Influencing the health outcomes of various populations is one of the foundations of nursing. One of the most underserved populations of our nation are individuals living and working in urban areas. American urban cities are frequently cited for their perennial rates of poverty, violence, and crime. Children growing up in these cities are often plagued with emotional scars from witnessing crimes, being abused, and living in poverty. Providing a learning environment that is safe and nurturing for these children is an overall goal for both the teachers and nurses who work in the school environment. However, in trying to meet this goal, urban faculty and staff are experiencing a stress-like phenomenon known as compassion fatigue. This phenomenon was an ongoing challenge for a nurse–practitioner-run urban school wellness center, where compassion fatigue has led to a 24% faculty attrition rate. An evidence-based health promotion project centering around mindfulness was developed by the school’s wellness center to help reduce the effects of stress and improve the health of the school faculty population. The purpose of the project was to see if mindfulness can be used as a nurse-initiated therapeutic intervention, to help reduce compassion fatigue and to improve faculty attrition rates.
The term compassion fatigue is undergoing a concept evolution. Figley (2002) initially coined the term compassion fatigue by equating it to burnout and secondary traumatic stress (STS). Current researchers, however, are refuting Figley’s parallelism. For example, Lynch and Lobo (2012) delineate the difference between STS and compassion fatigue in their concept analysis, noting that compassion fatigue exclusively incorporates the role of empathy and the desire to help those in need. Potter et al. (2010) addressed the dissimilarity between burnout and compassion fatigue, seeing that compassion fatigue occurs from exposure to individuals who have experienced trauma while burnout results from the cumulative of one’s stress with daily life and work. To understand the relationship between compassion fatigue and burnout, Coetzee and Klopper (2010), in a concept analysis, looked at compassion fatigue as being a progressive and culminating process. Compassion fatigue, they note, occurs from intense and prolong caring producing both physical and psychological symptomatology. Hoffman, Palladino, and Barnett (2007), in a qualitative study of special education teachers, looked at the outcomes of compassion fatigue noting a variety of common manifestations such as depression, sleep difficulties, gastrointestinal upset, headaches, and palpitations. Further, studies by Wagner et al. (2013) and Wendt, Tuckey, and Prosser (2011) found it to be a contributor to high attrition rates for faculty and staff.
To minimize the consequences of stress and compassion fatigue, researchers have tested various interventions. Interestingly, most interventions tested confirm a cohesive underlying message of self-care (Alkema, Linton, & Davies, 2008; Kravits, McAllister-Black, Grant, & Kirk, 2010; Shapiro, Brown, & Biegel, 2007). For example, Kravits et al. (2010) utilized a large sample size of 234 nurses to evaluate the self-care interventions of art therapy, journaling, guided imagery, and mindfulness relaxation. Findings revealed that self-care strategies significantly reduced emotional exhaustion (Kravits et al., 2010).
Mindfulness and Mindfulness-Based Stress Reduction
Mindfulness-based stress reduction (MBSR) is an evidence-based self-care strategy that can be utilized to prevent and reduce compassion fatigue. The MBSR program, created by Jon Kabat-Zinn (2003), rests on the Buddhist concept of mindfulness. Mindfulness teaches the mind to develop an awareness and appreciation of what is occurring in the here and now. It orients one to current feelings, which allows one to respond rather than react (Kabat-Zinn, 2003). Mindfulness is practiced formally through meditation and breathing exercises, and informally through acknowledgment of current life experiences. It is learning to live in the here and now, that formulates this therapeutic measure for combating stress and compassion fatigue (Kabat-Zinn, 2003). The use of mindfulness in everyday living has successfully proven to improve stress levels and compassion fatigue in a variety of situations (Decker, Constantine-Brown, Ong, & Stiney-Ziskind, 2015; Thieleman & Cacciatore, 2014).
