*All names have been changed for anonymity purposes. Cases described are based on the author’s clinical practice.
As professional nurses, we often bear witness to our clients’ suffering. We are committed to alleviating such suffering, to healing the whole person within the context of his or her environment and culture. Early in our careers, we learn that suffering takes many forms—physical, emotional, or spiritual; acute or chronic—and that pain and suffering affect individuals across cultures, social and economic levels, and ages. When our clients are suffering, we continue to care and be present for them. Mindfulness meditation is one way to help alleviate such suffering. This article focuses on the use of mindfulness meditation by nurses as a way to work with clients who are suffering and help provide relief.
Types of Meditation
There are two basic types of meditation: concentrative meditation and mindfulness meditation. They share the intentional training of individuals’ attention and concentration, but the objects of that attention are different for each type. In concentrative meditation, practitioners learn how to cultivate one point of attention by focusing on a mantra, sound, visual image, object, or koan. For example, in transcendental meditation, students are taught to repeat a sound or phrase to focus and concentrate the mind. On the other hand, a Zen Master may give students a koan (i.e., a phrase or question to occupy the mind and cut through discursive thinking). Examples of koans include: “What was your face before your parents were born?” and “What is the sound of one hand clapping?” Other meditation methods are taught by having students focus on a single visual object, such as a candle or icon.
The second basic type is mindfulness meditation, also known as vipassana or insight meditation. Like concentrative meditation, mindfulness meditation is a conscious discipline of intentional self-regulation that can be practiced by anyone. It begins by focusing individuals’ attention on their breathing. This attention to breathing trains the mind to develop concentration and awareness. Close observation of breathing teaches individuals that each breath is unique and impermanent. With practice, students develop a more acute awareness of their breathing through observation of the physical sensation of breathing. As their experience deepens, students are taught to shift their attention from breathing as the only point of awareness to a range of objects of attention, as they change from moment to moment in the field of awareness. These objects of awareness include thoughts, sounds, physical sensations, and emotions.
Although mindfulness meditation has its origins in Buddhism, it is not a religious practice and can be learned and practiced regardless of religious affiliation. Mindfulness meditation is a process of paying attention on purpose to what is happening in the present moment, with no other goal. It is about being open to, curious about, and aware of one’s own experience in the moment—not making judgments, developing plans, or strategizing. According to Kabat-Zinn (1998):
Mindfulness is about being fully awake in our lives. It is about perceiving the exquisite vividness of each moment. We feel more alive. We also gain immediate access to our own powerful inner resources for insight, transformation, and healing. (inside cover)
Mindfulness meditation is a skill that can be learned and, when practiced in a disciplined manner, has been consistently effective in reducing stress and controlling pain. However, it is not a “technique” for stress reduction and pain control; rather, it is a way of life. Initially, individuals deliberately maintain focused attention on their breathing as a way to cultivate their concentration. Consistent, daily practice promotes the development of stability, inner calmness, and non-reactivity of the mind, which in turn, allows individuals to face, and even embrace, all aspects of daily life regardless of pain, anxiety, or fear. In addition, stability and non-reactivity support individuals’ ability to become compassionate observers of themselves, as well as of others. Tanahashi (cited in Santorelli, 1999) described the Japanese character of mindfulness as two interactive figures—one representing mind and the other the heart. Mindfulness meditation helps integrate the two.
The practice of mindfulness meditation allows individuals to develop a moment-to-moment awareness of the present. It requires discipline and a willingness to observe what is happening without judgment, and without getting caught up in the current situation, the past, or what may happen in the future. Discipline is learned by patiently observing each breath in its entirety. Whenever the mind wanders and begins to solve problems, make plans, review past events, anticipate the future, or get caught up in the drama of one’s personal life experience, individuals should gently and firmly return their attention to the breath in the present moment. Their attention is focused simply on breathing in and out. As concentration deepens, a subtle, but powerful, transformation occurs.
Joan, a wife and mother of three young children who was receiving treatment for breast cancer, expressed it this way:
This practice has allowed me to get my life back. Before, I was so filled with anxiety and fear about what was happening and what the future would be that I couldn’t enjoy anything in my life…. Now, even though things aren’t perfect, and I don’t have guarantees about the future, I find I have times of great joy and deep peacefulness.
Jason, a 12-year-old boy, who was experiencing pain from mucositis during a bone marrow transplant, described how, when he gave his whole attention to the pain in his mouth and throat (rather than trying to block it out), he
...was surprised to discover I could even get a little interested in it. Ya [sic] know, it’s weird. It changes. At first, I thought it was just one huge, wicked bad, constant pain. But it’s not really. Like, mostly it’s there; but it changes all the time too. Ya don’t notice it at first, but it does. And when I watch how it changes, it hurts, but not as much, and sometimes for a little bit, it even stops. I guess you could say it’s like the weather. Well, not always your favorite weather. But it’s there all the time, and it’s always changing.
