Journal of Psychosocial Nursing and Mental Health Services

Original Article 

Effects of a Mindfulness Activity on Nursing Service Staff Perceptions of Caring Behaviors in the Workplace

Camille King, EdD, MS, RN, PMHCNS-BC; Jeanette Rossetti, EdD, RN; Thomas J. Smith, PhD; Megan Raison, MSN, RN; Deana Gallegos, MS, RN; Rodney Gorman, BSN, RN; Sarah Moscatel, PhD, RN; Siobhan Smyth, PhD, RPN, Dip CPN, RNT, PG Dip CHSE; Jean Watson, PhD, RN, AHN-BC, FAAN

Abstract

Research on caring in nurse-to-nurse relationships is not extensive, but studies have shown that health care workers can experience incivility in the workplace and unhealthy relationships can increase stress and influence nurse retention. The current study examined nurse perceptions of caring in the workplace and the effect of a mindfulness activity. A mixed method design was used, and data were collected on 164 nursing staff members after a 1-minute mindfulness activity. Pre- and post-survey growth in caring behavior indicated a statistically significant positive effect for the treatment group. Qualitative reports showed that after completing a mindfulness activity, staff members were more focused, and willing to set a good example, off er help to others, and encourage a positive overall work environment. Mindfulness activities can improve nurse-to-nurse caring and reduce incivility in the workplace. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Abstract

Research on caring in nurse-to-nurse relationships is not extensive, but studies have shown that health care workers can experience incivility in the workplace and unhealthy relationships can increase stress and influence nurse retention. The current study examined nurse perceptions of caring in the workplace and the effect of a mindfulness activity. A mixed method design was used, and data were collected on 164 nursing staff members after a 1-minute mindfulness activity. Pre- and post-survey growth in caring behavior indicated a statistically significant positive effect for the treatment group. Qualitative reports showed that after completing a mindfulness activity, staff members were more focused, and willing to set a good example, off er help to others, and encourage a positive overall work environment. Mindfulness activities can improve nurse-to-nurse caring and reduce incivility in the workplace. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Nurses experience stress in workplace settings and it can occur for many reasons, such as staff member shortages, workloads, or even simply keeping up with demands of continual changes in the health care industry (Clark, 2015). Distress in the workplace can lead to job dissatisfaction, intentions to leave the profession, and lack of respect or incivility in communication (Clark, 2015; Lo, Chien, Hwang, Huang, & Chiou, 2018). In addition to influencing nurse retention, psychological and physical stress among nurses can ultimately jeopardize the delivery of quality patient care (Bala, 2018).

Psychiatric–mental health nurses are experts in caring for others with mental health stressors (American Psychiatric Nursing Association, 2018). They can be advocates for conflict resolution, can help heal difficult relationships, cope with uncivil behavior, and educate others to reduce bullying behavior. Nurses trained in mental health care are also familiar with mindfulness techniques, which have the potential to be effective for coping with workplace stressors.

Health care policies on reducing workplace stressors and incivility can improve care in nursing relationships and have positive effects in the workplace. Watson's (2008) theory on human caring, which emphasizes facilitating authentic kindness and mindful interactions through the process of mindfulness activities, is one theory that has been posed to increase the quality of caring in nursing relationships. This theory could be a support for policies intended to improve workplace relationships (Sparks, 2018; Watson, 2008). The purpose of the current study was to examine nursing service staff (NSS) (e.g., RNs, licensed practical nurses [LPNs], certified nursing assistants [CNAs]) perceptions on caring behaviors in the workplace, and the effect that a mindfulness activity paired with kind behaviors can have on caring for other NSS. The authors hypothesized that the mindfulness/caring activity would increase perceptions of caring in the workplace.

Literature Review

Facilitating a positive work environment in health care settings is important. One aspect of a positive environment is workplace caring, which is the act of one NSS caring for another colleague by helping, and being supportive, respectful, appreciative, and professional (Longo, 2011). For NSS to care for others, they must have the ability to care for themselves. NSS who care for themselves can promote ethical positive relationships in the nursing workplace. The American Nurses Association (ANA) Code of Ethics for Nurses, refers to nurses' self-care duties as “wholeness of character, attention to one's own welfare or self-care, and emotional integrity reliant upon maintaining relational boundaries” (Fowler, 2015, p. 78). The ethical practices they discuss recommend that nurses treat each other fairly and do not engage in behaviors that would cause distress to others.

