children living at home
was 1 (range = 0-2). Employed in the healthcare
field for an average of 23 years (range = 10-43), they
had been employed at LVHHN for an average of 12
years (range = 4 months to 23 years). Predominently
nurses (81%), the sample also included a social
worker, a physical therapist, and an occupational
therapist.
A consensus process further reduced the
codebook items. Consensus was achieved when at
least 2 of 3 researchers agreed on the coding for each
paragraph of the 5 "test transcripts," with the revised,
6-item coding scheme. The remaining 41 documents
were then coded by the principal investigator and
reviewed by the research team, using the new 6-item
codebook.
After consensus coding was completed by hand, it
was transferred into the computer for analysis, using
NVivo"* software, because the data were predominently
text data. Printouts for each code (node) were retrieved
and analyzed to understand informant perspectives on
each topic, or node. The final coding scheme, with
sample quotes from each category, is shown in
Table 5.

13. RESULTS
Sample
In the first 2 cohorts, the mean participant age was
46 years (range = 32-60). The sample was all-female
(100%), with 96% of participants being Caucasian.
The majority (65%) reported being married. The mean
Reasons for MBSR program participation
Fifteen nurses were represented in this node: 11 who
completed the Getting to Know You Form and 4 who
were interviewed by the journalist. In response to the
question, "Tell us about your stressors," 12 of 15
(80%) mentioned family stressors first, before any
work stressors. The most common family stressor
was aging, illness, or recent death of a family
member {n = 9; 60%). Other stressors were
significant family conflict (n = 3; 20%): parenting
issues (n — 5; 33%); balancing work and family
(n = 3; 20%); and having a child in Iraq (n = 1, 7%).
Three respondents (20%) listed work stressors first,
including the challenge of working part-time (n = 2;
13%) and performance anxiety at work (n = 1; 7%).
Both part-time employees had young children and felt
conflict between wanting to be at home with their
children and needing to be at work.
Among the 15 respondents, other work stressors
included demanding jobs {n — 4; 27%), learning
a new job (n = 3; 20%), and a changing work
environment {n — 2; 13%). Nonfamily and nonwork
stressors in this group included moving {n — 3; 20%),

14. illness in a close friend (n = 1; 7%), and bankruptcy
82 HOLISTIC NURSING PRACTICE • MARCH/APRIL 2005
TABLE 5. MBSR codebook and sample quotes
I. Reasons for participating in the MBSR program
a. Family stressors
"I'm parenting two teenagers, my mother is aging and lives with
us, and my father died in the past year. Also, my eldest child is
in
Iraq."
b. Work stressors
"Challenged by work changes, and I'm the only one on at night
who can do my role."
II. Challenges of participating in the MBSR program
a. Restlessness
"It's very hard to stay focused and concentrate. My mind is
everywhere."
b. Physical pain and/or medical issues
"I felt pain in my right arm during the entire body scan."
c. Dealing with difficult emotions
"This weekend, I found it extremely difficult get back to
practice. After the retreat I had many negative feelings. Glad I
pushed myself
to practice."
d. Work-related issues (logistics)

15. "It's hard to leave on time from work so that I arrive on time to
class."
e. Sleepiness
"Had difficulty getting through the exercise without falling
asleep. This week I'll change the time of day and position to see
if It gets
easier."
f. Weather and driving
"My biggest challenge is getting off work on time to get here."
g. Finding time to do the homework
"This week was a challenge to find the time to get to the
homework."
h. Feeling distracted by others in the group
"I'm challenged by the responses of others."
i. Guilt
"I feel guilty about taking the time for myself to do this."
III. Benefits of participating in the MBSR program
a. Increased relaxation/calmness
"I'm feeling a greater calm and peace." Learning to be present
"I'm learning to focus more on the moment."
b. Self-acceptance/self-compassion
"It's okay that I'm distracted when I practice. I can accept my
thoughts and let them pass."
c. Self-awareness
"I'm much more aware of my feelings and thoughts during
stressful events."

16. d. Self-care
"I'm worrying about my own needs first, and trying to take care
of them."
e. Feeling more self-reliant
"Every time I practice, I'm encouraged that I can do this, and I
can take care of myself"
(also coded as self-care)
f. Decreased physical pain
"My pain has improved."
g. Improved sleep
"I always sleep better after the body scan."
IV. Impact of MBSR on relationships
a. Feeling more connected to others in the group
"By listening to others tonight, I realized I'm not so different."
(also coded as a benefit: self-acceptance)
b. Wanting to fix others in the group
"I find myself wanting to fix others in the group and having
trouble staying focused on myself."
(also coded as a challenge: wanting to fix others in the group)
c. Communication
"I'm starting to become aware of other people's needs when I
communicate. I listen more and talk less."
d. Increased presence in relationships
"As a result of this course, I've more to give to others. That
"more" is patience, presence, and caring."
e. Able to be less reactive in relationships (less defensive)
"I find I'm reacting less and stepping back and looking at the

17. bigger picture more."
f. Increased self-confidence in relationships
"I'm more confident because I know what my needs are and how
to express them."
g. Teaching techniques to others
"I use the body scan every night with my daughter to help her
sleep."
h. Increased empathy/appreciation of others
"I think I'm kinder and less judgmental of others now."
V. Overall value of the course
"I totally enjoyed being part of the stress management program.
It's a very effective method to help healthcare workers. Patients
and
coworkers benfit from the change in me. I hope many others get
to do this class!"
VI. How to maintain the practice over time
"I want you to know I just bought a book on mindfulness and
am enjoying it tremendously!"
Mindfulness-based Stress Reduction 83
Challenges of MBSR program participation
Overall, 88 comments, from all 25 participants, were
coded that related to the node of challenges, with the
most common being restlessness, pain and/or medical
issues, and dealing with difficult emotions.
Restlessness was mentioned by 13 of 15 nurses (52%;

18. 17 comments). Typical comments were, "My mind is
everywhere," "My body feels restless," and "It's so
hard to concentrate!" Comments about restlessness
peaked in Week 2, however, and declined thereafter.
Similarly, physical pain and/or medical issues
(7 nurses; 28%) were mentioned frequently in the early
weeks of the program; these comments peaked during
Week 4 and were not mentioned again after Week 5.
Five nurses (20%; 10 comments) discussed dealing
with difficult emotions that surfaced during the
program. Interestingly, the frequency of their
comments increased in the later weeks. A typical
quote was, "The body scan caused me to abruptly tear
up. I felt sadness and anxiety, seemingly out of
nowhere." This nurse wrote frequently in her weekly
evaluations (and shared privately with the teachers)
about intense flashbacks of childhood abuse incidents
that were emerging during the program. Nevertheless,
she completed the program. Other challenges are
listed in Table 5.
Benefits of MBSR program participation
Analyses of the data revealed significant benefits of
the MBSR program. Data sources are divided into 2
categories, those mentioned during or on completion
of the program and those mentioned after the program
had been completed for several weeks or months.
Data collected during program
In the early weeks of the program, most benefits
were related to increased relaxation, slowing down,
feeling a sense of peace, and learning how to be in the
present moment. Interestingly, no benefits were

19. mentioned in weeks 3 and 4. A large increase in
comments relating to self-acceptance, self-awareness,
and self-care (14 of 25 nurses; 18 comments) occurred
in Week 5, which continued through Week 8 and the
final evaluation. Tbe following are samples from each
category:
• Self-acceptance/self-compassion: "I'm important." "I
have needs."
• Self-awareness: "I've learned that my emotions
affect my body and that there are physiologic changes
that go with my thoughts." "I can feel healing hap-
pening in meditation. I've stuffed/suppressed a lot
inside." This comment was clarified in an e-mail to
tbe first author. Apparently, during one meditation,
the participant began to relive a childhood experience
in which a family member disappeared (ran away).
She not only blamed herself for what happened but
also had never forgiven herself. Now, she realized that
this childlike perception of what happened could be
reevaluated.
• Self-care: "I stop when a difficult problem arises. I
think about my needs and orally state them to myself,
and then try to address my needs."
Postprogram data
Of the 4 women interviewed by the journalist, all
reported increased patience, calmness, or relaxation as
a primary benefit of tbe program. One participant
stated, "I used to stand by the microwave, impatient
that the food wasn't cooking fast enough. Now, I can
step back when I start to do that, laugh, and then slow

