Evaluation and Synthesis of Reviewed Evidence

Running head: CRITICAL APPRAISAL OF THE EVIDENCE 1 

Critical Appraisal of the Evidence 

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Critical Appraisal of the Evidence 

Introduction 

Available research has already proven that the practice of nursing in general, more so, in the emergency response section, can be extremely stressful, and unless the stress is mitigated, can be harmful to both the nurse and the practice. Several interventions for stress mitigation have been implemented some of which include mindfulness while others do not. A lot of research has been undertaken to establish the efficacy of the mindfulness-based and non-mindfulness-based intervention. The instant research paper is a critical appraisal of the available evidence as engendered in peer-reviewed articles that compare the efficacy of mindfulness therapy and no mindfulness therapy in reducing stress symptoms in emergency room nurses over a period of two months. 

Search Strategies and Yield 

The two primary avenues used to search for peer-reviewed articles for the instant research paper were Google Scholar and EBSCO Information Services. Through these avenues, a number of professional and research databases were accessed including Academic Search Complete, International journal of nursing studies, Applied Nursing Research. The search was predicated on a combination number of keywords including “effectiveness”, “mindfulness”, “nursing Stress mitigation” and “intervention”. The chosen range for the search was eight years between 2010 and 2018. Upon entry of the search parameters into the Google Scholar search engine, 954 results were obtained while the EBSCO database produced 386 results. A large number of the articles produced in the respective searches were not readily available other than their respective abstracts. A study of these abstracts was also undertaken to give a general understanding relating to the available research on the issue in question within the instant research paper. 

Inclusion and Exclusion Criteria 

The selection process included the elimination of any articles whose sample was not relevant to the nursing profession such as samples involving patients, children, or the elderly. The second general criterion was focusing on the articles that reveal the efficiency of the use of mindfulness for the alleviation of stress symptoms and those about non-mindfulness approaches to the alleviation of symptoms of stress. Among the specific research preferences included the use of a variety search having primary research articles, literature reviews, and also meta-analysis articles. The variety was geared towards providing a varied balanced approach towards the issue being researched on. 

Explanation of the Review Protocols 

The instant research paper focusses on t he evaluation of a phenomenon with a very specific set of factors. The phenomenon is based on the hypothesis that mindfulness-based interventions are more effective in the short term (two months) mitigation of stress symptoms among nurses than non-mindfulness-based interventions. The factors within the hypothesis include being a nurse, which inter alia entails being an adult but not a senior citizen and also being in relatively stable mental and physical health. Further, to evaluate the hypothesis, there was a need to find articles that evaluated mindfulness as an intervention on one hand, and those that evaluated other available interventions such as pharmacological interventions on the other. It is on this basis that the search parameters used as defined above were arrived at. 

Literature Review & Critical Appraisal of Evidence 

Ireland et al. (2017) synthesize the findings of a randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners hence a level I on levels of evidence (LoE). Whereas the instant study was not based specifically on ER nurses, it is still based on professionals in the healthcare industry who face the same stress factors as nurses, who then use mindfulness as their primary intervention. The study sample was 44 intern doctors in a cosmopolitan hospital. Whereas emails had been used to make the study voluntary, all the interns in the hospital agreed to participate. The doctors were divided into two equal groups of 22 doctors each, one being the experimental group that was given a 10-week training mindfulness-based stress symptom intervention and the control group that, over and above using any other stress mitigation measures were allowed an extra hour of free time per week. The results of the research showed a tangible reduction in both the stress levels and the burnout rates within the experimental group that was not accompanied by any tangible changes within the control group. Appeal for mindfulness meditation was high (F¼0.73, p¼0.401, g2¼0.02), and so was potential for helpfulness (F<0.01, p¼0.963, g2 <0.01). Positive change for stress factors was at (F¼5.88, p¼0.007, g2¼0.28) as compared to the control group at (F¼1.58, p¼0.222, g2¼0.10). Therefore, the mindfulness-based intervention was more effective than any approach that the control group may have used, even when the same was enhanced with extra time off from work. The researchers thus recommended mindfulness for use in stress alleviation within healthcare professionals. 

The journal article by Goyal et al. (2014) report on the results of a meta-analysis on the efficacy of mindfulness-based meditation interventions for stress symptoms among nurses hence a Level II-2 LoE. The meta-analysis was conducted by collecting a large volume of articles from databases, such as MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL, AMED. Hand searches were also undertaken, inter alia in the Cochrane Library. The purpose of the search was to investigate how effective mindfulness-based meditation and also other forms of mediation are in mitigating symptoms of the myriad of stresses within and without the healthcare profession. The stress mitigation was based both on self-assessment and evaluation of a variety of stress symptoms. After carefully selecting the relevant studies, a total of 18, 753 articles were selected. These included 47 trials and a sample of 3,515 participants. The results specifically showed that mindfulness-based meditation is constantly seen to be effective as a means of mitigating symptoms of stress among the various population samples that were tested in the trials within a duration of 8 weeks. For anxiety, the results showed improved anxiety (effect size, 0.38 [95% CI, 0.12-0.64] within two months while for depression the results showed (0.30 [0.00-0.59]. The researchers noted that meditation was not seen to be better than other interventions such as pharmacological interventions when it came to symptoms such as insomnia and substance abuse but it was almost as effective. Based on the results above and also the discussion and analysis published in Goyal et al. (2014), mindfulness-based medication is an effective tool for mitigation of stress symptoms that is almost as effective as other more complex interventions such as medication. The effectiveness of mindfulness thus makes it extremely suitable for ER nurses who have to deal with stress factors on almost a continuous basis. 