Jason continued receiving a morphine drip for pain, but he found he needed less medication when he practiced mindfulness meditation.
Attitudinal Foundations of Mindfulness Practice
Mindfulness meditation is basically a life-affirming process in which individuals are asked to continually return to the physical sensation of breath (life) moving in and out of the body. This process requires individuals to set aside their usual and familiar ways of being in the world. Kabat-Zinn (1990) described the attitudinal foundation of mindfulness practice. The process of mindfulness meditation is one of learning to bear witness to one’s own experience without judgment. Rather than judging, individuals are asked to simply watch, observe, and feel what is happening from moment to moment. This simple awareness of whatever is happening in the present moment requires patience. It requires individuals to return again and again to their original intention of being present for each breath. In doing so, individuals need to have what is described as a “beginner’s mind” or a “don’t know mind,” meaning they are open to seeing and experiencing each breath, and each moment, as a new beginning.
With practice, over time, individuals discover that having a “beginner’s mind” affects other aspects of their lives. When approached as if for the first time, old thought patterns and emotional reactions can lead to new possibilities and outcomes. There is a certain freedom in this because individuals find themselves opening up to new possibilities and responding outside their habitual, reactive behavior patterns. Mindfulness meditation involves a non-striving, non-“doing” orientation, which allows for more spaciousness and kindness toward self and others.
Studies have documented the efficacy of mindfulness meditation in a variety of adult populations. Mindfulness-based stress reduction (MBSR) has been shown to decrease the subjective experience of physical pain in individuals with chronic pain from a variety of etiologies (Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney, 1985; Kabat-Zinn, Lipworth, Burney, & Sellers, 1986). It has also been shown to decrease anxiety and increase self-esteem (Kabat-Zinn et al., 1992; Miller, Fletcher, & Kabat-Zinn, 1995). Studies by Roth and Creaser (1997) and Roth and Stanley (2002) have demonstrated that MBSR is effective across cultures and economic levels. Completion of a MBSR program resulted in changes in health care utilization, with fewer chronic care visits, in an inner-city population, suggesting that MBSR may help contain health care costs (Roth & Creaser, 1997; Roth & Stanley, 2002).
Mindfulness meditation has been shown to decrease symptoms of fibromyalgia (Kaplan, Goldenberg, & Galvin-Nadeau, 1993) and provide relief from psoriasis (Kabat-Zinn et al., 1998). More recently, MBSR has resulted in significantly reduced physical and psychological symptoms, as well as increased self-esteem, among people living with cancer (Speca, Carlson, Goodey, & Angen, 2000). In addition, these results were found to be consistent 6 months after treatment (Carlson, Ursuliak, Goodey, Angen, & Speca, 2001).
Developing the ability to be a compassionate witness of one’s own experience has proven powerful in transforming the way individuals respond to life events, and appears to have promising implications for the treatment of affective disorders (Astin, 1997; Teasdale, Segal, & Williams, 1995). Recently completed, yet to be published data suggest positive outcomes from a MBSR program offered to inmates and staff in a prison environment (Center for Mindfulness in Medicine, Health Care, and Society, n.d.).
A current study investigating the usefulness of MBSR and pain control among patients undergoing bone marrow transplant indicates that mindfulness meditation shows promise as an effective intervention (Bauer-Wu, 2004). Although there is no research on the use of mindfulness meditation with children, case reports show that children can learn and use it effectively to reduce stress and lessen pain (Ott, 2002).
The Process of Mindfulness Meditation
For most people, learning to meditate is challenging. It requires commitment to a daily discipline of practice. Although people breathe approximately 17,000 to 24,000 breaths every 24 hours, most people are not aware of their breathing. In addition, it has been estimated that people have approximately 50,000 thoughts during the course of a day; yet, most of them go by without conscious awareness. Paying attention to one’s breathing and thoughts sounds simple enough, but individuals quickly discover it is not as easy as it sounds. Mindfulness meditation requires patience, practice, and a willingness to forgive oneself and to begin over and over again. It also requires a sense of humor as individuals discover all of the innovative and creative ways they prevent themselves from following through on their intention.
Mindfulness Meditation Practice
Formal mindfulness meditation practice is one of the three primary forms of practice taught in MBSR (the others are the body scan and mindful hatha yoga, described below). It is possible to meditate anytime and anywhere. However, it is important to set aside a period of time each day to practice. Individuals can meditate while sitting (e.g., in a chair, on a cushion on the floor), kneeling, lying down, or standing. Individuals begin by finding a comfortable, dignified position, one that allows the back, neck, and head to be straight and tall, yet relaxed. If sitting in a chair, the individuals’ feet are flat on the floor, with the hands resting softly in the lap or on the thighs. If using a cushion, individuals sit cross-legged, with the hands resting softly in the lap or on the thighs. If lying down, individuals lie on their back, knees soft (i.e., relaxed), legs straight, feet gently falling to the outside, arms alongside (not touching) the body, with the palms facing up. The spine is in a straight line from the tailbone to the crown of the head. A small, rolled towel or cushion can by placed under the knees to prevent pressure on the lower back. If standing, individuals’ feet are comfortably apart and parallel, knees soft (not locked). Again, the spine is straight and tall (not rigid), and the belly is soft.
