Today's nurses experience high levels of work-related stress, burnout, job dissatisfaction, and poor health due to staff shortages, greater workload, and higher patient demands (Zhou et al., 2015). Negative effects of job satisfaction and burnout elicit emotional fatigue and anxiety (Trifiletti et al., 2017), which negatively influence nurses' life satisfaction (Unanue et al., 2017). Nurses have a much higher prevalence of depression and anxiety than the general population (Cheung & Yip, 2015) and have reported low levels of self-efficacy (Wang et al., 2015). One study that surveyed 335 Korean nurses also found high levels of burnout and secondary traumatic stress, as well as low levels of professional quality of life (Kim et al., 2015). Nurses' stress and burnout also are associated with poor patient safety and patient satisfaction (Hall et al., 2016; Nantsupawat et al., 2016). It is necessary to address these factors to improve the quality of life of both nurses and their patients.
Nurse managers especially are exposed to a greater risk of role stress and burnout due to increasing workloads and expanded roles (Moore et al., 2016). The literature indicates many nurse managers wish to leave their positions due to burnout, which is a serious problem because their role is critical to staff nurse retention (Warshawsky & Havens, 2014). Moreover, nurse managers' leadership is a significant factor that influences the general well-being of the nursing staff (Zwink et al., 2013) and enhances nurses' quality of life (Lin et al., 2015). Therefore, by promoting nurse managers' well-being and leadership, nurses' general well-being and retention can be improved, thereby influencing the quality of care delivered in clinical settings. However, resources to help nurse managers cope with their role stress and increase their self-efficacy remain limited (Udod et al., 2017).
In response to this situation, a number of studies have established that mindfulness-based meditation programs can reduce nurses' anxiety, depression, and burnout (Chang et al., 2016; dos Santos et al., 2016; Fortney et al., 2013; Gauthier et al., 2015; Hevezi, 2016). Such programs have been well received by nurses, who reported higher levels of satisfaction with life (Duarte & Pinto-Gouveia, 2016). There also was an attempt to develop a simple meditation program called the Holy Name Meditation and apply it to nurse managers so they would be able to practice meditation regardless of their religious background (Yong, Kim, Seo, & Yang, 2011). It has been verified that similar mantra-based programs have had positive effects on health care professionals' self-efficacy and quality of life (Oman et al., 2008; Richards et al., 2006). However, recent data on the effects of such an intervention have been virtually nonexistent.
Against this backdrop, the current study sought to apply the Holy Name Meditation as a spiritual intervention for nurse managers and verify its multidimensional effects. The core element of the Holy Name Meditation lies in silently reciting one's holy name or holy word. Based on the findings of Yong, Kim, Park, Seo, and Swinton (2011), this study applied the Holy Name Meditation (HNM) Program to middle-management nurses for a 6-month period to measure its effects on their spiritual well-being and needs, as well as their psychosocial state (i.e., leadership, job satisfaction, self-efficacy, anxiety, depression, and burnout). The conceptual framework of this study was based on Sulmasy's (2006) biopsychosocial-spiritual model. This model understands the person as a holistic being encompassing the biophysical, psychosocial, and spiritual dimensions. In this view, each dimension is inter-related and hence influences the other dimensions.
This study used a pretest/posttest nonequivalent control group design to measure the effects of the HNM Program on the psychosocial and spiritual state of middle manager nurses. The intervention program was offered solely to the experimental group for 6 months. The first five sessions were provided on a weekly basis, after which sessions were offered monthly for 3 months. This amounted to a total of eight sessions, with each session lasting 90 minutes. Data collected from the control group were used for comparison.
Participants were unit managers and unit charge nurses working at a tertiary-level university hospital in Seoul, South Korea. A unit charge nurse was perceived as a deputy manager of the unit. The primary investigator contacted two nursing team leaders who both agreed to volunteer. The team members who agreed to participate in the study were assigned to the experimental group (n = 27), and participants from the other nursing team were assigned to the control group (n = 27). Full data were obtained from 45 of these initial 54 nurses, resulting in an attrition rate of 17%. Sample size was calculated using G*Power Version 3.1.2, and a total of 30 participants were required based on a significance level of α = .05, statistical power of 1-ß = .90, and medium effect size of f = 0.25 (Cohen, 1988). In the repeated-measures analysis of variance (ANOVA), effect was defined as interaction between groups and at each phase. The covariance structure for repeated-measures ANOVA was compound symmetry, and the correlation coefficient between post-tests was assumed to be .5. Thus, at least 15 participants were required for each group.