The Gallup Ethics poll (Brenan, 2017) revealed that nurses are among the most trusted professionals for honesty and ethical behavior. Unfortunately, workplace stress and incivility have been shown to contribute to psychological distress among NSS, which is the opposite of trust and ethical behavior (Watson et al., 2008). Incivility and corresponding increased levels of psychological distress can cause disruption in relationships between NSS by decreasing human caring and respect in the workplace (Botha, Gwin, & Purpora, 2015). Workplace bullying, also known as lateral violence, is a particularly harmful form of disrespect, and may manifest as verbal abuse, intimidation, and humiliation (Hilton, 2018). Threatening behavior can create a hostile environment, impair facility operations, and frighten or inhibit others (Barnes, 2011).

One recent study by the Occupational Safety and Health Administration (OSHA; 2016) found that over a 12-month period, more than 50% of nurses and nursing students were verbally abused. The prevalence of bullying in the nursing workplace also contributed to a nurse in the United Kingdom committing suicide (Walker, 2018). Watson's theory on human caring has been proposed to provide some insight into defining workplace stress, incivility, and nurse-to-nurse caring. This theory has been discussed throughout academic and clinical forums in nursing and is frequently used as a theoretical underpinning for research studies. Watson's theory describes 10 Caritas Processes®, which refer to factors that involve unconditional or eternal love (Watson Caring Science Institute, 2018). Some core concepts of this theory include relational caring for the self and others, a commitment to enhance human dignity and respect, an authentic presence and intention of “doing” for another, and an inner harmony or equanimity (Watson, 2008). Watson (1999) defines caring as the moral ideal of nursing whereby the end is protection, enhancement, and preservation of human dignity, and that human caring involves values, a will and a commitment to care, knowledge, caring actions, and consequences. Specific components of Watson's theory describe human caring as practicing loving kindness, developing trusting-caring relationships, allowing for expression of positive feelings, and creating a healing environment (Watson, 2008). Practices have been proposed to enhance caring behaviors.

One such practice is mindfulness, which is the act of being profoundly aware of what an individual can sense and feel; the individual must be fully present at every moment without prejudice or interpretation (Sparks, 2018). Nurses are fully present when they focus on the “here and now” and are aware of the possibilities and challenges of the moment, as well as awareness of social relationships (Sitzman & Watson, 2017). Sitzman and Watson (2017) reported that caring is enhanced by a mindfulness activity that provides a full presence. Mindfulness practices, such as personal reflection, have been shown to reduce physiological and psychological stress (Foureur, Besley, Burton, Yu, & Crisp, 2014) and can easily be used in the workplace. Nurses who practice mindfulness reported an increase in well-being and openness to others (Foureur et al., 2014). The current study sought to assess how the pairing of two activities (mindfulness followed by caring behavior) influenced perceptions of caring in the workplace.

Method

Participants and Sampling

Institutional Review Board approval and participants' verbal consent to participate were obtained. The 164 participants in the current study comprised 118 (72%) RNs, 21 (12.8%) LPNs, and 25 (15.2%) CNAs employed at one of 19 inpatient and outpatient departments at a large health care system in a state in the western United States. The sample was a convenience sample, with NSS randomly selected from among all staff members in each department who expressed interest in participating, and with the number of participants selected from each department proportional to the department's size. A cluster randomized trial was used, where each of the 19 departments (clusters) were randomly assigned to either the treatment or control group.

Cluster randomization, rather than subject randomization, was necessary because NSS who engaged in treatment activities could potentially alter the climate of the department, thus influencing perceptions of behavior among other staff members not receiving treatment.

Treatment group participants (from nine departments) and control group participants (from 10 departments) were statistically equivalent, with no significant differences in their distributions of employee type (RN, LPN, or CNA; χ3 [2, N = 164] = 2.87, p = 0.24), or workplace status (χ3 [1, N = 164] = 0.08, p = 0.77). Most participants (95.7%) were NSS and 4.3% were contracted agency staff members. The total sample size excluded seven NSS who did not provide responses to seven or more questionnaire items, altered wording of items prior to responding, or endorsed multiple response options for individual items. For the analytic sample (N = 164), there were no missing data.