20. down." One woman reported she was not aware of
anger related to her divorce until the MBSR program
helped her feel free to release some anger and to move
forward (increased self-awareness).
Three of 4 participants felt more confident in the
work setting; 2 mentioned improved public speaking.
Other benefits included better sleeping, driving skills,
and work prioritization; more conscious eating habits;
and enhanced spirituality. The respondent who noted
more conscious eating habits after taking MSBR lost
weight successfully.
In the focus group, 5 of 7 women listed different
ways they were taking care of themselves, including
taking time after work before focusing on the children,
letting go of perfectionism regarding cooking and
cleaning, healthy eating, and exercising. Other
comments included increased calmness and
self-confidence and being in the moment. One
participant stated, "I've learned to do 1 day at a time, 1
duty at a time, 1 thing at a time." Another shared that
she now had the confidence to walk into a car
dealership alone and buy the car she wanted, including
negotiating the price—for the first time!
Impact of MBSR on relationships
Data collected during the program
In the weekly evaluations, 19 of 25 nurses (37
comments) dealt with relationships. One interesting
theme that emerged was a collection of comments

21. 84 HOLISTIC NURSING PRACTICE • MARCH/APRIL 2005
describing the benefit ofthe MBSR group setting. Of
25 nurses, 6 noted that hearing the other participants'
stories was therapeutic. Most of these comments are
reflected in the following quote, "I'm grateful to hear
others' stories. There's always someone handling
bigger life problems than I am. I feel blessed."
Another theme was a difficulty letting go of worry
about others. The tone ofthe comments were similar to
the nurse who wrote, "I'm having trouble focusing on
myself and not others' problems. It's the nurse in me."
The curriculum for weeks 6 and 7 explicitly
covered improved communications in relationships.
Interestingly, 14 comments (14 nurses) were coded in
weeks 6 and 7, listing improved communication in
relationships as a benefit. A sample comment was,
"I'm learning that my feelings and needs are important
and should be communicated effectively." Five
comments (5 participants) were included in the final
evaluation forms that directly related to improvements
in communication.
During the course, one nurse described how MBSR
had helped her attend to relationships with more
appreciation, "When trying to find a pleasant event, I
kept looking for something really big. Then I realized
that the simple interactions with others in my life are
the ones that are the most pleasurable—really noticing
how it feels when my husband's arms are around me
in bed or hugging my child and stroking her hair, or
feeling my dog's wet nose on my hand after her bath!"
(Note: the term pleasant event refers to an assignment
in which participants were asked to fully pay attention

22. during a pleasant event in their lives).
Postprogram comments (depth interviews, focus
group, postprogram e-mails)
One theme that clearly emerged among
participants in the focus group was being fully
present in relationships without becoming as
reactive or defensive; 6 of 9 nurses commented
on this theme. One nurse supervisor stated,
"I hear and listen to complaints or demands now
without being drawn in. I'm able to think that they're
just telling their story and how they see it. It doesn't
mean that it's the only story." Another nurse stated, "I
don't react as much. Things aren't personal or
intentional, people are just people, doing the best they
can in most situations."
The capacity to be nonreactive appears to have
affected various relationships. One supervisor believed
she had become fairer and more consistent in
assigning time and time off because she felt less
"hooked" (reactive) when people complained about
not getting exactly what they wanted. This tendency to
be less reactive may explain another change that one
nurse described in her workplace relationships: "I'm
much less interested in getting involved in gossiping
and griping about colleagues. I'm just not as upset as
much, so I don't find myself complaining about
others." Another nurse reported being less defensive in
family relationships: "I've been taking care of my new
granddaughter some. When my daughter doesn't want
my help, I feel much less defensive! I'm there if she
needs me, but I don't push myself on her now."

23. Increased nonreactivity may be related to another
theme in this data set: increased self-confidence. Of 9
nurses, 5 commented in this area. As one nurse in the
focus group stated, "I'm much clearer in my
statements of my own needs."
Therapeutic presence, which was noted as a key
attribute of the healing relationship, was discussed in
various contexts, including patient care. Of 9 women
in the interview and focus groups, 3 expressed
becoming more present for their patients. One nurse
said, "When you take care of yourself, you just have
more to give. I'm more focused on my patients now,
even though they probably wouldn't know it!"
Four women believed they were more present in
their relationships with their children, grandchildren,
and spouses. For example, "I spend more time with
my children and listen to them, without focusing on
the distractions around me. I used to read their
bedtime stories and would still be listening for the
dryer buzzer; now I'm actually aware of what I'm
reading and how my children are responding."
In addition, 6 women in the first 2 cohorts
reported teaching the techniques to family members
(children, 5; sister, 1) to help them relax. One woman
stated (via e-mail), "I do want you to know that I'm
now practicing Monday through Thursday. My
daughter does it with me. We do the yoga and the
body scan first thing in the morning and then the rest
of the day is awesome... Thanks for such a wonderful
gift."
Increased empathy and appreciation of others was
another similar theme that emerged. One nurse told

24. this story, "We had a family birthday party for my
mother and, normally, I'm just running around
frantically. But this time, I found myself stopping
and noticing all the work my sister had put into the
decorations—something I don't think I'd ever
seen in the past. I thanked her and think she was
shocked!"
Mindfulness-based Stress Reduction 85
As another example, after the program ended, one
nurse's 2 adult children moved back home after being
laid off from work. Previously, this may have been
experienced as a demand for greater caregiving;
however, she reported feeling more empathy and
understanding and less pressured to "fix the problem."
Overall value of MBSR program
The course value was reflected in the data in several
ways. First, the nurses were asked to rate the value of
the program on a scale from 0 to 10 (overall mean =
9.2; standard deviation = 0.97). The positive feedback
and goodwill generated by the program surprised the
fourth author. She was delighted to receive thank-you
cards and e-mails from about 80% of the program
participants, which again reflects a positive and
enthusiastic response. In addition, final evaluations
contained 12 responses stating that the course was
extremely valuable. Perhaps the most enthusiastic
comment came from a nurse in the first cohort,
"Absolutely awesome! Should be mandatory for all
employees at least every 5 years."

25. Moreover, the program generated requests to
present our work in various hospital settings: another
way to measure the course's overall value. All of these
requests resulted from word-of-mouth
recommendations by the graduates. One nurse, for
example, suggested we present the mindfulness work
to a group of colleagues involved in a leadership
training program; another nurse invited us to a group
that was meeting regularly to improve the work
environment.
Maintaining the MBSR practice
During weeks 7 and 8, the nurses realized the
challenge of moving forward without the formal
structure of the MBSR group. Several nurses (5 of 25)
expressed this concern in their weekly or final
evaluations, for example, "I'm sad that this group is
ending," "I'll miss the support," and "I wonder: Will I
be able to keep this going?"
Several informal networks were created in the
hospital system as an outlet for nurses to maintain
their practice. Prior to this project, a nurse graduate
from our ongoing treatment group formed a monthly
peer support group, in which meditation tapes are
played and discussions are held about the practice. In
addition, one nurse graduate requested the nurse
participant/observer in the second cohort to develop a
mutual practice time during the workday. Twice a
week, they practice a 20-minute meditation during
their lunch hour. Several nurses from the second
MBSR class requested this same nurse to also practice
with them. The first author has received e-mails from
3 participants, telling her how their practice is going

26. and reporting purchasing books and tapes to help them
further pursue their mindfulness studies.
When asked what would help maintain a long-term
practice, focus group participants responded, "Place
mindfulness materials in the hospital libraries," "Send
frequent e-mails with poetry and inspirational quotes
throughout the year," "Plan a weekend retreat for
nurses," and "Provide bibliographies of available
material." Presently, nurses are invited to attend all
future retreats that are given as part of the ongoing
MBSR classes.
DISCUSSION
Originally, we hypothesized that MBSR would be
especially useful for nurses at LVHHN because the
nursing staff is 94% women (average age = 44). We
predicted that balancing work and family would be a
significant issue for nurses, who may be raising
children while also caring for aging parents.
Furthermore, we believed that nurses are
particularly vulnerable to burnout because they are
often identified in the family or neighborhood as the
person to rely on in a medical crisis.^ Study data
support this assessment. Overall, family stressors
were more prevalent in this sample than work
stressors, with illness, recent death, or an aging family
member most commonly cited. Although nurses
clearly face a stressful work environment, it may be
just one facet of their challenge; they may go home to
a family situation that also includes intensive
caregiving—to children, parents, and friends and/or
relatives who are ill.
The theme of caring for others before caring for

27. oneself was highly relevant. As previously mentioned,
nurses are often socialized to care for everyone but
themselves. During the course, several nurses
expressed feeling guilty when caring for themselves;
they found themselves wanting to fix everyone else in
the group! As one stated, "It's the nurse in me!" As the
nurses acknowledged their needs and humanness, they
began to develop greater self-kindness and reported a
dramatic shift in their capacity to care for themselves.
As teachers, a moving aspect of this work was
observing this shift. The participants reported
86 HOLISTIC NURSING PRACTICE • MARCH/APRIL 2005
enjoying the simple pleasures around them, such as
practicing meditation without guilt or even feeling the
pleasure of a dog nuzzling them! For some, self-care
included caring for their health: their skin, their need
for exercise, and their desire for healthy eating. The
program participants became more aware of their
needs and more committed to communicating these
needs to others.
The impact of MBSR was felt throughout each
participant's relationship network. Participants
observed positive changes in their relationships with
spouses, children, and colleagues. They were more
fully present with others. They also reported paying
more attention to their current patient, rather than
thinking about tbe next assignment or where they were
going next. In addition, they noted becoming less
reactive and defensive in work and family
relationships.