In a comprehensive citation review of mindfulness, Chiesa, Fazia, Bernardinelli, and Morandi’s (2017) exploration culminated in 128 systematic reviews reflecting the psychological and neuropsychological effects of mindfulness, showing mindfulness as a promising therapy for stress reduction. In two noteworthy but dated meta-analyses (Grossman, Niemann, Schmidt, & Walach, 2004; Proulx, 2003), MBSR was significantly effective as a complementary therapy for both physical and emotional disorders. Further, Luken and Sammons’s (2016) systematic review showed mindfulness as a useful entity in reducing job burnout. Although no studies were found directly linking MBSR to compassion fatigue of urban educators, there are a few studies that correlate the effects of MBSR and mindfulness with the stress of teaching. Most recently, Flook, Goldberg, Pinger, Bonus, and Davidson (2013) conducted an MBSR study in the Midwest, with teachers whose students were from low-income minority families. This small, randomized controlled study showed that MBSR was effective in reducing psychological symptoms of stress and burnout (Flook et al., 2013). Utilizing a much larger sample of 113 teachers, Roeser et al. (2013) analyzed two random-controlled trials showing the likely effect of mindfulness and MBSR in reducing occupational stress and burnout. Finally, Gold et al. (2010) studied the impact of mindfulness on suburban primary school teachers showing its significance in reducing stress.
The wealth of studies reviewed support mindfulness as an effective intervention for preventing and combating the general effects of stress and compassion fatigue. However, limited studies have been conducted with teachers in urban settings, where stress levels can run higher. This project was undertaken to ascertain the feasibility and effects of implementing a mindfulness program with faculty in a stressful urban setting.
The overarching goal of this project was to introduce and implement an abbreviated MBSR program to faculty, in an urban school setting, to reduce compassion fatigue and the corresponding attrition rate. The intervention had three primary objectives: (a) to introduce the faculty to the concept of compassion fatigue; (b) to enhance faculty knowledge of the concept of mindfulness; and (c) to establish the feasibility of implementing a mindfulness program within the school as a cost-effective, intervention to combat compassion fatigue and produce a general sense of well-being.
The project was conducted in an urban educational institution located in the Mid-Atlantic States. The school houses both elementary and high school students, from pre-k to grade 12 and contains a nurse–practitioner-run wellness center. The school was chosen due to their unusually high faculty attrition rate. At the time of the study, the attrition rate for teachers was 24%. According to the National Commission on Teaching and America’s Future (2012), the average annual attrition rate is 12.5%. The main reasons for leaving were pay and burnout.
The project involved a convenience sample of all school faculty members that currently teach at an urban charter school. Inclusion criteria for the project were all elementary and high school instructors at the academic institution. Teachers who taught special classes such as art, music, languages, and reading skills were also invited. In addition, both principals and vice-principals of the elementary and high school, who also taught classes, were included. There were no exclusions for this study. The introduction to mindfulness project was part of back to school orientation. All 41 faculty members who were invited to participate, completed the study.
The Institutional Review Board application for research determination was submitted to the University of Miami for project approval. Before implementation, subjects were informed as to the purpose of the project and those faculty members unwilling to participate would be excused. All data were obtained anonymously and stored in a locked file box, at the school’s health center to assure confidentiality.
The Mindfulness Program consisted of three components: a power point presentation, mindfulness exercises, and a mindfulness web portal for sustainability. The program was presented in two consecutive sessions as a workshop during faculty orientation at the start of the school year. The morning session was the didactic portion of the program presented in a lecture format using a power point presentation. This presentation included the what, why, and the effects of both compassion fatigue and mindfulness. The afternoon session was more hands-on, demonstrating and practicing mindfulness activities and ways to begin the use of mindfulness in the classroom. To better comprehend the concept of mindfulness, the first exercise titled “Mindfully Eating a Raisin” was conducted (Stahl & Goldstein, 2010). Conscious breathing and the mindful “S.T.O.P.” pauses were additional activities presented (Stahl & Goldstein, 2010; Kabat-Zinn, 2006). Rounding out the program was instructions and performance of the skill of body scanning.