Outcomes were measured using the instruments listed below. When Korean versions of the instruments were absent, an interdisciplinary team of six scholars completed the process of adapting instruments for transcultural research including translation, reverse translation, comparison, and revision.
- Spiritual Well-Being: Korean version (Cheung et al., 2001) of the Spiritual Well-Being Scale (Paloutzian & Ellison, 1982). Cronbach's alpha was .85 for this study.
- Spiritual Need: Spiritual Needs Scale for Korean Nurses (Yong, Kim, Park, Seo, & Swinton, 2011). Cronbach's alpha was .90 for this study.
- Leadership: Leadership Practice Inventory (Kouzes & Posner, 2017). Cronbach's alpha was .98 for this study.
- Burnout: Maslach Burnout Inventory (Maslach & Jackson, 1981). Cronbach's alpha was .86 for this study.
- Job Satisfaction: Eight-item instrument (Chamiec-Case, 2006). Cronbach's alpha was .80 for this study.
- Anxiety and Depression: Korean version (Kim et al., 1984) of Symptom Checklist 90-Revised (Derogatis, 1977). Cronbach's alpha for this study was .94.
- Self-Efficacy: Self-Efficacy Scale (Sherer et al., 1982). Cronbach's alpha was .93 for this study.
Recruitment and Data Collection
After obtaining Institutional Review Board approval, the authors contacted the nursing department of Seoul St. Mary's Hospital of the Catholic University Hospital to recruit participants. Team leaders from two nursing teams agreed to help recruit nurses from their team. After explaining the objective of the research and study procedure to the selected nurses, written consent to participate was obtained. The two nursing teams were assigned respectively to the experimental and control groups.
A total of 54 nurses agreed to participate in the study. Although 27 nurses participated for 6 months as members of the experimental group, three were disqualified because they failed to meet the 80% attendance requirement and did not adequately complete their assignments. A total of 27 participants were recruited for the control group, but six were disqualified under the same criteria. In the end, 24 participants in the experimental group and 21 participants in the control group were included for analysis.
Data were collected at four intervals: baseline (pretest), 5 weeks postintervention (posttest 1), 12 weeks postintervention (posttest 2), and 24 weeks postintervention (posttest 3). At each point, the same questionnaire with the seven study variables was distributed to the two study groups and collected within 2 days.
The spiritual intervention applied in this study, called the HNM Program, was developed based on Easwaran's (2008) Eight Point Program (EPP) and adopted from Yong, Kim, Park, Seo, and Swinton (2011). The main content of the HNM Program is outlined in Table 1. The program began with 5 weekly sessions with the following themes:
- Session 1: This session introduced the participants to spiritual care and guided them to choose their own Holy Name, a word or a phrase that they found spiritually meaningful.
- Session 2: This session trained participants to practice the meditation throughout everyday life and not just during a designated time for meditation.
- Session 3: This session taught participants to slow down the mind, helping them to live in harmony by reducing stress and the unnecessary use of energy during daily life.
- Session 4: This session helped participants concentrate on the present moment while avoiding distractions, thereby silencing the mind.
- Session 5: This session guided participants to train the senses to overcome indulgence and learn to make good choices by reciting their Holy Name. The program continued with three monthly sessions.
- Session 6: This session led participants to train putting others first by refraining from self-centered ways of acting and thinking.
- Session 7: This session trained participants to read writings on spiritual themes to receive inspiration.
- Session 8: This session led participants to meet regularly with spiritual companions for mutual support.