28. Although we initially predicted that the nurses
would experience greater presence and less reactivity,
other findings in the area of work relationships were
unexpected. We were surprised (and delighted) to
learn that one nurse supervisor had become fairer and
more consistent and that one nurse was less interested
in gossiping and complaining. These findings are
promising because they suggest the potential of
MBSR to transform, not only individual relationships
but also the overall work environment.
Self-awareness is another area raised^ as critical for
the nurse as healer.^ Data affirmed MBSR as a useful
intervention for helping resolve old wounds and
unresolved issues. Interestingly, nurses in the
beginning of the program were challenged primarily
by restlessness. As they progressed and, presumably,
their minds began to settle down, unresolved
emotional issues began to surface. Some of these
issues included an unrecognized abuse history, a
long-suppressed sadness about an ended marriage, a
troubling sense of guilt about a childhood event, and a
pervasive sense of resentment that was largely unseen
by the participant. For the participants, becoming
aware of tbe wound was both painful and ultimately
extremely useful, helping them to move forward in
their lives.
SUMMARY
This study provides evidence for tbe importance of
continuing to explore the long-term impact of MBSR.
Tbe analysis of qualitative textual materials enhanced
our understanding of MBSR's impact on a nursing
population and helped determine possible directions
for future research. Relationship findings suggest the

29. importance of exploring methods for assessing the
impact of MBSR on family relationships and work
environments from both patient and other
perspectives. For example, do patients, colleagues, and
family members of nurses who have received
mindfulness training experience a difference? Do
these differences result in greater patient satisfaction
and improved patient outcomes, and improved work
and family environments? Also, as quantitative
measures largely explored work stress, other measures
that assess family stress would be relevant, given the
prevalence of caregiving burdens at home.
Finally, these qualitative data demonstrate that
MBSR is valuable for nurses. To realize MBSR's full
potential, it is critical to continue to explore it from a
range of methodological glasses. Questions for future
research include: What support is needed to continue
practicing these techniques and this approach to life?
How can the interventions be most accessible and most
useful? What benefits and challenges are experienced
over time? Most important, we have realized that
practicing mindfulness is a lifelong endeavor—one
that requires a great deal of support and ongoing effort.
REFERENCES
1. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of
Your Body
and Mind to Face Stress, Pain, and Illness, New York: Delta;
1990.
2. Cohen-Katz J, Wiley S, Capuano T, Baker D, Shapiro S. The
effects of
mindfulness-based stress reduction on nurse burnout and stress:
a quan-

30. titative and qualitative study. Holist Nurs Pract,
2004;18(6):302-308.
3. Cohen-Katz J, Wiley S, Capuano T, Baker D, Kimmel S. The
effects
of mindfulness-based stress reduction on nurse burnout and
stress: a
quantitative and qualitative study, Part II. Holist Nurs Pract,
2005; 19( 1):
26-35.
4. Gibbs GR. Qualitative Data Analysis, Explorations With
NVivo, Philadel-
phia: Buckingham; 2002.
5. Nouwen H. The Wounded Healer Garden City, NY: Image
Books; 1979.
Document
Professor Suggestions for the Highest Possible Grade
1. Utilize elements discussed regarding "RISK", types and
approaches for analysis.
2. Provide "your" best opinion and support it with at five are
more references.
3. Paper must have complete thoughts for each question.
4. It is recommended that "charting (those we have discussed,
Gant, Prato, histogram, flow chart, etc.)" be
used in your responses as a graphic demonstration of your

31. answer.
5. The "Conclusion" for your paper must reflect your
understanding of "risk" as it applies to "Supply Chain
Management" for the specific Case Study you have been
assigned.
××
1
Branching Paths: A Novel Teacher Evaluation Model for
Faculty Development
James P. Bavis and Ahn G. Nu
Department of English, Purdue University
ENGL 101: First Year Writing
Dr. Richard Teeth
January 30, 2020
Commented [AF1]: At the top of the page you’ll see the
header, which does not include a running head for student

32. papers (a change from APA 6). Page numbers begin on the
first page and follow on every subsequent page without
interruption. No other information (e.g., authors' last names)
is required.
Note: your instructor may ask for a running head or your last
name before the page number. You can look at the APA
professional sample paper for guidelines on these.
Commented [AF2]: The paper's title should be centered,
bold, and written in title case. It should be three or four lines
below the top margin of the page. In this sample paper, we've
put four blank lines above the title.
Commented [AF3]: Authors' names are written below the
title, with one double-spaced blank line between them.
Names should be written as follows:
First name, middle initial(s), last name.
Commented [AF4]: Authors' affiliations follow
immediately after their names. For student papers, these
should usually be the department containing the course for
which the paper is being written.
Commented [AWC5]: Note that student papers in APA do
not require author notes, abstracts, or keywords, which
would normally fall at the bottom of the title page and on the
next page afterwards. Your instructor may ask for them
anyway — see the APA professional sample paper on our
site for guidelines for these.
Commented [AF6]: Follow authors' affiliations with the
number and name of the course, the instructor's name and
title, and the assignment's due date.

33. 2
Branching Paths: A Novel Teacher Evaluation Model for
Faculty Development
According to Theall (2017), “Faculty evaluation and
development cannot be considered
separately… evaluation without development is punitive, and
development without evaluation is
guesswork” (p.91). As the practices that constitute modern
programmatic faculty development
have evolved from their humble beginnings to become a
commonplace feature of university life
(Lewis, 1996), a variety of tactics to evaluate the proficiency of
teaching faculty for development
purposes have likewise become commonplace. These include
measures as diverse as peer
observations, the development of teaching portfolios, and
student evaluations.
One such measure, the student evaluation of teacher (SET), has
been virtually ubiquitous
since at least the 1990s (Wilson, 1998). Though records of SET-
like instruments can be traced to
work at Purdue University in the 1920s (Remmers &
Brandenburg, 1927), most modern histories

34. of faculty development suggest that their rise to widespread
popularity went hand-in-hand with
the birth of modern faculty development programs in the 1970s,
when universities began to
adopt them in response to student protest movements criticizing
mainstream university curricula
and approaches to instruction (Gaff & Simpson, 1994; Lewis,
1996; McKeachie, 1996). By the
mid-2000s, researchers had begun to characterize SETs in terms
like “...the predominant measure
of university teacher performance [...] worldwide” (Pounder,
2007, p. 178). Today, SETs play an
important role in teacher assessment and faculty development at
most universities (Davis, 2009).
Recent SET research practically takes the presence of some
form of this assessment on most
campuses as a given. Spooren et al. (2017), for instance, merely
note that that SETs can be found
at “almost every institution of higher education throughout the
world” (p. 130). Similarly,
Darwin (2012) refers to teacher evaluation as an established
orthodoxy, labeling it a “venerated,”
“axiomatic” institutional practice (p. 733).

35. Commented [AF7]: The paper's title is bolded and
centered above the first body paragraph. There should be no
"Introduction" header.
Commented [AWC8]: Here, we've borrowed a quote from
an external source, so we need to provide the location of the
quote in the document (in this case, the page number) in the
parenthetical.
Commented [AWC9]: By contrast, in this sentence, we've
merely paraphrased an idea from the external source. Thus,
no location or page number is required. You can cite a page
range if it will help your reader find the section of source
material you are referring to, but you don’t need to, and
sometimes it isn’t practical (too large of a page range, for
instance).
Commented [AWC10]: Spell out abbreviations the first
time you use them, except in cases where the abbreviations
are very well- known (e.g.,
"CIA").
Commented [AWC11]: For sources with two authors, use
an ampersand (&) between the authors' names rather than the
word "and."
Commented [AWC12]: When listing multiple citations in
the same parenthetical, list them alphabetically and separate
them with semicolons.
3
Moreover, SETs do not only help universities direct their
faculty development efforts.