In any position, the eyes are gently closed or downcast, with a soft, unfocused gaze. Individuals then focus their complete attention on the physical sensation of each breath, observing the flow of air in and out of the nostrils, the rise and fall of the chest, or the movement of the abdomen expanding and contracting. Each inspiration and expiration is observed with a sense of curiosity and interest. Each breath is experienced for what it is, a new and unique experience. In each individual’s lifetime, each breath is breathed only once; there is no going back to do it differently, and no guarantee the next breath will happen. Whenever the mind wanders or attention falters, individuals simply return their attention to their breathing. It is important to do this firmly, with determination, yet gently, without harshness or judgment. The discipline of consistently returning to one’s breathing allows individuals the experience of forgiving themselves and starting over again. Over time, this discipline develops one’s ability to focus and concentrate, as well as experience a sense of deep quietude and stillness.
In addition to the experience described above, mindfulness meditation can also be experienced in the body scan, in mindful movement (e.g., hatha yoga), walking meditation, and eating meditation. As components of MBSR, these have useful application in pain and symptom management. These forms will be described below.
The body scan is the second useful meditation skill learned in MBSR (Kabat-Zinn, 1990). The body scan allows individuals to develop a focused, concentrated awareness of the body. Individuals develop the ability to be compassionate witnesses to whatever is happening in the body at any particular moment, and to be present without judgment, expectations, or demands, and without a need to change anything.
Often when an unpleasant sensation arises in the body, the immediate (and unconscious) reaction is to physically tense the muscles in that area. This tension increases the physical discomfort, while decreasing the total volume of air exchanged with each breath. After individuals learn the body scan, it can be used to work with the experience of physical pain. Paradoxically, focused awareness on the specific pain as it occurs in the body allows individuals to experience the subtle shifts and changes that occur during the subjective experience of pain in the present moment. As a result, pain is not magnified by individuals’ becoming caught up in stories and memories of previous pain or anticipation of prolonged or future pain. Instead, individuals’ attention is focused on the here and now (i.e., what is occurring in the present moment with this particular physical sensation of pain). Individuals begin to learn subtle cues from the body that indicate an imbalance or the need for a particular intervention, such as a change in position or rest. The body becomes the teacher. With continued practice, individuals begin to identify subtle physical changes in the body that precede and accompany emotional responses.
Mindful hatha yoga is the third major meditation taught in MBSR. It consists of slowly, mindfully moving the body through a variety of lengthening, flexing, and strengthening exercises. This is performed with careful moment-to-moment awareness of one’s breathing and of sensations that arise in the body as it is moving or being held in one position for a series of breaths. When done mindfully, this movement becomes more than exercise; it becomes a form of meditation.
Mindful hatha yoga is a pathway to self-discovery and to the experience of being able to live in one’s body, regardless of its physical condition. Individuals practice accepting their bodies as they are in the moment. Individuals also learn what limits they have, and when they find them, they practice breathing and being with that limit, without trying to make it different or push through it.
If individuals pay attention to walking, it can also become a mindfulness meditation. The purpose of walking meditation is simply to pay attention to the whole experience of walking—not walking to get somewhere, but instead walking and being acutely aware of walking. When first learning, individuals are asked to walk slowly and to pay attention to all that happens in the process of taking a step. Individuals becomes absorbed in the physical sensation of walking. The experience can be enhanced by walking in bare feet.
The focus is on three components of the body while walking: lifting the foot, moving the foot, and placing the foot on the ground. This process can be coordinated with one’s breathing by inhaling as the foot is lifted up and while moving the foot, and exhaling as the foot is placed on the ground. If in a public place, individuals can walk more quickly, while still coordinating the breathing with the walking, to avoid calling attention to a slow walking pace.
Mindful eating is a process that supports, reinforces, and expands individuals’ ability to develop awareness. In MBSR programs, a raisin is frequently used to offer participants an opportunity to eat mindfully. However, any food or liquid could be used. Doing so requires individuals to pay attention to the complete experience, as well as the details, of eating. The raisin is approached as if for the first time. Curiosity and discovery are encouraged. Without labeling it, what does it look like? How would one describe it to another person who has never seen it before? What does it feel like in the palm or fingers? How does it smell? Does it make sounds? What happens in one’s mind and body at the anticipation of putting it in one’s mouth? Is it possible to describe without using nouns or familiar labels? How would one end of it be described, compared to the other? Paying close attention to this object, is it possible to see, hear, feel, touch, and connect with what it was before it became what it is now? When eating mindfully, individuals may find their eating habits change. Some report eating less, choosing more nutritious foods, and finding nonfood alternatives for stress management.