Content of The Holy Name Meditation Program
Each session lasted 90 minutes, including 40 minutes of lecture, 30 minutes of small group discussion, and 20 minutes of meditation practice. Participants were required to keep a spiritual diary, which was filled out and submitted every week until Session 5. In the diary, participants recorded the frequency of their Holy Name recitation and wrote about their experience. The total length of the program was 6 months.
Effects of the intervention on the outcome variables were assessed in seven separate hierarchical linear regression (HLM) models that adjusted for preexisting individual differences in outcome level (with a Level 2 random effect) and allowed for correlated errors within individuals across time (an autoregressive model, AR). To explore whether the intervention effect might change or decay over time, initial regression models permitted the intervention effect to vary between posttests 1, 2, and 3 (time-varying treatment effect). Subsequently, models assumed that the intervention effect was constant across these three examinations (time-constant treatment effect).
For outcomes that departed significantly (p < .10) from a normal distribution in Shapiro-Wilk tests, HLM analyses were supplemented with nonparametric Wilcoxon tests for group differences in change from pretest to post-tests 1–3 and the median of posttests 1–3. For normally distributed outcomes, t tests were used. For both analyses, Bonferroni adjustment was used to control the multiplicity of tests due to the seven outcomes and repeated measurements. Moderation by pretest covariates was explored through their inclusion as Level 2 predictors in time-constant HLM models, testing for statistical interaction with treatment.
Intervention effects were expressed as means (SD) and standardized effect sizes (d, mean difference divided by SD). Homogeneity of baseline characteristics between groups was verified by t test and chi-square test. All statistical analyses were performed using SAS® 9.1, with a two-sided p value <.05 considered statistically significant.
Average age of the participants was 35.5 years (SD = 6.2), with the average age being 34.8 years in the experimental group (SD = 5.9) and 36.4 years (SD = 6.5) in the control group. On reviewing the two groups' homogeneity for general characteristics, no significant difference was found (Table 2).
Homogeneity Test for General Characteristics of Participants (N = 45)
Effects of Intervention
Results of the repeated measures are listed in Table 3 and Figure 1. Spiritual well-being showed strong effect (d = 0.36, p = .057). In posttest 3, spiritual need of the experimental group showed a significant increase (d = 0.63, p = .012). The mean time constant intervention effect of posttests 1–3 was significantly higher in the experimental group (4.46, d = 0.42, p = .029).
Pretest Scores and Intervention Effects at Posttests 1, 2, and 3 (N = 45)
Changes in outcome variables by group and time (N = 45).
Job satisfaction showed a significant increase in the experimental group compared with the control group in posttests 2 (d = 0.04, p = .001) and 3 (d = 1.15, p = .049). The mean time constant intervention effect of posttests 1–3 also showed a significant increase in the experimental group (2.73, d = 0.69, p = .005).
Leadership showed an increasing tendency in the experimental group during posttest 1 (d = 0.18, p = .082) but did not show a significant difference in posttests 2 and 3. The mean time constant intervention effect of post-tests 1–3 showed increasing tendency in the experimental group (10.15, d = 0.26, p = .057).
Burnout in the experimental group was significantly reduced compared with the control group during posttest 1 (d = −1.54, p < .001) and posttest 2 (d = −2.41, p < .001). However, no significant difference was found in posttest 3; the mean time constant intervention effect of posttests 1–3 also was not significant.
No significant differences were found in the two groups' anxiety and depression during posttest 1; however, a significant reduction in the experimental group was identified during posttest 2 (d = −0.64, p = .034). Posttest 3 showed a decreasing tendency in the experimental group (d = −0.55, p = .074), and the mean time constant intervention effect of posttests 1–3 showed a decreasing tendency in the experimental group (−6.75, d = −0.49, p = .053).
Self-efficacy between the two groups showed no significant difference during posttest 1, but did show a significant increase in the experimental group during post-test 2 (d = 0.69, p = .024). Posttest 3 showed increasing tendency in the experimental group (d = 0.55, p = .067), and the mean time constant intervention effect of post-tests 1–3 showed increasing tendency in the experimental group (4.50, d = 0.45, p = .052).