36. They have also come to occupy a place of considerable
institutional importance for their role in
personnel considerations, informing important decisions like
hiring, firing, tenure, and
promotion. Seldin (1993, as cited in Pounder, 2007) finds that
86% of higher educational
institutions use SETs as important factors in personnel
decisions. A 1991 survey of department
chairs found 97% used student evaluations to assess teaching
performance (US Department of
Education). Since the mid-late 1990s, a general trend towards
comprehensive methods of teacher
evaluation that include multiple forms of assessment has been
observed (Berk, 2005). However,
recent research suggests the usage of SETs in personnel
decisions is still overwhelmingly
common, though hard percentages are hard to come by, perhaps
owing to the multifaceted nature
of these decisions (Boring et al., 2017; Galbraith et al., 2012).
In certain contexts, student
evaluations can also have ramifications beyond the level of
individual instructors. Particularly as
public schools have experienced pressure in recent decades to
adopt neoliberal, market-based

37. approaches to self-assessment and adopt a student-as-consumer
mindset (Darwin, 2012;
Marginson, 2009), information from evaluations can even
feature in department- or school-wide
funding decisions (see, for instance, the Obama
Administration’s Race to the Top initiative,
which awarded grants to K-12 institutions that adopted value-
added models for teacher
evaluation).
However, while SETs play a crucial role in faulty development
and personnel decisions
for many education institutions, current approaches to SET
administration are not as well-suited
to these purposes as they could be. This paper argues that a
formative, empirical approach to
teacher evaluation developed in response to the demands of the
local context is better-suited for
helping institutions improve their teachers. It proposes the
Heavilon Evaluation of Teacher, or
Commented [AWC13]: Here, we've made an indirect or
secondary citation (i.e., we've cited a source that we found
cited in a different source). Use the phrase "as cited in" in the
parenthetical to indicate that the first-listed source was
referenced in the second-listed one.

38. Include an entry in the reference list only for the secondary
source (Pounder, in this case).
Commented [AWC14]: Here, we've cited a source that
has an institution as author rather than one named person.
The corresponding reference list entry would begin with "US
Department of Education."
Commented [AWC15]: Sources with three authors or
more are cited via the first-listed author's name followed by
the Latin phrase "et al." Note that the period comes after "al,"
rather than "et."
4
HET, a new teacher assessment instrument that can strengthen
current approaches to faculty
development by making them more responsive to teachers’ local
contexts. It also proposes a pilot
study that will clarify the differences between this new
instrument and the Introductory
Composition at Purdue (ICaP) SET, a more traditional
instrument used for similar purposes. The
results of this study will direct future efforts to refine the
proposed instrument. Methods section,
which follows, will propose a pilot study that compares the
results of the proposed instrument to
the results of a traditional SET (and will also provide necessary

39. background information on both
of these evaluations). The paper will conclude with a discussion
of how the results of the pilot
study will inform future iterations of the proposed instrument
and, more broadly, how
universities should argue for local development of assessments.
Literature Review
Effective Teaching: A Contextual Construct
The validity of the instrument this paper proposes is contingent
on the idea that it is
possible to systematically measure a teacher’s ability to teach.
Indeed, the same could be said for
virtually all teacher evaluations. Yet despite the exceeding
commonness of SETs and the faculty
development programs that depend on their input, there is little
scholarly consensus on precisely
what constitutes “good” or “effective” teaching. It would be
impossible to review the entire
history of the debate surrounding teaching effectiveness, owing
to its sheer scope—such a
summary might need to begin with, for instance, Cicero and
Quintilian. However, a cursory
overview of important recent developments (particularly those

40. revealed in meta-analyses of
empirical studies of teaching) can help situate the instrument
this paper proposes in relevant
academic conversations.
Commented [AF16]: Common paper sections (literature
review, methods, results, discussion) typically use Level 1
headings, like this one does. Level 1 headings are centered,
bolded, and use title case. Text begins after them as a new
paragraph.
Commented [AF17]: This is a Level 2 heading: left
aligned, bolded, title case. Text begins as a new paragraph
after this kind of heading.
5
Meta-analysis 1
One core assumption that undergirds many of these
conversations is the notion that good
teaching has effects that can be observed in terms of student
achievement. A meta-analysis of
167 empirical studies that investigated the effects of various
teaching factors on student
achievement (Kyriakides et al., 2013) supported the
effectiveness of a set of teaching factors that

41. the authors group together under the label of the “dynamic
model” of teaching. Seven of the
eight factors (Orientation, Structuring, Modeling, Questioning,
Assessment, Time Management,
and Classroom as Learning Environment) corresponded to
moderate average effect sizes (of
between 0.34–0.41 standard deviations) in measures of student
achievement. The eighth factor,
Application (defined as seatwork and small-group tasks oriented
toward practice of course
concepts), corresponded to only a small yet still significant
effect size of 0.18. The lack of any
single decisive factor in the meta-analysis supports the idea that
effective teaching is likely a
multivariate construct. However, the authors also note the
context-dependent nature of effective
teaching. Application, the least-important teaching factor
overall, proved more important in
studies examining young students (p. 148). Modeling, by
contrast, was especially important for
older students.
Meta-analysis 2
A different meta-analysis that argues for the importance of
factors like clarity and setting

42. challenging goals (Hattie, 2009) nevertheless also finds that the
effect sizes of various teaching
factors can be highly context-dependent. For example, effect
sizes for homework range from
0.15 (a small effect) to 0.64 (a moderately large effect) based
on the level of education examined.
Similar ranges are observed for differences in academic subject
(e.g., math vs. English) and
student ability level. As Snook et al. (2009) note in their critical
response to Hattie, while it is
Commented [AF18]: This is an example of a Level 3
heading: left aligned, bolded and italicized, and using title
case. Text starts as a new paragraph after this. Most papers
only use these three levels of headings; a fourth and fifth
level are listed on the OWL in the event that you need them.
Many student papers, however, don’t need more than a title
and possibly Level 1 headings if they are short. If you’re not
sure about how you should use headings in your paper, you
can talk with your teacher about it and get advice for your
specific case.
Commented [AWC19]: When presenting decimal
fractions, put a zero in front of the decimal if the quantity is
something that can exceed one (like the number of standard
deviations here). Do not put a zero if the quantity cannot
exceed one (e.g., if the number is a proportion).
6

43. possible to produce a figure for the average effect size of a
particular teaching factor, such
averages obscure the importance of context.
Meta-analysis 3
A final meta-analysis (Seidel & Shavelson, 2007) found
generally small average effect
sizes for most teaching factors—organization and academic
domain- specific learning activities
showed the biggest cognitive effects (0.33 and 0.25,
respectively). Here, again, however,
effectiveness varied considerably due to contextual factors like
domain of study and level of
education in ways that average effect sizes do not indicate.
These pieces of evidence suggest that there are multiple
teaching factors that produce
measurable gains in student achievement and that the relative
importance of individual factors
can be highly dependent on contextual factors like student
identity. This is in line with a well-
documented phenomenon in educational research that
complicates attempts to measure teaching
effectiveness purely in terms of student achievement. This is
that “the largest source of variation

44. in student learning is attributable to differences in what
students bring to school - their abilities
and attitudes, and family and community” (McKenzie et al.,
2005, p. 2). Student achievement
varies greatly due to non-teacher factors like socio-economic
status and home life (Snook et al.,
2009). This means that, even to the extent that it is possible to
observe the effectiveness of
certain teaching behaviors in terms of student achievement, it is
difficult to set generalizable
benchmarks or standards for student achievement. Thus is it
also difficult to make true apples-to-
apples comparisons about teaching effectiveness between
different educational contexts: due to
vast differences between different kinds of students, a notion of
what constitutes highly effective
teaching in one context may not in another. This difficulty has
featured in criticism of certain
meta-analyses that have purported to make generalizable claims
about what teaching factors
7
produce the biggest effects (Hattie, 2009). A variety of other

45. commentators have also made
similar claims about the importance of contextual factors in
teaching effectiveness for decades
(see, e.g., Bloom et al., 1956; Cashin, 1990; Theall, 2017).
The studies described above mainly measure teaching
effectiveness in terms of academic
achievement. It should certainly be noted that these quantifiable
measures are not generally
regarded as the only outcomes of effective teaching worth
pursuing. Qualitative outcomes like
increased affinity for learning and greater sense of self-efficacy
are also important learning goals.
Here, also, local context plays a large role.
SETs: Imperfect Measures of Teaching
As noted in this paper’s introduction, SETs are commonly used
to assess teaching
performance and inform faculty development efforts. Typically,
these take the form of an end-of-
term summative evaluation comprised of multiple-choice
questions (MCQs) that allow students
to rate statements about their teachers on Likert scales. These
are often accompanied with short-
answer responses which may or may not be optional.