Procedure

Research members (C.K., M.R., D.G., R.G., S.M.) met with each study participant in the treatment group prior to the beginning of data collection. Participants had the opportunity to discuss what they knew about mindfulness. The research member taught participants the concept of mindfulness and how to take part in the activity. Participants then provided their own explanation of mindfulness and how they would use it in the current study. Participants had the opportunity to ask questions or have their concerns clarified regarding what was expected. Most NSS were aware of the concept of mindfulness or had used it in their personal lives. The LPN (n = 1) and CNAs (n = 3) were unfamiliar with the concept of mindfulness.

The intervention in the current study involved a combination of two activities, where participants completed 1 minute of mindfulness (measured by a wristwatch or clock) and followed it with a caring behavior. Mindfulness can promote a calm, focused mind and pairing mindfulness with caring/kindness promotes compassion (Ricard, 2017). Mindfulness behaviors included, but were not limited to, concentrated breath control, self-reflected “centeredness” on a special moment, positive thinking, or slowing of thoughts. Caring behaviors included, but were not limited to, written compliments to a supervisor about a coworker's individual work, offering to help a coworker with a task, engaging in active listening with a coworker, acknowledging and thanking a coworker for a contribution or work done, or simply smiling at a coworker.

This intervention sequence was performed at three time points per shift (chosen by participants), for three consecutive shifts. NSS rarely work the same schedule and do not always work three shifts in 3 days. Thus, researchers worked with NSS to identify three consecutive shifts. The shifts varied from 3 days in a row to having multiple days off between shifts. None of the participants changed their routine schedules to accommodate the current research study. Participants in the treatment group completed the quantitative survey before the first shift and after the third shift. Control group participants completed the survey at identical time points, before their first shift and after their third shift, but did not engage in intervention activities. Participants from both groups completed a seven-item qualitative survey at the end of their three shifts.

A nursing service workplace quantitative survey was developed based on initial review of Wolf's 28-item Caring Behavior Inventory for Elders (Wolf, Zuzelo, Goldberg, Crothers, & Jacobsen, 2006). Author approval to use the screening tool was received. As the current study design underwent development, it was apparent that some of the inventory items did not adequately address nurse-to-nurse interactions. The researchers wanted to examine nurse-to-nurse relationship issues, such as stress, respect, accountability, trust, and expression of feelings. Five items from Wolf's initial tool were selected and modified to align with Watson's theory for use in the current study, and the authors generated 12 additional items. The instrument comprised 17 items designed to assess NSS perceptions of the extent of caring behavior in the workplace.

Each of the 17 items on the quantitative instrument described a behavioral attribute of NSS (e.g., “Nurses I work with display professional behavior”), and each item included five Likert response options (0 = never, 1 = almost never, 2 = occasionally, 3 = usually, 4 = almost always, and 5 = always), with negatively worded items reverse-coded. A composite score was computed for each participant as the mean of the 17-item scores (Table 1). Responses to the quantitative survey showed good internal consistency reliability, with Cronbach's alphas of 0.928 and 0.924 for the pre- and post-survey, respectively. Scores also showed good test–retest reliability, with Pearson's r = 0.910 and 0.859 for the treatment and control groups, respectively. In addition, a nursing service workplace qualitative survey was constructed, consisting of items pertaining to nurses' personal experiences in the workplace and their responses to the intervention (Table 2). The survey questions were developed based on literature reviews and a group consensus.

Items on the Nursing Service Workplace Quantitative Survey

Table 1:

Items on the Nursing Service Workplace Quantitative Survey

Items on the Nursing Service Workplace Qualitative Survey

Table 2:

Items on the Nursing Service Workplace Qualitative Survey

A convergent mixed method design was used in which quantitative and qualitative data were collected together and analyzed separately. A quantitative approach was used to assess differences between the treatment and control groups in their pre- and post-survey growth in caring behavior. A descriptive qualitative approach was used to understand participants' perceptions before and after implementation of the intervention. Integration of quantitative and qualitative data enhanced the interpretation of study results and substantiated validation of perceptions before and after the intervention. The mixed analysis supported reconciliation of responses for NSS working in different locations and shifts.

Data Analyses

Quantitative Analysis. To assess growth differences in caring behavior between the treatment and control groups, a linear mixed model with a random intercept (participants clustered into departments) and a single fixed effect (group membership) was fitted. In addition, a linear mixed model was fitted to assess group differences in post-survey scores, controlling for pre-survey scores. An a priori level significance criterion of α = 0.05 was used. The R statistical programming version 3.4.3 application was used for statistical analysis.