Handouts of the presentation and exercises were distributed to faculty for reiteration of content. Also, take-home assignments consisting of a 3- to 5-minute daily mindfulness exercises were assigned. The purpose of this homework was to continue the momentum of using mindfulness throughout the upcoming weeks until a follow-up session occurred. Adding a mindfulness link to the school's employee website helped to encourage the use of mindfulness throughout the day. This portal operates 24/7 so employees can access it from home, giving faculty a quick moment to escape anytime from the stresses of the day for free. Within the portal is a mindfulness calendar that provides a brief mindfulness activity each day of the month.
Demographic data were obtained through a self-report questionnaire given to the faculty before the start of the program. Data collected included age, gender, ethnicity, marital status, education, and years of teaching. Before the intervention, data were also collected to establish a picture of the degree of compassion fatigue present among faculty. Compassion fatigue was evaluated using the Professional Quality of Life Scale V (ProQOL-V Scale; Stamm, 2010). The ProQOL-V is a 30-item tool that looks at compassion fatigue on three subscales. The first subscale is burnout; the second is STS; the third is compassion satisfaction. Each subscale is represented by 10 questions and is answered on a 5-point Likert scale (Stamm, 2010). The ProQOL-V has been used in over 200 studies and has reliability scores ranges of .75 to .88 on all subscales; it is in its fifth version since the original ProQOL was introduced in 1988 by Charles Figley (Stamm, 2010).
To assess feasibility, the program was evaluated in terms of knowledge and satisfaction by an author-created postintervention survey given to faculty. This survey contained seven questions on a 5-point Likert scale. Questions assessed the knowledge of mindfulness and compassion fatigue gained from this experience, the usefulness of material, and interest in future learning. To assess mood/emotional change following the workshop, all participants were given a 5-point emotion graphic rating scale (Mills, 2013) related to feelings of anxiety and happiness. Participants were asked to rate their current emotion at the start of the program and then, upon completion. This assessment was used as a self-gauge to quantify any changes in mood/emotion that occurred following the session. Last, to calculate attrition rate, the human resource department tallied the attrition numbers at the end of the school year, comparing it to data from the previous year.
The project outcomes that were analyzed consisted of demographics, the presence of compassion fatigue, knowledge obtained, and overall satisfaction with the program, indicating feasibility. Descriptive analysis was initially performed using central tendency (mean and range) to assess the general demographics of staff. To determine the presence of compassion fatigue within this population, raw scores on both the burnout and STS test were obtained and assessed according to the ProQOL-V manual. Responses from the postintervention survey were analyzed using descriptive statistics to determine if knowledge of mindfulness and compassion fatigue were attained, in addition to, program satisfaction and future interest to assure sustainability of the program. Finally, the attrition number was calculated at the end of June and compared with the previous year statistics.
A total of 41 faculty members, predominately female (76%), participated in this project. Ages ranged from 23 to 59 years, with a mean age of 36 years. Faculty members demonstrated an array of teaching experience ranging from 0 (this being their first) to 23 years. The majority of teachers (75%) held a bachelor’s degree with 25% of teachers holding master’s or doctoral degrees. Table 1 provides the descriptive statistics for the general characteristics that made up the sample.
|Age in Years (range; M [SD])||23–57; 36.4 (11.5)|
| African American/Black||09|
| Bachelor’s degree||30|
| Master’s degree||08|
| Doctorate degree||03|
|Years teaching (range, M [SD])||0–25; 9.3 (9.6)|
Compassion fatigue was looked at in terms of both burnout and STS using the ProQOL-V. Scores for STS ranged from 43 to 77, with 3% faculty members experiencing no exposure to STS; nine members (21%) showing some exposure to STS and the remaining 76% faculty members having high exposures to STS. Scores for burnout ranged from 43 to 72 with 13 (32%) teachers scoring over 57 suggesting a high level of burnout. Seventeen scores (41%) showed low indication of burnout with the remaining 27% of the scores classified as an average standard of burnout (Table 1).