46. SETs serve important institutional purposes. While
commentators have noted that there
are crucial aspects of instruction that students are not equipped
to judge (Benton & Young,
2018), SETs nevertheless give students a rare institutional
voice. They represent an opportunity
to offer anonymous feedback on their teaching experience and
potentially address what they
deem to be their teacher’s successes or failures. Students are
also uniquely positioned to offer
meaningful feedback on an instructors’ teaching because they
typically have much more
extensive firsthand experience of it than any other educational
stakeholder. Even peer observers
only witness a small fraction of the instructional sessions
during a given semester. Students with
Commented [AWC20]: To list a few sources as examples
of a larger body of work, you can use the word "see" in the
parenthetical, as we've done here.
8
perfect attendance, by contrast, witness all of them. Thus, in a
certain sense, a student can

47. theoretically assess a teacher’s ability more authoritatively than
even peer mentors can.
While historical attempts to validate SETs have produced mixed
results, some studies
have demonstrated their promise. Howard (1985), for instance,
finds that SET are significantly
more predictive of teaching effectiveness than self-report, peer,
and trained-observer
assessments. A review of several decades of literature on
teaching evaluations (Watchel, 1998)
found that a majority of researchers believe SETs to be
generally valid and reliable, despite
occasional misgivings. This review notes that even scholars who
support SETs frequently argue
that they alone cannot direct efforts to improve teaching and
that multiple avenues of feedback
are necessary (L’hommedieu et al., 1990; Seldin, 1993).
Finally, SETs also serve purposes secondary to the ostensible
goal of improving
instruction that nonetheless matter. They can be used to bolster
faculty CVs and assign
departmental awards, for instance. SETs can also provide
valuable information unrelated to
teaching. It would be hard to argue that it not is useful for a

48. teacher to learn, for example, that a
student finds the class unbearably boring, or that a student finds
the teacher’s personality so
unpleasant as to hinder her learning. In short, there is real value
in understanding students’
affective experience of a particular class, even in cases when
that value does not necessarily lend
itself to firm conclusions about the teacher’s professional
abilities.
However, a wealth of scholarly research has demonstrated that
SETs are prone to fail in
certain contexts. A common criticism is that SETs can
frequently be confounded by factors
external to the teaching construct. The best introduction to the
research that serves as the basis
for this claim is probably Neath (1996), who performs
something of a meta-analysis by
presenting these external confounds in the form of twenty
sarcastic suggestions to teaching
9
faculty. Among these are the instructions to “grade leniently,”
“administer ratings before tests”

49. (p. 1365), and “not teach required courses” (#11) (p. 1367).
Most of Neath’s advice reflects an
overriding observation that teaching evaluations tend to
document students’ affective feelings
toward a class, rather than their teachers’ abilities, even when
the evaluations explicitly ask
students to judge the latter.
Beyond Neath, much of the available research paints a similar
picture. For example, a
study of over 30,000 economics students concluded that “the
poorer the student considered his
teacher to be [on an SET], the more economics he understood”
(Attiyeh & Lumsden, 1972). A
1998 meta-analysis argued that “there is no evidence that the
use of teacher ratings improves
learning in the long run” (Armstrong, 1998, p. 1223). A 2010
National Bureau of Economic
Research study found that high SET scores for a course’s
instructor correlated with “high
contemporaneous course achievement,” but “low follow-on
achievement” (in other words, the
students would tend to do well in the course, but poor in future
courses in the same field of study.
Others observing this effect have suggested SETs reward a

50. pandering, “soft-ball” teaching style
in the initial course (Carrell & West, 2010). More recent
research suggests that course topic can
have a significant effect on SET scores as well: teachers of
“quantitative courses” (i.e., math-
focused classes) tend to receive lower evaluations from students
than their humanities peers (Uttl
& Smibert, 2017).
Several modern SET studies have also demonstrated bias on the
basis of gender
(Anderson & Miller, 1997; Basow, 1995), physical
appearance/sexiness (Ambady & Rosenthal,
1993), and other identity markers that do not affect teaching
quality. Gender, in particular, has
attracted significant attention. One recent study examined two
online classes: one in which
instructors identified themselves to students as male, and
another in which they identified as
Commented [AWC21]: This citation presents quotations
from different locations in the original source. Each
quotation is followed by the corresponding page number.
10

51. female (regardless of the instructor’s actual gender) (Macnell et
al., 2015). The classes were
identical in structure and content, and the instructors’ true
identities were concealed from
students. The study found that students rated the male identity
higher on average. However, a
few studies have demonstrated the reverse of the gender bias
mentioned above (that is, women
received higher scores) (Bachen et al., 1999) while others have
registered no gender bias one
way or another (Centra & Gaubatz, 2000).
The goal of presenting these criticisms is not necessarily to
diminish the institutional
importance of SETs. Of course, insofar as institutions value the
instruction of their students, it is
important that those students have some say in the content and
character of that instruction.
Rather, the goal here is simply to demonstrate that using SETs
for faculty development
purposes—much less for personnel decisions—can present
problems. It is also to make the case
that, despite the abundance of literature on SETs, there is still
plenty of room for scholarly
attempts to make these instruments more useful.

52. Empirical Scales and Locally-Relevant Evaluation
One way to ensure that teaching assessments are more
responsive to the demands of
teachers’ local contexts is to develop those assessments locally,
ideally via a process that
involves the input of a variety of local stakeholders. Here,
writing assessment literature offers a
promising path forward: empirical scale development, the
process of structuring and calibrating
instruments in response to local input and data (e.g., in the
context of writing assessment, student
writing samples and performance information). This practice
contrasts, for instance, with
deductive approaches to scale development that attempt to
represent predetermined theoretical
constructs so that results can be generalized.
11
Supporters of the empirical process argue that empirical scales
have several advantages.
They are frequently posited as potential solutions to well-
documented reliability and validity

53. issues that can occur with theoretical or intuitive scale
development (Brindley, 1998; Turner &
Upshur, 1995, 2002). Empirical scales can also help researchers
avoid issues caused by
subjective or vaguely-worded standards in other kinds of scales
(Brindley, 1998) because they
require buy-in from local stakeholders who must agree on these
standards based on their
understanding of the local context. Fulcher et al. (2011) note
the following, for instance:
Measurement-driven scales suffer from descriptional
inadequacy. They are not sensitive
to the communicative context or the interactional complexities
of language use. The level
of abstraction is too great, creating a gulf between the score and
its meaning. Only with a
richer description of contextually based performance, can we
strengthen the meaning of
the score, and hence the validity of score-based inferences. (pp.
8–9)
There is also some evidence that the branching structure of the
EBB scale specifically can
allow for more reliable and valid assessments, even if it is
typically easier to calibrate and use

54. conventional scales (Hirai & Koizumi, 2013). Finally, scholars
have also argued that theory-
based approaches to scale development do not always result in
instruments that realistically
capture ordinary classroom situations (Knoch, 2007, 2009).
[Original paragraph removed for brevity.]
Materials and Methods
This section proposes a pilot study that will compare the ICaP
SET to the Heavilon
Evaluation of Teacher (HET), an instrument designed to combat
the statistical ceiling effect
described above. In this section, the format and composition of
the HET is described, with
Commented [AF22]: Quotations longer than 40 words
should be formatted as block quotations. Indent the entire
passage half an inch and present the passage without
quotation marks. Any relevant page numbers should follow
the concluding punctuation mark. If the author and/or date
are not referenced in the text, as they are here, place them in
the parenthetical that follows the quotation along with the
page numbers.
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from the same author(s), simply list the author(s), then list
the years of the sources separated by commas.

55. 12
special attention paid to its branching scale design. Following
this, the procedure for the study is
outlined, and planned interpretations of the data are discussed.
The Purdue ICaP SET
The SET employed by Introductory Composition at Purdue
(ICaP) program as of January
2019 serves as an example of many of the prevailing trends in
current SET administration.
[Original two paragraphs removed for brevity.]
The remainder of the MCQs (thirty in total) are chosen from a
list of 646 possible
questions provided by the Purdue Instructor Course Evaluation
Service (PICES) by department
administrators. Each of these PICES questions requires students
to respond to a statement about
the course on a five-point Likert scale. Likert scales are simple
scales used to indicate degrees of
agreement. In the case of the ICaP SET, students must indicate
whether they strongly agree,
agree, disagree, strongly disagree, or are undecided. These
thirty Likert scale questions assess a
wide variety of the course and instructor’s qualities. Examples

56. include “My instructor seems
well-prepared for class,” “This course helps me analyze my own
and other students' writing,”
and “When I have a question or comment I know it will be
respected,” for example.
[Original paragraph removed for brevity.]
Insofar as it is distributed digitally, it is composed of MCQs
(plus a few short-answer
responses), and it is intended as end-of-term summative
assessment, the ICaP SET embodies he
current prevailing trends in university-level SET administration.
In this pilot study, it serves as a
stand-in for current SET administration practices (as generally
conceived).
The HET
Like the ICaP SET, the HET uses student responses to questions
to produce a score that
purports to represent their teacher’s pedagogical ability. It has a
similar number of items (28, as
Commented [AWC24]: Italicize the anchors of scales or
responses to scale-like questions, rather than presenting them
in quotation marks. Do not italicize numbers if the scale
responses are numbered.