Qualitative Analysis. A qualitative descriptive framework, which gave study participants a voice about their workplace, was used to gather and analyze response data. Thematic analysis substantiated perceptions before and after implementation of the intervention (Nowell, Norris, White, & Moules, 2017). Constant comparing of data was used to obtain theme saturation and identify subthemes (Bengtsson, 2016). An external reviewer/auditor concurred on the team's theme/subtheme identification and offered minor edits and additions. The result was a simultaneous comparison of the quantitative and qualitative data and substantiated the change in participant perceptions after the mindfulness intervention.

Results

Quantitative

Results from a linear mixed model assessing differences between the treatment and control groups in their pre- to post-survey growth in caring behavior indicated a statistically significant positive effect for the treatment, with treatment group participants showing significantly greater growth (Mgrowth = 0.13) than control group participants (Mgrowth = 0.01; t [16.67] = 2.37, p = 0.03). A moderate effect size (R2 = 0.064) was observed. Table 3 provides descriptive statistics for the mean pre- and post-survey scores for each group. Level-1 residuals were normally distributed and homoscedastic.

Descriptive Statistics for the Nursing Service Workplace Quantitative Survey Scoresa by Group

Table 3:

Descriptive Statistics for the Nursing Service Workplace Quantitative Survey Scores by Group

Prior to examining post-survey score differences, initial analysis showed statistically significant differences between the intervention and control group pre-survey scores (t [16.91] = 2.10, p = 0.038), with the control group showing higher mean scores. Therefore, it was important to control for these existing differences. Results from a second linear mixed model assessing group differences in post-survey scores after controlling for these pre-survey score differences showed a statistically significant group difference in post-survey scores (t [16.91] = 2.14, p = 0.047). After adjusting for pre-survey scores, the treatment group's adjusted mean caring behavior score (Madj = 4.00) was significantly higher than the control group's adjusted mean score (Madj = 3.89). The effect size was small to moderate (R2 = 0.05). Level-1 residuals were normally distributed and homoscedastic.

Qualitative

Three main themes and 13 subthemes emerged from the qualitative data (Table 4). Excerpts with participant quotes are included to illustrate the findings and give participants a voice.

Theme/Sub-Theme Identification from the Qualitative Data

Table 4:

Theme/Sub-Theme Identification from the Qualitative Data

Theme 1: Perceptions of Human Caring in the Current Nursing Environment. Subthemes that emerged under this first theme were (a) mutual trust, respect, and feeling valued as team members; (b) heavy and challenging workload; (c) poor and disrespectful communication and lack of teamwork; and (d) undermining, discourteous, and rude behaviors.

Staff members alluded to the importance of being valued as a team and made statements such as: “Actions speak louder than words most of the time. Act respectful. Be a team player. Support your coworkers in an enthusiastic and positive way. Be approachable.” The subtheme on workload was exemplified negatively through one nurse's quote, “I request help as needed through two of my fellow RNs who don't readily agree to help. I try not to schedule shifts on days they work and frequently consider taking a day off as sick leave. I dread those shifts.” Staff members highlighted instances of poor and disrespectful communication. One staff member stated, “Occasionally, I have overheard conversation from other staff members criticizing my nursing techniques or workflow.”

These comments can erode a sense of effective communication and supportive teamwork. Another perception of the workplace environment that surfaced was discourteous and rude behaviors. These behaviors were not limited to NSS but included administrators, physicians, and patients. A staff member shared an experience with a coworker and made the following statement, “Another coworker belittles me and makes rude comments to and about me.”

These reported behaviors can have a devastating impact, as one nurse described feeling belittled in front of others, resulting in this nurse considering leaving the nursing field. A participant stated, “One nurse would often scold me for things in front of other staff and patients. These moments made me consider quitting health care altogether. Her public derision made me feel less than human.”

Participants had positive and negative perceptions of caring in their current nursing environment.

Theme 2: Important Values Identified by NSS. Subthemes that emerged under this second theme were (a) professionalism and approachability; (b) openness and communication; (c) good work ethic—appreciating and supporting each other; (d) dignity, trust, and respect; and (e) valuing education and training opportunities. Participants shared values that were important to them in their day-to-day interactions with the team.