Knowledge of Mindfulness and Program Satisfaction
The postintervention survey showed that many faculty (71%) did not understand or participate in any mindfulness before the presentation. All participants strongly agreed that they understood the concept of mindfulness after the presentation. Most participants stated they were interested in using mindfulness activities with all but one wanting to have future programs on mindfulness. Eighty-eight percent of teachers acknowledged a positive change in mood upon leaving the workshop. Table 2 shows results of the exit survey.
This project had three primary objectives: (a) to introduce the concept of mindfulness and compassion fatigue to educators at an urban school housed in a highly violent neighborhood; (b) to see if mindfulness is an intervention that could be accepted and implemented to reduce compassion fatigue; and (c) to see if mindfulness activities can decrease the current attrition rate of faculty.
Regarding the first objective, before the presentation, most of the participants were unfamiliar with the terms mindfulness and compassion fatigue. However, after the presentation, a high majority of faculty stated a heightened awareness of both concepts. As to compassion fatigue, many faculty members openly expressed concerns of experiencing some degree of compassion fatigue, while scores on the ProQOL-V substantially verified its presence. Since the presence of compassion fatigue was noted early in the school year, it raises a red flag indicating the need for immediate stress intervention. Regarding mindfulness, by the end of the workshop, all participants were aware of the concept, its benefits, and how to begin to achieve a mindfulness state. Outcomes from the survey showed most of the faculty favorably rated the program and were amicable to future mindfulness programs.
The large number of positive scores, for mood improvement postintervention, showed the use of mindfulness as a possible intervention to combat compassion fatigue. Pro-QOL testing was repeated 6 months postintervention with a 37% return rate, showing no scores indicating high levels of burnout or compassion fatigue. Since the school staff accepted this pilot program, future research can focus on determining whether the mindfulness intervention can significantly reduce compassion fatigue and sustain an overall feeling of well-being.
As to attrition rate, the year-end tally did show an improvement, decreasing from 24% to 14%. Whether this reduction was significant or due to other factors, needs to be determined. However, if the faculty continues to incorporate the given mindfulness activities, it should help improve their well-being as well as their skills to respond to stressful situations rather than react, which is an overall goal of mindfulness (Kabat-Zinn, 2003). Learning to cope with stress may reduce the commonly heard complaint of burnout and keep teachers teaching longer in this environment.
Limitations of This Project
There are numerous threats to this project’s validity. First is the sample selection and generalizability of the results. Although the size of the study was acceptable, the use of a convenience sampling limits the results from this project to this environment. Another limitation is the measurement tools, in that all instruments were self-reported; therefore, one needs to determine if the surveys are answered honestly. Also, the postintervention survey, being author-created, has no validity or reliability testing to support its use. Finally, limitation is noted in the time frame for execution. The workshop initially proposed was to be done in two sessions, a month apart; however, due to changes in the institution’s schedules, the only time allotted to execute the project was on staff orientation day. This questions the program’s potential for sustainability. Spacing between the presentations gives the opportunity for more practice and content digestion creating a better evaluation for continued interest. Finally, without having a second session, survey results must be questioned as to whether the faculty’s interest in mindfulness is just due to the presentation’s “honeymoon” or newness effect, rather than its actual benefits.