Results demonstrate the HNM Program significantly enhanced middle manager nurses' spiritual well-being and job satisfaction. The program also significantly increased their recognition of their spiritual need and showed increasing tendency on their leadership and self-efficacy, while also showing decreasing tendency on their depression and anxiety. The program as a whole thus can improve their overall quality of life (Duarte & Pinto-Gouveia, 2016), as Sulmasy's (2006) biopsychosocial-spiritual model indicated. These results are similar to findings that mindfulness-based programs enhanced nurse' job satisfaction (Gauthier et al., 2015), reduced anxiety and depression (dos Santos et al., 2016; Fortney et al., 2013; Orellana-Rios et al., 2017), and improved quality of life and life satisfaction (Duarte & Pinto-Gouveia, 2016). The findings also are supported by studies reporting that Passage Meditation raised nurses' self-efficacy (Oman et al., 2008) and that inner self-care enhanced job satisfaction and quality of life (Sansó et al., 2015).
Uniqueness of the Holy Name Meditation
The following features distinguish the Holy Name Meditation's effects from those of similar interventions. First, the Holy Name Meditation showed effects on both the spiritual and psychosocial dimensions. Most studies have focused on measuring the effects of mindfulness-based meditation on the psychosocial dimension by studying three to four selected variables such as anxiety and depression, job satisfaction, and burnout (dos Santos et al., 2016; Duarte & Pinto-Gouveia, 2016; Fortney et al., 2013; Gauthier et al., 2015; Hevezi, 2016; Orellana-Rios et al., 2017). In a study that measured the effects of mindfulness-based meditation on quality of life, the spiritual dimension was not included under quality of life (Chang et al., 2016). In contrast, this study measured a total of seven variables, two of which addressed the spiritual dimension.
“Spiritual” intervention is to be distinguished from “psychosocial” intervention by the fact that the former promotes spiritual well-being. Spiritual well-being is positively correlated to attitude toward spiritual care (Azarsa et al., 2015; Chang et al., 2016) and can positively influence anxiety, burnout, and life satisfaction (Fabbris et al., 2017). Sulmasy's (2006) conceptual model used in this study implies that changes in a person's spiritual dimension may influence the biopsychosocial dimension, which is reflected in a finding that spirituality had a mediating effect on senior nursing students' self-efficacy (Jun & Lee, 2016). Although further research is needed, these findings enable one to infer that enhanced spiritual well-being could positively influence the psychosocial well-being of middle manager nurses. The HNM Program also significantly increased awareness of spiritual need of the experimental group; further research is required.
The HNM Program also showed long-term effects for a 6-month period. Spiritual well-being showed large effects throughout this period, and job satisfaction continued to increase during posttest 2 and posttest 3. The positive effects on other variables also persisted throughout the 6-month period. Fortney et al. (2013) likewise verified long-term effects of the applied intervention during a 9-month period, but most other studies did not contain such follow-up data. For example, dos Santos et al. (2016) and Gauthier et al. (2015) failed to show that initial positive effects lasted during follow-up. The HNM Program was offered once a month even after the five intensive weekly sessions, which suggests that continuous training contributes to long-term effects.
It is noteworthy that although burnout showed significant reduction until posttest 2, the effect abated by the time of posttest 3. Because literature on meditation programs has verified their positive effects on burnout (dos Santos et al., 2016; Duarte & Pinto-Gouveia, 2016; Hevezi, 2016; Orellana-Rios et al., 2017), the HNM Program's effects on burnout require further analysis. Because environmental factors such as low workplace support strongly influence burnout (Aronsson et al., 2017), the present findings may suggest that institutional support needs to complement enhanced spiritual well-being of individual staff members to effectively reduce burnout.
This HNM Program was provided to nurse leaders. Häggman-Laitila and Romppanen (2018) reported that only five intervention studies included nurse leaders in the study sample and that only one by Yong, Kim, Park, Seo, and Swinton (2011) included spiritual well-being as a study variable. The current study is unique in that it introduced an intervention that promoted multidimensional well-being of middle manager nurses, which is important because of the scarcity of research measuring a meditation-based program's multidimensional effects on nurse leadership. The HNM Program especially enhanced “inspiring a shared vision,” which is a domain of leadership in the Leadership Practices Inventory that was shown to promote nurses' job satisfaction (Moneke & Umeh, 2013).