57. 13
opposed to the ICaP SET’s 34). However, despite these
superficial similarities, the instrument’s
structure and content differ substantially from the ICaP SET’s.
The most notable differences are the construction of the items
on the text and the way
that responses to these items determine the teacher’s final score.
Items on the HET do not use the
typical Likert scale, but instead prompt students to respond to a
question with a simple “yes/no”
binary choice. By answering “yes” and “no” to these questions,
student responders navigate a
branching “tree” map of possibilities whose endpoints
correspond to points on a 33- point ordinal
scale.
The items on the HET are grouped into six suites according to
their relevance to six
different aspects of the teaching construct (described below).
The suites of questions correspond
to directional nodes on the scale—branching paths where an
instructor can move either “up” or
“down” based on the student’s responses. If a student awards a
set number of “yes” responses to

58. questions in a given suite (signifying a positive perception of
the instructor’s teaching), the
instructor moves up on the scale. If a student does not award
enough “yes” responses, the
instructor moves down. Thus, after the student has answered all
of the questions, the instructor’s
“end position” on the branching tree of possibilities corresponds
to a point on the 33-point scale.
A visualization of this structure is presented in Figure 1.
14
Figure 1
Illustration of HET’s Branching Structure
Note. Each node in this diagram corresponds to a suite of
HET/ICALT items, rather than to a
single item.

59. The questions on the HET derive from the International
Comparative Analysis of
Learning and Teaching (ICALT), an instrument that measures
observable teaching behaviors for
Commented [AF25]: Tables and figures are numbered
sequentially (i.e., 1, 2,
3 ...). They are identified via a second-level heading (flush-
left, bold, and title case) followed by an italic title that
briefly describes the content of the table or figure.
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by the label "Note." written in italics. General notes that
apply to the entire table should come before specific notes
(indicated with superscripted lowercase letters that
correspond to specific locations in the figure or table). For
more information on tables and figures, see our resource on
the OWL.
Table notes are optional.
15
the purpose of international pedagogical research within the
European Union. The most recent
version of the ICALT contains 32 items across six topic
domains that correspond to six broad
teaching skills. For each item, students rate a statement about
the teacher on a four-point Likert
scale. The main advantage of using ICALT items in the HET is

60. that they have been
independently tested for reliability and validity numerous times
over 17 years of development
(see, e.g., Van de Grift, 2007). Thus, their results lend
themselves to meaningful comparisons
between teachers (as well as providing administrators a
reasonable level of confidence in their
ability to model the teaching construct itself). The six “suites”
of questions on the HET, which
correspond to the six topic domains on the ICALT, are
presented in Table 1.
Table 1
HET Question Suites
Suite Description No. of items
Safe learning
environment
Whether the teacher is able to maintain positive,
nonthreatening relationships with students (and
to foster these sorts of relationships among
students).
4
Classroom
management

61. Whether the teacher is able to maintain an orderly,
predictable environment.
4
Clear instruction Whether the teacher is able to explain class
topics
comprehensibly, set clear goals, and connect
assignments and outcomes in helpful ways.
7
Activating teaching
methods
Whether the teacher uses strategies that motivate
students to think about the class’s topics.
7
Learning strategies Whether teachers take explicit steps to teach
students how to learn (as opposed to merely
providing students informational content).
6
Differentiation Whether teachers can successfully adjust their
behavior to meet the diverse needs of individual
students.
4

62. Note. Item numbers are derived from original ICALT item
suites.
Commented [AF27]: Tables are formatted similarly to
figures. They are titled and numbered in the same way, and
table-following notes are presented the same way as figure-
following notes. Use separate sequential numbers for tables
and figures. For instance, this table is presented as Table 1
rather than as Table 2, despite the fact that Figure 1 precedes
it.
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possible use of borders. Tables should not include shading
unless shading in cells is necessary to convey meaning (and
in this case, the meaning should be indicated in the note
below the table). You can find more information about
formatting tables on the OWL in our Tables & Figures
resource.
Note that if a table is long enough that it cannot fit onto a
single page, you should replicate the heading row (the top
row indicating what information can be found in each
column) on the second page for ease of use. If a table is this
large, you may want to split the table into two tables if
appropriate or put it in an appendix rather than in the body of
the text.
16
The items on the HET are modified from the ICALT items only
insofar as they are
phrased as binary choices, rather than as invitations to rate the

63. teacher. Usually, this means the
addition of the word “does” and a question mark at the end of
the sentence. For example, the
second safe learning climate item on the ICALT is presented as
“The teacher maintains a relaxed
atmosphere.” On the HET, this item is rephrased as, “Does the
teacher maintain a relaxed
atmosphere?” See Appendix for additional sample items.
As will be discussed below, the ordering of item suits plays a
decisive role in the
teacher’s final score because the branching scale rates earlier
suites more powerfully. So too does
the “sensitivity” of each suite of items (i.e., the number of
positive responses required to progress
upward at each branching node). This means that it is important
for local stakeholders to
participate in the development of the scale. In other words,
these stakeholders must be involved
in decisions about how to order the item suites and adjust the
sensitivity of each node. This is
described in more detail below.
Once the scale has been developed, the assessment has been
administered, and the

64. teacher’s endpoint score has been obtained, the student rater is
prompted to offer any textual
feedback that they feel summarizes the course experience, good
or bad. Like the short response
items in the ICaP SET, this item is optional. The short-response
item is as follows:
• What would you say about this instructor, good or bad, to
another student considering
taking this course?
The final four items are demographic questions. For these,
students indicate their grade level,
their expected grade for the course, their school/college (e.g.,
College of Liberal Arts, School of
Agriculture, etc.), and whether they are taking the course as an
elective or as a degree
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tables in the text, you may also present them in appendices at
the end of the document.
You may also use appendices to present material that would
be distracting or tedious in the body of the paper. In either
case, you can use simple in-text references to direct readers
to the appendices. If you have multiple appendices, you
would reference in the text “Appendix A,” “Appendix B,”
and so on. This paper only has one appendix, so it is simply
labeled Appendix.

65. Commented [AF29]: For the sake of brevity, the rest of
the body of the paper has been omitted.
17
References
Ambady, N., & Rosenthal, R. (1993). Half a minute: Predicting
teacher evaluations from thin
slices of nonverbal behavior and physical attractiveness. Journal
of Personality and
Social Psychology, 64(3), 431–441.
http://dx.doi.org/10.1037/0022-3514.64.3.431
American Association of University Professors. (n.d.).
Background facts on contingent faculty
positions. https://www.aaup.org/issues/contingency/background-
facts
American Association of University Professors. (2018, October
11). Data snapshot: Contingent
faculty in US higher ed. AAUP Updates.
https://www.aaup.org/news/data-snapshot-
contingent-faculty-us-higher-ed#.Xfpdmy2ZNR4
Anderson, K., & Miller, E. D. (1997). Gender and student
evaluations of teaching. PS: Political
Science and Politics, 30(2), 216–219.

66. https://doi.org/10.2307/420499
Armstrong, J. S. (1998). Are student ratings of instruction
useful? American Psychologist,
53(11), 1223–1224. http://dx.doi.org/10.1037/0003-
066X.53.11.1223
Attiyeh, R., & Lumsden, K. G. (1972). Some modern myths in
teaching economics: The U.K.
experience. American Economic Review, 62(1), 429–443.
https://www.jstor.org/stable/1821578
Bachen, C. M., McLoughlin, M. M., & Garcia, S. S. (1999).
Assessing the role of gender in
college students' evaluations of faculty. Communication
Education, 48(3), 193–210.
http://doi.org/cqcgsr
Basow, S. A. (1995). Student evaluations of college professors:
When gender matters. Journal of
Educational Psychology, 87(4), 656–665.
http://dx.doi.org/10.1037/0022-0663.87.4.656
Becker, W. (2000). Teaching economics in the 21st century.
Journal of Economic Perspectives,
14(1), 109–120. http://dx.doi.org/10.1257/jep.14.1.109
Commented [AF30]: Start the references list on a new
page. The word "References" (or "Reference," if there is only

67. one source), should appear bolded and centered at the top of
the page. Reference entries should follow in alphabetical
order. There should be a reference entry for every source
cited in the text.
All citation entries should be double-spaced. After the first
line of each entry, every following line should be indented a
half inch (this is called a "hanging indent"). Most word
processors do this automatically via a formatting menu; do
not use tabs for a hanging indent unless your program
absolutely will not create a hanging indent for you.
Commented [AWC31]: Source with two authors.
Field Code Changed
Commented [AWC32]: Source with organizational
author.
Field Code Changed
Field Code Changed
Field Code Changed
Field Code Changed
Commented [AWC33]: Note that sources in online
academic publications like scholarly journals now require
DOIs or stable URLs if they are available.
Field Code Changed
18
Benton, S., & Young, S. (2018). Best practices in the evaluation
of teaching. Idea paper, 69.