The following staff comments describe how they contribute to an open environment: “I listen to all staff and acknowledge good work. I try to treat all coworkers with respect, and I value their opinions.”

Nurses also stressed the importance of being supported by their leaders. One participant quoted the phrase, “An environment with transparent leadership that allows equal opportunities for all.”

Another participant concurred, stating “Good management is crucial.”

Dignity, trust, and respect were viewed as an important value. Another participant highlighted, “Mutual respect of all age groups and levels of experience.”

Other comments included important attributes, such as “trust and respect, constructive feedback, open and honest communication, fairness.” Staff members valued educational and training opportunities and provided examples of what would be appreciated stating, “employee education and encourage[ment] with awards or written certificates.” Staff members also gave suggestions of what educational offerings would be beneficial reporting, for example, “continued education on how to treat others with respect,” and “continue to educate others about lateral/actual violence in the workplace, respecting others in the workplace.”

Theme 3: Impact of Caring Behaviors and Mindfulness. Subthemes that emerged under this third theme were (a) decreased stress, increased positivity, and a sense of calmness; (b) increased cohesiveness, trust, and respect; (c) engaged work environment and job satisfaction; and (d) connectedness and collegiality as team members with happier patient-focused clinical care. Staff members spoke to how caring behaviors and mindfulness exercises decreased their stress and increased their positivity and sense of calm. The following comment illustrates this: “It helped to create a more Zen calm work area. Some of the underlying tension that was perceived had dissipated.” Another response indicated how it allowed for one's attitude to be “reset”: “It allowed me to pause and redirect my thinking in stressful scenarios.”

The mindfulness/caring activity increased cohesiveness. One participant commented, “I realized I should take an opportunity to do more good things and have more meaningful interactions with my coworkers.”

One staff member powerfully stated, “I felt it grew an environment of trust and respect.”

Another participant highlighted, “It made me feel better about the overall shift. It's been a heavy 2 months on the unit, so assisting a coworker also gave me a moment to reflect on when I received assistance, and how it made me feel valued by my fellow RNs.”

Participation in caring behaviors and mindfulness can have a positive impact on the work environment. The following excerpts highlight how the intervention impacted the team. A staff member reported, “It made me appreciate my coworkers more and to really focus on what great people they are, and how much they really do care.”

Another participant stated, “I believe it fosters a great sense of team-work and professional gratitude.”

Finally, one staff member stated, “I got warmth and support from the interaction. I felt good and I felt loved.”

Connectedness and collegiality are significant, as study participants reported perceiving a rather stressful work environment and heavy workload in their day-to-day experiences providing patient care.

Discussion

Quantitative and qualitative results from the current study provided a collection of rich data and complemented each other. Results from the quantitative data showed that the intervention—1 minute of mindfulness combined with a caring behavior—improved perceptions of caring behaviors in the environment. Perceptions of participants from various nursing units/locations and shifts from the qualitative analysis were consistent before and after the intervention. Before the intervention, participants revealed perceptions of incivility and psychological distress. Postintervention, participant responses indicated positive benefits such as reduced stress and increased teamwork. The three themes that emerged from the qualitative analysis were congruent with the quantitative results and provided additional evidence that implementation of a mindfulness intervention induced positive effects.

The qualitative results showed that NSS value professionalism, approachability, openness, communication, good work ethic, support for each other, and basic values of dignity, trust, and respect. One element of professionalism is the ability to create therapeutic relationships through appropriate communication (Vertino, 2014). Therapeutic communication exemplifies an honest expression of ideas and feelings, along with congruent body language, in a supportive, compassionate environment (Vera, 2016). Trust is important to build dependability, reliability, and integrity necessary for therapeutic relationships. Body language, nonverbal communication, and smiling can promote a positive openness and approachability for staff members to build therapeutic relationships. Dependability and teamwork are also elements of a good work ethic (Kourkouta & Papathanasiou, 2014; Schreiner, 2019). Nurses expressed that they want these values to be evident in their workplace. An expression of these values can enhance caring in the workplace. Many individuals enter the nursing profession because of a desire to care for others (Alyson, 2019). Based on this, one would expect to see caring behaviors consistently occurring in nursing relationships.