Conclusion and Implication for Practice
Mindfulness and MBSR is an old Buddhist intervention turned new. Through the works of Kabat-Zinn (2003), use of MBSR and mindfulness occurs in a variety of situations as a safe, effective intervention. This project shows that mindfulness is an applicable intervention by school health centers in an urban school environment to enhance faculty wellness. Initial results show both the need and desire of such a program. Added support for the utilization of this program in schools comes from the Policy Statement on School Health (Council of Chief State School Officers, 2011) that states the “incorporation of staff health promotion programs produces teachers that are more energetic and optimistic, can better handle job stress, and are absent less often” (p. 4). The use of mindfulness programs by school faculty can be expanded to incorporate the entire student body, leading to a less stressful school environment for students/teachers with lower absenteeism/attrition rates for both. Mindfulness projects, such as this, can be easily replicated for use at any educational level, including undergraduate and graduate programs. Its usefulness can, even, extend outside the educational arena to any highly stressful occupation, where burnout or compassion fatigue can occur, such as nursing (Evans, Pereira, & Parker, 2008; Happell et al., 2013).
The potential for mindfulness to grow as an innovative, cost-effective approach to reducing stress is tremendous. However, its use within nursing is just beginning to evolve. More pure and translational research studies within the nursing discipline are needed to discover the beneficial outcomes of mindfulness as a nursing intervention. It is hoped that this article will create an active effort to spur more nursing research on the application and efficacy of mindfulness, both, within and outside of the healthcare arena.
Exit Survey of Knowledge and Satisfaction
|Question||Strongly Disagree||Disagree||Unsure||Agree||Strongly Agree|
|1. Mindfulness activities are something I did before this presentation.||66% (n = 27)||0%||0%||34% (n = 14)||0%|
|2. Following the workshop, I understand what is meant by mindfulness.||0%||0%||0%||39% (n = 16)||61% (n = 25)|
|3. Following the workshop, I know what is meant by the concept of compassion fatigue.||0%||0%||6% (n = 3)||46% (n = 19)||46% (n = 19)|
|4. I believe I have some aspect of compassion fatigue.||6% (n = 3)||6% (n = 3)||22% (n = 9)||39% (n = 16)||27% (n = 11)|
|5. My mood/emotion improved on the emotional line, that was given to me at the start of this workshop.||0%||12% (n = 5)||0%||66% (n = 27)||22% (n = 9)|
|6. I would like to try to use mindfulness activities for myself.||0%||2% (n = 1)||10% (n = 4)||39% (n = 16)||49% (n = 20)|
|7. I was satisfied with the workshop and would like to see future programs on mindfulness.||3% (n = 1)||0%||6% (n = 3)||57% (n = 23)||34% (n = 14)|
Alkema, K., Linton, J. M., & Davies, R. (2008). A study of the relationship between self-care, compassion satisfaction, compassion fatigue, and burnout among hospice professionals. Journal of Social Work in End-Of-Life & Palliative Care, 4(2), 101–119. 10.1080/15524250802353934
Chiesa, A., Fazia, T., Bernardinelli, L., & Morandi, G. (2017). Citation patterns and trends of systematic reviews about mindfulness. Complementary Therapies in Clinical Practice, 28, 26–37. 10.1016/j.ctcp.2017.04.006
Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A concept analysis. Nursing & Health Sciences, 12(2), 235–243. 10.1111/j.1442-2018.2010.00526.x
Decker, J. T., Constantine-Brown, J., Ong, J., & Stiney-Ziskind, C. A. (2015). Mindfulness, compassion fatigue, and compassion satisfaction among social work interns. Social Work and Christianity, 42(1), 28.