68. Berk, R. A. (2005). Survey of 12 strategies to measure teaching
effectiveness. International
Journal of Teaching and Learning in Higher Education, 17(1),
48–62.
Bloom, B. S., Englehart, M. D., Furst, E. J., Hill, W. H., &
Krathwohl, D. R. (1956). Taxonomy
of educational objectives: The classification of educational
goals. Addison-Wesley
Longman Ltd.
Carrell, S., & West, J. (2010). Does professor quality matter?
Evidence from random assignment
of students to professors. Journal of Political Economy, 118(3),
409–432.
https://doi.org/10.1086/653808
Cashin, W. E. (1990). Students do rate different academic fields
differently. In M. Theall & J. L.
Franklin (Eds.), Student ratings of instruction: Issues for
improving practice (pp. 113–
121).
Centra, J., & Gaubatz, N. (2000). Is there gender bias in student
evaluations of teaching? The
Journal of Higher Education, 71(1), 17–33.

69. https://doi.org/10.1080/00221546.2000.11780814
Davis, B. G. (2009). Tools for teaching (2nd ed.). Jossey-Bass.
Denton, D. (2013). Responding to edTPA: Transforming
practice or applying shortcuts?
AILACTE Journal, 10(1), 19–36.
[For the sake of brevity, the rest of the references have been
omitted.]
Commented [AWC34]: Example of a book in print.
Commented [AWC35]: Chapter in an edited collection.
Field Code Changed
Commented [AWC36]: Academic article for which a DOI
was unavailable.
19
Appendix
Sample ICALT Items Rephrased for HET
Suite Sample ICALT item HET phrasing
Safe learning
environment
The teacher promotes mutual

70. respect.
Does the teacher promote
mutual respect?
Classroom
management
The teacher uses learning time
efficiently.
Does the teacher use learning
time efficiently?
Clear instruction The teacher gives feedback to
pupils.
Does the teacher give feedback
to pupils?
Activating teaching
methods
The teacher provides interactive
instruction and activities.
Does the teacher provide
interactive instruction and
activities?
Learning strategies The teacher uses multiple

71. learning strategies.
Does the teacher use multiple
learning strategies?
Differentiation The teacher adapts the
instruction to the relevant
differences between pupils.
Does the teacher adapt the
instruction to the relevant
differences between pupils?
Commented [AF37]: Appendices begin after the
references list. The word "Appendix" should appear at the
top of the page, bolded and centered. If there are multiple
appendices, label them with capital letters (e.g., Appendix A,
Appendix B, and Appendix C). Start each appendix on a new
page.
Paragraphs of text can also appear in appendices. If they do,
paragraphs should be indented normally, as they are in the
body of the paper.
If an appendix contains only a single table or figure, as this
one does, the centered and bolded "Appendix" replaces the
centered and bolded label that normally accompanies a table
or figure.
If the appendix contains both text and tables or figures, the
tables or figures should be labeled, and these labels should
include the letter of the appendix in the label. For example, if
Appendix A contains two tables and one figure, they should

72. be labeled "Table A1," "Table A2," and "Figure A1." A table
that follows in Appendix B should be labeled "Table B1." If
there is only one appendix, use the letter "A" in table/figure
labels: "Table A1," "Table A2," and so on.
Document
APA Research Paper Format Details
Use this website and follow instructions for formatting APA
Research paper. Please note that this provides, font
size, font selection, line spacing and all details of paper
headings and necessary inclusions;
https://owl.purdue.edu/owl/research_and_citation/apa_style/apa
_formatting_and_style_guide/general_format.html
××
Document
Final Paper Four Questions + Bonus Question
Each Final Paper will include a review of the database provided
to each student, who will then answer the following
four questions (note: each question requires a definite
understanding of your database.):
1. All RISK requires consideration in the following five areas of
a business: corporate strategy, supply chain

73. organization, process management, performance metrics and
information & technology.
a. What could be the main "risk" for your database?
b. Of the four possible solutions for the "risk", which is most
applicable to the "risk" you selected?
2. Use the "risk" selected in question 1 and build a risk-
assessment-matrix explaining each selection made for
column headings.
3. If you could locate the database firm (your selection) and
consider it a development company, anywhere in
the world, which place would you choose and why? You must
consider the Supply Chain impacts.
4. Can the Supply Chain for your company (database) become
too lean? Explain and provide supporting
references.
BONSUS COMPOUND QUESTION:
In March 2021, the Suez Canal was blocked for six days after
the grounding of Ever Given, a 20,000 TEU container
ship. The 400-metre-long (1,300 ft) vessel was buffeted by
strong winds on the morning of 23 March and ended up
wedged across the waterway with its bow and stern stuck in the
canal banks.
a. Do the colors of the containers have a significance?
b. How does a company know which container is theirs?
c. How can you identify a refrigerated container from a plain
container?

74. Provide support for your responses.
××
Critical Review
The Effects of Mindfulness Meditation
on Stress and Burnout in Nurses
Alyssa A. Green, BSN, RN
Elizabeth V. Kinchen, PhD, RN, AHN-BC
University of Central Florida College of Nursing
Background: Occupational burnout related to stress in the
workplace is experienced by nurses who are
regularly confronted with trauma, suffering, and high
workloads. Burnout can negatively impact patient
care and have detrimental effects on nurses’ physical and
mental health. Mindfulness-based stress reduc-
tion programs have been researched as a potential holistic
intervention for reducing stress and burnout in
nurses through cultivating present awareness, emotional
regulation, and positive thinking. Purpose: This
critical review of the literature explores current knowledge on
the effectiveness of mindfulness meditation
on stress and burnout in nurses, examines gaps in the current
literature, and provides recommendations
for future research on this topic.Methods: Search terms included
mindfulness, meditation, mindfulness-
based stress reduction , occupational stress, stress, burnout, and
nurs*. Peer-reviewed research directly
related to the impact of mindfulness-based stress reduction on
nurses experiencing stress and/or

75. burnout was reviewed. Findings: Findings reveal evidence that
mindfulness meditation is effective in
decreasing stress and burnout in nurses. Mindfulness-based
interventions have been shown to signifi-
cantly decrease stress, improve all aspects of burnout, and
increase self-compassion and compassion sat-
isfaction in practicing nurses. Conclusions: Mindfulness
meditation has the potential to decrease
stress and burnout in nurses by decreasing self-judgment and
overidentification with experience, and
by increasing resiliency, compassion, and emotional regulation.
Keywords: mindfulness meditation; MBSR; nursing; stress;
burnout; occupational stress; stress
management; alternative/complementary therapies; health and
wellness coaching; stress and coping
Chronic exposure to psychological stress resulting
from an imbalance between occupational demand
and an individual’s ability to cope is known as
“burnout” (Saeidi et al., 2020). A growing number
of health care professionals are finding themselves
unable to cope with high levels of stress, with
studies reporting that up to 70% of intensive care
unit (ICU) nurses and over 40% of hospital nurses
experience work-related burnout (Vahey et al.,
2004; van Mol et al., 2015).
Burnout is characterized by emotional exhaus-
tion, depersonalization, and decreased personal
accomplishment, and is often a gradual process
wherein the individual’s physical and emotional capa-
bilities are diminished after prolonged exposure to
stress in the workplace (Maslach & Jackson, 1981).
The high demands of the health care system are

76. often out of an individual nurse’s control, and
heavy workloads, lack of support, constrained
resources, the emotional nature of the job, and inad-
equate staffing are major contributing factors
(Flynn & Ironside, 2017; Spence Laschinger &
Leiter, 2006).
Nurses suffering from burnout are at risk for
experiencing physical and psychological symptoms,
such as fatigue, anxiety, depression, and overall job
Authors’ Note: Please address correspondence to Alyssa
A. Green, BSN, RN, University of Central Florida College of
Nursing, Orlando, FL 32826, USA; e-mail: [email protected]
knights.ucf.edu
356
jh
n
Journal of Holistic Nursing
American Holistic Nurses Association
Volume 39 Number 4
December 2021 356–368
© The Author(s) 2021
Article reuse guidelines:
sagepub.com/journals-permissions
10.1177/08980101211015818
journals.sagepub.com/home/jhn
https://orcid.org/0000-0001-8535-8893
mailto:[email protected]