However, the qualitative results showed that some of these values and behaviors are not always present in the work environment. Consistent with the literature of the OSHA study, the current study found that nurses perceived difficulty with stressful work relationships. In a study by Valizadeh et al. (2016), some nurses harbored negative attitudes and showed disrespect, discrimination, and lack of support. A few of the NSS in the current study made similar comments reporting that sometimes they felt “scolded,” “judged,” or “dismissed.” These types of feelings can reduce job satisfaction and well-being. Watson's theory suggests that a mindfulness/caring activity might reinforce the positive values nurses want to see in their workplace and may reduce the negative effects of stress and incivility. Connecting the practice of mindfulness/caring, which is an activity taught with the message of compassion and altruism, to the practice of caring has potential to promote a more benevolent society (Ricard, 2017).

In the current study, NSS in the treatment group who took part in the mindfulness/caring exercise showed increased perceptions of workplace caring when compared to the control group. In addition, NSS reports from the qualitative survey showed that participants who took part in the intervention discussed and increased their ability to remain quiet and centered in the workplace after the mindfulness activity. They also reported that they became more focused on their peers and were willing to set a good example, offer help, and encourage a positive environment. Quotes from NSS were consistent with Watson's theory that participants were able to use the mindfulness activity to refocus in that moment and remain mindful of the environment around them. Participants emphasized that they felt calmer after only 1 minute of the activity, which was consistent with Watson's Caritas Processes of harmony/equanimity. After engaging in the activity, staff members appreciated their coworkers more and discussed the take-away “good feelings” that they harbored. Taking part in the mindfulness/caring activity reduced episodes of incivility, which was consistent with other studies on mindfulness and breathing (Green, 2017).

Nurses and their interdisciplinary colleagues are busy professionals, but a brief, 1-minute mindfulness activity paired with a caring activity has the potential to exert a positive impact on their environment, increasing role model kindness to peers, thereby reducing incivility. NSS comments from the qualitative survey were consistent with the current literature and OSHA findings. The responses of some participants stating that they wanted to know how to handle situations where a peer was disrespectful or how to communicate with physicians or management when they felt disrespected, illustrates that these nurses were interested in pro-actively and positively changing their workplaces through human caring. Other participants reported that they wanted to teach mindfulness to their peers so that they could experience an increase in the perception of caring. The results of the current study, based on qualitative and quantitative data, showed that the mindfulness/caring activity led to increased positive respectful interactions, reduced stress, and enhanced trust and teamwork among peers. NSS also suggest that using principles of Watson's theory, which includes mindfulness at its core, allows improved staff caring to be more visible in the workplace.

Limitations

The current study had some limitations. First, data collection was limited to NSS within one health care system in the western United States. Although experimental criteria of randomization and treatment/control group principles were met, a convenience sample was used, comprising volunteer participants. Second, the current study was limited to direct patient care workers only; therefore, no managers or educators were included. Should the current study be replicated, the authors recommend that future research include an interprofessional sample of workers. It would be interesting to understand how other health care disciplines (e.g., social work, physical therapy) would respond to a mindfulness and caring activity in the workplace. Other future research possibilities should include a replication of the current study that includes a comparison of nurse-to-nurse versus nurse-to-patient perceptions of caring behaviors.

Implications

The practice of mindfulness paired with caring behaviors can improve perceptions about relationships, enhance teamwork and workplace cohesiveness, increase positive feelings, and reduce stress. The impact of 1 minute of mindfulness to reset and refocus on creating a calmer workplace environment followed by an act of caring can be powerful and may remedy some of the loss of caring and human dignity that can occur in the nursing workplace. Mindfulness activities and caring behaviors can improve nursing relationships in the workplace, which have implications for the quality of care that patients receive. In addition, NSS who have good relationships with their fellow colleagues tend to have increased job satisfaction and better overall well-being. This increase in satisfaction/well-being can lead to improved nurse retention.

Conclusion

The health care field, and the continuous, rapid changes occurring within it, have the potential to increase stress among nursing staff. A stressful workplace can increase the time and effort needed to maintain healthy relationships. When NSS are mindful and consciously engaging in a small number of caring behaviors, they can enhance human dignity and overall authentic kindness for colleagues. Mindfulness/caring activities have the potential to reset one's personal attitude, subsequently affecting colleagues and improving the workplace environment. Psychiatric nurses can help enhance responsiveness in nurse-to-nurse relationships, which ultimately can improve health, increase empathy, and reduce incivility. Themes of caring, mindfulness, incivility, and stress reduction are regularly addressed by psychiatric nurses in their work.