Evans, A. M., Pereira, D. A., & Parker, J. M. (2008). Occupational distress in nursing: A psychoanalytic reading of the literature. Nursing Philosophy, 9(3), 195–204. 10.1111/j.1466-769X.2008.00356.x
Figley, C. R. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Journal of Clinical Psychology, 58(11), 1433–1441. 10.1002/jclp.10090
Flook, L., Goldberg, S. B., Pinger, L., Bonus, K., & Davidson, R. J. (2013). Mindfulness for teachers: A pilot study to assess effects on stress, burnout and teaching efficacy. Mind, Brain, and Education, 7(3), 182–195. 10.1111/mbe.12026
Gold, E., Smith, A., Hopper, I., Herne, D., Tansey, G., & Hulland, C, . (2010). Mindfulness-based stress reduction (MBSR) for primary school teachers. Journal of Child and Family Studies, 19(2), 184–189. 10.1007/s10826-009-9344-0
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits. A meta-analysis. Journal of Psychosomatic Research, 57(1), 35–43. 10.1016/S0022-3999(03)00573-7
Happell, B., Dwyer, T., Reid-Searl, K., Burke, K. J., Caperchione, C. M., & Gaskin, C. J. (2013). Nurses and stress: Recognizing causes and seeking solutions. Journal of Nursing Management, 21(4), 638–647. 10.1111/jonm.12037
Hoffman, S., Palladino, J. M., & Barnett, J. (2007). Compassion fatigue as a theoretical framework to help understand burnout among special education teachers. Journal of Ethnographic & Qualitative Research, 2(1), 15–22.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2), 144–156. 10.1093/clipsy.bpg016
Kabat-Zinn, J. (2006). On mindfulness for beginners. (CD). Louisville, CO: Sounds True Inc.
Kravits, K., McAllister-Black, R., Grant, M., & Kirk, C. (2010). Self-care strategies for nurses: A psycho-educational intervention for stress reduction and the prevention of burnout. Applied Nursing Research, 23(3), 130–138. 10.1016/j.apnr.2008.08.002
Luken, M., & Sammons, A. (2016). Systematic review of mindfulness practice for reducing job burnout. American Journal of Occupational Therapy, 70(2), 7002250020p1. 10.5014/ajot.2016.016956
Lynch, S. H., & Lobo, M. L. (2012). Compassion fatigue in family caregivers: A Wilsonian concept analysis. Journal of Advanced Nursing, 68(9), 2125–2134. 10.1111/j.1365-2648.2012.05985.x
Mills, J. (2013). Lecture on the introduction to mindfulness in education. Philadelphia, PA: Personal Collections of J. Mills, Penn’s Program from Mindfulness.
Potter, P., Deshields, T., Divanbeigi, J., Berger, J., Cipriano, D., Norris, L., & Olsen, S. (2010). Compassion fatigue and burnout. Clinical Journal of Oncology Nursing, 14(5), E56–E62. 10.1188/10.CJON.E56-E62
Proulx, K. (2003). Integrating mindfulness-based stress reduction. Holistic Nursing Practice, 17(4), 201–208. 10.1097/00004650-200307000-00007
Roeser, R. W., Schonert-Reichl, K. A., Jha, A., Cullen, M., Wallace, L., Wilensky, R., …Harrison, J. (2013). Mindfulness training and reductions in teacher stress and burnout: Results from two randomized, waitlist-control field trials. Journal of Educational Psychology, 105(3), 787–804. 10.1037/a0032093
Shapiro, S. L., Brown, K. W., & Biegel, G. M. (2007). Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology, 1(2), 105–115. 10.1037/1931-3922.214.171.124
Stahl, B., & Goldstein, A. (2010). A mindfulness-based stress reduction workbook. Oakland, CA: New Harbinger Publications.
Thieleman, K., & Cacciatore, J. (2014). Witness to suffering: Mindfulness and compassion fatigue among traumatic bereavement volunteers and professionals. Social Work, 59(1), 34–41. 10.1093/sw/swt044
Wagner, S. L., Forer, B., Cepeda, I. L., Goelman, H., Maggi, S., D’Angiulli, A., …Grunau, R. E. (2013). Perceived stress and canadian early childcare educators. Child & Youth Care Forum, 42(1), 53–70. 10.1007/s10566-012-9187-5
Wendt, S., Tuckey, M. R., & Prosser, B. (2011). Thriving, not just surviving, in emotionally demanding fields of practice. Health & Social Care in the Community, 19(3), 317–325. 10.1111/j.1365-2524.2010.00983.x