It should be noted that the control group exhibited negative changes in the study variables between posttest 2 and posttest 3. However, during the same period, the experimental group showed positive changes in the same variables. In fact, this was a period when study participants were experiencing high levels of workload and stress as nurse leaders due to their hospital's ongoing evaluation for Joint Commission International accreditation. The fact that the experimental group's well-being increased while the control group experienced negative changes in well-being further attests to the efficacy of the HNM Program.
Implications for Spiritual Care
An important aspect of the Holy Name Meditation is that it can be practiced by anyone, regardless of one's religious backgrounds. Holy Name Meditation is transreligious, as it defines spirituality as “a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred” that is “expressed through beliefs, values, traditions, and practices” (Puchalski et al., 2014, p. 646).
The Holy Name Meditation also offers a highly practical means to integrate spiritual care into clinical practice. Although nurses are aware of the need for spiritual self-care, they cite factors such as a lack of time as a barrier to practicing such self-care (Ross et al., 2017). The simplicity of the Holy Name Meditation enables it to be practiced anywhere and at any time as on-the-job meditation, greatly adding to its clinical utility. The HNM Program as spiritual self-care is efficacious for professional development for nurses; therefore, the program needs to be provided as continuing education for nurses.
The study has several limitations. First, the research was limited to female nurse leaders working in the same university hospital. Because most of the nurses were Christians, it is necessary to verify the HNM Program's effects on a more diverse study sample. Thus, future studies are needed to reinforce the study findings with more diverse groups, including nurses of diverse religious and cultural background as well as male nurses through a larger randomized sample. Second, these findings alone do not sufficiently explain the relationship between the positive effects on both spiritual and psychosocial well-being. To establish this, a conceptual model needs to be constructed to conduct a pathway analysis.
The results of this study indicate that Holy Name Meditation has positive effects on middle manager nurses' spiritual and psychosocial well-being during a 6-month period. This provides evidence that Holy Name Meditation can be an efficacious means for nurse managers to practice spiritual self-care that improves their quality of life, thus enabling them to provide quality care to their patients.
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Content of The Holy Name Meditation Program
|Weekly||1||Workshop: Introduction to Spiritual Care
Choosing a Holy Word/Name, Practicing Meditation|
|2||Repetition of a Holy Word: silently repeat a holy word, passage, or mantra from major religious traditions as often as possible during the day|
|3||Slowing Down: guard against hurry and tension to reduce carelessness by prioritizing activities and simplifying life|
|4||One-Pointed Attention: do one activity at a time to increase attention and to conserve energy, leading to efficiency and poise|
|5||Training the Senses: overcoming indulgence or conditioned habits and learn to make good choices|