77. mailto:[email protected]
https://us.sagepub.com/en-us/journals-permissions
https://journals.sagepub.com/home/jhn
dissatisfaction (Flynn & Ironside, 2017), and are
more likely to abuse substances including caffeine,
alcohol, and illicit drugs (Jarrad et al., 2018).
Burnout has also been shown to negatively impact
an individual’s personal relationships and home life,
and is associated with higher rates of physical
illnesses such as hypertension, heart disease, and
sleep disorders (Ferguson et al., 2020).
Research has shown that dissatisfaction, disinterest,
and overwork among nurses can also have negative
impacts on job satisfaction and patient outcomes, as a
result of decreased quality of care. (Flynn & Ironside,
2017; Vahey et al., 2004). Inadequate staffing (a contrib-
uting factor) has been linked to inpatient mortality and
adverse events for patients, including falls and medica-
tion errors. (Spence Laschinger & Leiter, 2006).
Understaffing also contributes to “time–pressure”, or
stress that occurs when one has less time than needed
to perform tasks, and time–pressure has been found to
reduce the tendency of nurses to provide appropriate
interventions. A high level of “burnout” is also an indica-
tor of a reduction in perceived patient safety among crit-
ical care nurses (Al Ma’mari et al., 2020; Thompson
et al., 2008).
Burnout among nurses can also have long-term
negative effects on the facilities that employ them.
Research has shown that higher levels of burnout
potentiate rates of sick leave and absenteeism
(Parker & Kulik, 1995), as well as tardiness and turn-

78. over (Vahey et al., 2004). These factors can contribute
to the overworking of staff members, further increasing
the likelihood of nurses experiencing burnout. High
levels of turnover and absenteeism can be costly for
health care organizations that find themselves hiring
and training new employees, in addition to paying over-
time to existing employees when understaffing is an
issue. Burnout has also been noted as one of the
main contributing factors to attrition and a gradual
decrease in effectiveness among health care profession-
als (Flynn & Ironside, 2017).
Prevention of burnout in nurses is aimed at pro-
moting personal well-being and development of
coping mechanisms for occupational stress (Kravitz
et al., 2010), and holistic therapies such as mindful-
ness meditation may be particularly effective.
Mindfulness Meditation
Meditation is defined as an engagement in con-
templation or reflection and is traditionally known
as an integral part of Buddhism, which aims to
seek wisdom from expanding awareness and devel-
oping compassion. There are many subcategories
of meditation, each with distinct traditions, guid-
ance, and methods of practice. The practice of
Vipassanā, the Pali word for “special seeing” or
“insight,” began in Burma in the 1950s.
Meditation is strongly associated with the concept
of mindfulness, which involves active participation
in the present moment and examination of the
nature of reality. Because of this association, it is
often referred to as “mindfulness meditation.”

79. Mindfulness has been described as a shift in per-
spective and a detachment to sensations and thought,
allowing one to accept rather than avoid unpleasant
sensations and cravings. Aversions and cravings
promote stress and unhappiness by taking one out
of the present moment and judging the current expe-
rience as “good” or “bad” (Szekeres & Wertheim,
2014). Similarly, postulating about the future and
ruminating about the past may promote stress and
contribute to unhealthy coping mechanisms (Baer,
2003). The practice of mindfulness is aimed at main-
taining a nonjudgmental view of experience, whether
it be internal thought and emotion, or external stimuli
such as sights and sounds (Baer et al., 2006).
Through repeated acceptance of unpleasant sensa-
tion, and nonjudgmental observation of the present,
the individual may be better equipped to find a
balance between environmental demands and the
ability to cope with stress.
Theoretical Support for the Use
of Mindfulness Meditation
Reed’s theory of self-transcendence may be used
to support the practice of mindfulness meditation in
treating stress and burnout in nurses, as it provides a
framework for the “promotion of well-being in the
midst of difficult life situations” (Reed, 2018,
p. 119). Self-transcendence, a form of self-awareness,
is an integral component of holistic caring, as the
ability to accept an adverse situation that cannot
be changed contributes to inner growth, an overall
sense of health, and well-being (Rew, 2009,
p. 198). Reed’s theory has three main concepts:
self-transcendence, well-being, and vulnerability.
Self-transcendence, as a characteristic of developmental

80. maturity, is the capacity to expand personal boundar-
ies, to enhance awareness of the environment, and to
broaden the life perspective. It is the ability to
The Effects of Mindfulness Meditation on Stress and Burnout in
Nurses / Green and Kinchen 357
transcend or rise above life-altering experiences, such
as the debilitating clinical environments that contrib-
ute to burnout in nurses. Well-being, for Reed, is a
“sense of feeling whole and healthy,” and indicators
of well-being include life satisfaction, positive self-
concept, hopefulness, self-care, and a sense of
meaning in life, all goals of interventions addressing
stress and burnout in nurses. Vulnerability is an
“awareness of personal mortality or risk to one’s well-
being” (Reed, 2018, pp. 121-123). Reed posits that
life events that heighten one’s sense of inadequacy
or vulnerability can motivate a person to seek a
renewed sense of self-awareness and identity, and
Reed’s theory has been used to study meditative prac-
tices as a way to increase the nurses’ self-awareness
and “make sense” of difficult work situations
(Hunnibell et al., 2008; Palmer et al., 2010; Reed,
2018, p. 123).
Mindfulness-based Stress Reduction
The mindfulness-based stress reduction (MBSR)
program, developed by Kabat-Zinn in the 1970s, is
the most widely used mindfulness meditation modal-
ity, and serves as the blueprint for many modern
mindfulness programs. MBSR consists of engaging
in guided meditations focused on cultivating non-

81. judgmental awareness. The “traditional” program
requires a lengthy time commitment, as it comprises
2.5-h weekly group sessions and 45-min daily medita-
tions over 8 weeks, in addition to one full-day retreat
lasting 6 h. The program focuses on increasing mind-
fulness and attention through various techniques,
including formal sitting practice and mindful move-
ment (Kabat-Zinn, 1990).
Studies aimed at determining the effectiveness of
mindfulness meditation have found that MBSR pro-
grams significantly reduce psychological distress in
a variety of populations, including patients with breast
cancer and vascular disease, veterans, and university
students (Aikens et al., 2014; Benzo et al., 2018;
Ghawadra et al., 2020; van der Riet et al., 2018).
Imaging studies have also shown that mindfulness med-
itation calms a part of the brain that triggers fear and
anger, and increases brain activity associated with posi-
tive emotions (Bartol & Courts, 2009, p. 602).
Nurses experience occupational stress and
burnout at alarmingly high rates. Nurses suffering
from burnout are at a higher risk for depression and
anxiety, in addition to physical illnesses such as
hypertension. This can negatively impact the quality
of patient care and put additional strain on the work-
place. Mindfulness meditation can improve self-
awareness and well-being and may offer nurses the
ability to achieve self-transcendence, an integral
component of holistic caring, soMBSR is a promising
holistic intervention for the prevention and treatment
of stress and burnout in nurses.
Purpose

82. The purpose of this critical review of literature is
to explore current knowledge on the effectiveness of
mindfulness meditation (MBSR) for stress and
burnout in nurses, to identify gaps in the literature,
and to provide recommendations for future research
on the topic.
Methods
Critical Review Framework
Carnwell and Daly’s (2001) critical review frame-
work was used to guide the review of studies.
Carnwell and Daly (2001, p. 62) suggest that provid-
ing a clear structure to a scholarly review will facili-
tate a critical appraisal of the literature and provide
insight, thereby avoiding the charge of “being
merely descriptive”. In the framework, they advocate
clearly defining the scope of the review, identifying
relevant sources of information, describing inclusion
and exclusion criteria, and using a structured format
for the review of literature. Four suggested methods
for structuring the critical review are: examining the
theoretical and methodological literature, examining
the theoretical and empirical literature, dividing the
literature into content themes, and examining the lit-
erature chronologically (Carnwell & Daly, 2001,
pp. 60-62). This critical review of literature for mind-
fulness meditation on stress and burnout in nurses
follows the “content theme” structure. This method
allowed the authors to synthesize the literature by
intervention effectiveness, impact on outcomes, and
implications for nursing practice.
Literature Search

83. This critical review of literature utilized
CINAHL, APA PsycInfo, MEDLINE, and Web of
Science databases to identify peer-reviewed research
published in academic journals. Search terms
included mindfulness, meditation, mindfulness-
358 Journal of Holistic Nursing / Vol. 39, No. 4, December
based stress reduction or MBSR, burnout, stress,
occupational stress, and nurs*. Inclusion criteria
consisted of peer-reviewed articles in the English lan-
guage published between 2000 and 2020, quantita-
tive research using Kabat-Zinn’s traditional MBSR
intervention or adaptations of it, and studies directly
related to the impact of mindfulness on nurses who
are experiencing stress and/or burnout. Excluded
were studies exploring the impact of mindfulness on
health care professionals other than nurses, qualitative
and mixed methods research, and mindfulness medita-
tion interventions other than MBSR. Inclusion and
exclusion criteria are described in Table 1. The
sample (n=8) was obtained after careful review of
potentially relevant material and references, discarding
literature that was inaccessible, redundant, or did not fit
the inclusion criteria. The selection process is described
in more detail in Figure 1.
Results
Sample Characteristics
This critical review of literature examined eight
studies involving mindfulness meditation interven-