References

Items on the Nursing Service Workplace Quantitative Survey

Item
Nursing staff I work with attentively listen to me.
Nursing staff I work with refuse to take responsibility for their actions.
Nursing staff I work with show me respect.
Nursing staff I work with reject or criticize decisions and recommendations I make.
Nursing staff I work with are honest with me.
Nursing staff I work with blame me for things I am not responsible for.
I am comfortable asking questions of nursing staff in my work area.
Nursing staff I work with consider my work to be without value or importance.
Nurses I work with display professional behavior.
I overhear nursing staff gossiping about others.
I am comfortable expressing my thoughts and concerns to my peers.
Nursing staff I work with are distant with me.
Nursing staff I work with insult me.
People are treated respectfully on my unit.
Nursing staff I work with speak to me in a demeaning or belittling manner in the presence of others.
Nursing staff I work with are controlling and quick-tempered towards me.
I trust the nursing staff I work with.

Items on the Nursing Service Workplace Qualitative Survey

Item
Describe your personal experience, including if you were disrespected or not valued in your current work area.
How did you respond to this type of behavior?
What is needed to create a safe, respectful work environment and one which values your contributions?
What are you willing to do personally to demonstrate that you value and respect your coworkers?
What impact, if any, did the mindfulness practice that you engaged in (concentrated breath control, getting “centered,” focusing on the moment, thinking positively, slowing your thinking) have on you personally? (Answer only if you completed the required activity.)
What impact, if any, did the caring activities that you engaged in have on you personally? (Answer only if you completed the required activity.)
How did caring activities you completed each shift affect your current work area? (Answer only if you completed the required activity.)

Descriptive Statistics for the Nursing Service Workplace Quantitative Survey Scoresa by Group

GroupMean (SE)
Pre-SurveyPost-SurveyAdjusted Post-Surveyb
Treatment (n = 85)3.79 (0.06)3.92 (0.06)4.00 (0.06)
Control (n = 79)3.97 (0.06)3.99 (0.07)3.89 (0.07)
Total (N = 164)3.87 (0.06)3.95 (0.06)3.95 (0.06)

Theme/Sub-Theme Identification from the Qualitative Data

ThemesSub-Themes
Perceptions of human caring in the current nursing environment

Mutual trust, respect, and feeling valued as team members

Heavy and challenging workload

Poor and disrespectful communication and lack of teamwork

Undermining, discourteous, and rude behaviors

Important values identified by the nursing service staff

Professionalism and approachability

Openness and communication

Good work ethic–appreciating and supporting each other

Dignity, trust, and respect

Valuing education and training opportunities

Impact of caring behaviors and mindfulness

Decreased stress levels, increased positivity, and a sense of calmness

Increased cohesiveness, trust, and respect

Engaged work environment and job satisfaction

Connectedness and collegiality as team members and happier patient-focused clinical care

Authors

Dr. King is Quality Management Specialist-Performance Measures, Ms. Raison is Utilization Management Supervisor, Ms. Gallegos is Bar Code Medication Administration, Nursing Services, Mr. Gorman is Safe Patient Handling Manager/Falls Prevention, and Dr. Moscatel is Education and Workforce Development, Eastern Colorado Health Care System, Rocky Mountain Regional VAMC, Aurora, Colorado; Dr. Rossetti is Presidential Teaching Professor, School of Nursing, and Dr. Smith is Presidential Teaching Professor, Department of Educational Technology, Research and Assessment, Northern Illinois University, DeKalb, Illinois; Dr. Smyth is Lecturer/Programme Director School of Nursing and Midwifery, Aras Moyola, National University of Ireland, Galway, Ireland; and Dr. Watson is Founder/Director of Watson Caring Science Institute, and Distinguished Professor/Dean Emerita, University of Colorado, Denver, Colorado.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank all the Nursing Service Staff who took part in this study.

Address correspondence to Camille King, EdD, MS, RN, PMHCNS-BC, Quality Management Specialist-Performance Measures, Eastern Colorado Health Care System, Rocky Mountain Regional VAMC, 1700 N. Wheeling Street, Aurora, CO 80045; e-mail: Camille.King3@va.gov.

Received: May 25, 2019
Accepted: June 06, 2019
Posted Online: July 12, 2019

10.3928/02793695-20190626-01

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