|Monthly||6||Putting Others First: obtaining freedom from self-will and separateness, expanding the circle of love|
|7||Inspirational Reading: receiving inspiration from religious scriptures and writings by great spiritual figures to effect personal changes|
|8||Spiritual Companionship: meeting regularly with spiritual aspirants for mutual support and inspiration|
Homogeneity Test for General Characteristics of Participants (N = 45)
|Characteristic||Experimental (n = 24)||Control (n = 21)||t/χ2||p|
|n (%) or M (SD)||n (%) or M (SD)|
|Age, y||34.8 (5.9)||36.4 (6.5)||−0.91||.369|
| Unit manager||13 (54.2)||13 (61.9)||0.28||.764|
| Senior nurse||11 (45.8)||8 (38.1)|
|Length of career as unit manager||36.9 (54.5)||41.1 (53.0)||−0.26||.798|
|Total length of career (mo)||152.2 (68.3)||167 (79.1)||−0.67||.504|
| Other than three shifts||10 (41.7)||6 (28.6)||0.84||.533|
| Three shifts||14 (58.3)||15 (71.4)|
| Three-year college||2 (8.3)||0 (0)|
| Baccalaureate||6 (25.0)||7 (35.0)|
| Master||15 (62.5)||12 (60.0)|
| Doctoral||1 (4.2)||1 (5.0)|
| Catholic||20 (83.3)||13 (61.9)|
| Protestant||1 (4.2)||6 (28.6)|
| Buddhist||1 (4.2)||0 (0)|
| None||2 (8.3)||2 (9.5)|
| Single||7 (29.2)||5 (23.8)|
| Married||17 (70.8)||16 (76.2)|
Pretest Scores and Intervention Effects at Posttests 1, 2, and 3 (N = 45)a
|Variable||Pretest Mean (SD)||Intervention Effects Exp Change – Control Change||Exp Change Mean (SE)||Control Change Mean (SE)|
|Spiritual well-being||59.93 (8.07)||1||1.99||(−1.06, 5.08)||.065b||1.38 (5.93)||−0.62 (4.02)|
|2||10.05||(6.13, 13.97)||<.001||2.33 (5.29)||−7.71 (7.68)|
|3||7.04||(2.72, 11.36)||.002||4.04 (6.40)||−3.00 (7.95)|
|1–3c||6.36||(3.59, 9.13)||<.001||2.58 (4.73)||−3.78 (4.44)|
|Spiritual needs||92.38 (10.59)||1||3.85||(−0.13, 7.83)||.057||3.38 (7.49)||−0.48 (5.39)|
|2||2.89||(−2.35, 8.13)||.272||2.42 (9.32)||−0.48 (7.92)|
|3||6.64||(1.56, 11.72)||.012||6.17 (8.85)||−0.48 (7.92)|
|1–3c||4.46||(0.48, 8.44)||.029||3.99 (7.02)||−0.48 (6.10)|
|Job satisfaction||28.27 (4.33)||1||0.18||(−1.70, 2.06)||.849||−0.25 (3.04)||−0.43 (3.20)|
|2||5.00||(2.35, 7.66)||.001||0.29 (3.13)||−4.71 (5.52)|
|3||3.00||(0.01, 5.99)||.049||1.33 (3.66)||−1.67 (6.13)|
|1–3c||2.73||(0.87, 4.49)||.005||0.46 (2.41)||−2.27 (3.72)|
|Leadership practice||202.78 (39.14)||1||6.97||(−10.66, 24.60)||.082b||14.88 (27.67)||7.90 (30.97)|
|2||6.84||(−8.18, 21.86)||.345b||18.13 (20.45)||11.29 (29.25)|
|3||16.65||(−4.09, 37.39)||.113||22.13 (25.02)||5.48 (42.73)|
|1–3c||10.15||(−4.75, 25.06)||.057b||18.38 (20.88)||8.22 (28.53)|
|Burnout||65.91 (13.72)||1||6.97||(−10.66, 24.60)||<.001b||−2.54 (9.41)||18.62 (18.62)|
|2||6.84||(−8.18, 21.86)||<.001b||−2.42 (8.95)||30.67 (15.80)|
|3||16.65||(−4.09, 37.39)||.113||−0.63 (13.88)||21.05 (15.16)|
|1–3c||10.15||(−4.75, 25.06)||.177||−1.86 (9.46)||23.44 (10.83)|
|Depression & anxiety||42.24 (13.69)||1||−3.90||(−10.03, 2.23)||.207||−3.38 (12.56)||0.52 (6.44)|
|2||−8.80||(−16.83, −0.76)||.034b||−5.08 (13.22)||3.71 (13.47)|
|3||−7.55||(−15.42, 0.33)||.074b||−3.83 (12.72)||3.71 (13.47)|
|1–3c||−6.75||(−13.12, −0.38)||.053b||−4.10 (11.44)||2.65 (9.48)|
|Self-efficacy||61.62 (9.22)||1||1.44||(−2.20, 5.08)||.891b||1.92 (6.64)||0.48 (5.28)|
|2||6.67||(1.47, 11.87)||.024b||2.00 (8.31)||−4.67 (8.98)|
|3||5.39||(−1.57, 12.34)||.067b||3.29 (13.60)||−2.10 (8.58)|
|1–3c||4.50||(−0.02, 9.01)||.052b||2.40 (8.14)||−2.10 (6.67)|