As nurses, we have the unique privilege of witnessing and nurturing the healing process of the whole person—mind, body, and spirit. Teaching mindfulness meditation is a nursing intervention that can foster healing. The consistent practice of mindfulness meditation has been shown to decrease the subjective experience of pain and stress in a variety of research settings. Formal and informal daily practice fosters development of a profound inner calmness and non-reactivity of the mind, allowing individuals to face, and even embrace, all aspects of daily life, regardless of circumstances. By emphasizing being, not doing, mindfulness meditation provides a way through suffering for patients, families, and staff. This practice allows individuals to become compassionate witnesses to their own experiences, to avoid making premature decisions, and to be open to new possibilities, transformation, and healing.
- Astin, J.A. (1997). Stress reduction through mindfulness meditation: Effects on psychological symptomatology, sense of control, and spiritual experiences. Psychotherapy and Psychosomatics, 66, 97–106. doi:10.1159/000289116 [CrossRef]
- Bauer-Wu, S. ( 2004, March. ). Facing the challenges of stem cell/bone marrow transplant: Results from a pilot study. Paper presented at the Integrating Mindfulness-Based Interventions into Medicine, Health Care, and Society, 2nd annual conference. , Worcester, MA. .
- Carlson, L.E., Ursuliak, Z., Goodey, E., Angen, M. & Speca, M. (2001). The effects of mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Support Care Cancer, 9, 112–123. doi:10.1007/s005200000206 [CrossRef]
- Center for Mindfulness in Medicine, Health Care, and Society. (n.d.). Major research findings. Retrieved June 2, 2004, from http://www.umassmed.edu/cfm/research/findings.cfm
- Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33–47. doi:10.1016/0163-8343(82)90026-3 [CrossRef]
- Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York: Dell.
- Kabat-Zinn, J. (1998). Preface. In The stress reduction and relaxation program workbook. (Available from Center for Mindfulness in Medicine, Health Care, and Society, University of Massachusetts Memorial Health Care, 55 Lake Avenue North, Worcester, MA 01655)
- Kabat-Zinn, J., Lipworth, L. & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8, 163–190. doi:10.1007/BF00845519 [CrossRef]
- Kabat-Zinn, J., Lipworth, L., Burney, R. & Sellers, W. (1986). Four-year follow-up of a meditation-based program for the self-regulation of chronic pain: treatment out-comes and compliance. Clinical Journal of Pain, 2, 159–173. doi:10.1097/00002508-198602030-00004 [CrossRef]
- Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K.E. & Pbert, L. et al. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936–943. doi:10.1176/ajp.149.7.936 [CrossRef]
- Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Scharf, M.J. & Cropley, T.G. et al. (1998). Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UBV) and photochemotherapy (PUVA). Psychosomatic Medicine, 60, 625–632. doi:10.1097/00006842-199809000-00020 [CrossRef]
- Kaplan, K., Goldenberg, D. & Galvin-Nadeau, M. (1993). The impact of a meditation based stress reduction program on fibromyalgia. General Hospital Psychiatry, 15, 284–289. doi:10.1016/0163-8343(93)90020-O [CrossRef]
- Miller, J.J., Fletcher, K. & Kabat-Zinn, J. (1995). Three year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17, 192–200. doi:10.1016/0163-8343(95)00025-M [CrossRef]
- Ott, M.J. (2002). Mindfulness meditation in pediatric practice. Pediatric Nursing, 28, 487–490, 535.
- Roth, V. & Creaser, R. (1997). Mindfulness meditation-based stress reduction: Experience with a bilingual inner-city program. The Nurse Practitioner, 22, 150–176. doi:10.1097/00006205-199703000-00013 [CrossRef]
- Roth, V. & Stanley, T.W. (2002). Mindfulness-based stress reduction and healthcare utilization in the inner city: Preliminary findings. Alternative Therapies, 8, 60–66.
- Santorelli, S. (1999). Heal thy self: Lessons on mindfulness in medicine. New York: Bell Tower.
- Speca, M., Carlson, L.E., Goodey, E. & Angen, M. (2000). A randomized, wait-list controlled clinical trail: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine, 62, 613–622. doi:10.1097/00006842-200009000-00004 [CrossRef]
- Teasdale, J.D., Segal, Z. & Williams, J.M. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help?Behavior, Research and Therapy, 33, 25–39. doi:10.1016/0005-7967(94)E0011-7 [CrossRef]