Williams, Simmons, and Tanabe (2015) report on an extensive literature review on the use of mindfulness-based stress reduction (MBSR) in mainstream medical practice specifically by Advanced Practice Nurses thus a Level II-2 LoE . The article is relevant to the instant research paper as it outlines the general concepts relating to mindfulness as a clinical tool and its effectiveness. The researchers evaluate information gleaned from 114 sources to create a substantive and comprehensive argument for the use of mindfulness in the mitigation of mental health issues, including stress and depression. Among the results from the review is that 40% of American patients and 44% of British patients are comfortable with alternative therapy such as mindfulness. Most importantly, the article makes an argument for the use of mindfulness not as alternative therapy but rather incorporating it into mainstream clinical interventions. Based on the research findings as analyzed and presented in Williams, Simmons, and Tanabe (2015), mindfulness-based interventions have been consistently tested and found to be effective in the mitigation of stress symptoms and depression. Further, there has been growing acceptance of mainstream usage of what was erstwhile considered only as an alternative medication, including mindfulness. 

Wolever et al. (2012) report on yet another randomized control trial that investigates the effectiveness of mindfulness in the mitigation of workplace stress thus a level I LoE. The instant study is significant in that it not only evaluates the effectiveness of mindfulness as compared to other interventions but also compares the effectiveness of online mindfulness therapy and in-person mindfulness therapy. The trial sample was 239 employees drawn from workers within a healthcare insurance company which is a stressful environment almost akin to working in the ER of a busy hospital. Of the sample, 53 were placed in the control group, 96 in the mindfulness group and 90 in the Yoga group. The mindfulness group was divided into two with 45 being placed in the online group while 45 were placed in the in-person group. According to the results, the mindfulness group had better results in decreased perceived stress when compared with the control group F (1, 144) = 21.31, p & .001, n 2 =.13 and with the Yoga group F(1, 137) = 8.79, p & .01, n 2 =.06, and decrease in sleep depravity F (1, 144) = 5.17, p & .05, n 2 = .04. The online mindfulness group also showed a slightly higher coherence level than the in-person group. Based on the results, analysis and discussion, mindfulness was shown to not only be effective but also superior to Yoga as an intervention for work-related stress more so when utilized on a brief period. 

A cohort study on the use of Mindfulness-based training (MBT) to mitigate on stress among ER nurses was reported in Wong et al.(2018) thus a level Level II-2 LoE . Within the study, mindfulness-based stress reduction (MBSR) was used to extenuate on stress symptoms within a group of 36 nurses (mean age = 30.3, SD = 8.52; 2 male). Psychomotor vigilance task (PVT) and electroencephalography (EEG) were used to determine the efficacy of the intervention. The results from the study based on subjective data revealed a significant effect on time ( F (1,33) = 5.679, p = 0.023, η 2pηp2 = 0.147) and subjective energy (r = 0.372, p = 0.028) and also changes across time and session attended (r = −0.344, p = 0.043). Finally, session and time attended was also seem to be significant ( F (1,33) = 3.472, p = 0.71, η 2pηp2 = 0.093). Based on the analysis and conclusion, MBSR was definitively recommended for mitigation of work-related stresses for nurses. 

The article by Khoury, Sharma, Rush, and Fournier (2015) report on a meta-analysis of the use of mindfulness-based stress reduction (MBSR) interventions, specifically on healthy individuals thus being a Level II-2 LoE . The relevance of the study lies in the fact that practicing ER nurses are more often than not healthy both physiologically and psychologically yet constantly plagued by a variety of stress factors. After carefully evaluating available English-language studies on the subject, a total of 29 studies with a total sample of 2668 was arrived at. The available results created a trend in which MBSR was found to be effective in the mitigation of symptoms of stress and depression (n = 26; Hedge's g = .55; 95% CI [.44, .66], p < .00001) as per pre-post analysis and (n = 18; Hedge's g = .53; 95% CI [.41, .64], p < .00001) as per inter-group comparison. Significant results were also observed in the improvement of the quality of life. However, it was noticed that there was a very high inter-study heterogeneity of results that the researchers attributed to the different approaches used by the different research groups both on their approach to MBSR and testing of outcomes. Based on the results, analysis, and discussion in Khoury, Sharma, Rush, and Fournier (2015), MBSR was adjudged as effective in the mitigation of stress symptoms on healthy individuals. 

The article by Duffy, Avalos, and Dowling (2015) report on the results of a primary study that was undertaken to assess the level of stress factors and manifestation of stress amongst ER nurses thus a level II LoE. From the perspective of relevance, the instant article is important as it shows why nurses would be in need of proper mitigation for stress factors. The study was carried out on a group of 117 registered nurses who presented their self-assessment of the stress factors in ER practice and the impact it has on them. Based on the results of the research, the rate of secondary traumatic stress in the staff nurse group was 82% (p = 0.042), desire for a career change was high (p = 0.017) and there was a desire to use alcohol to extenuate the stress (p = 0.004). These results show that practicing nursing in the ER unit exposes practitioners to a high level of stress factors which have a major direct impact on them. Evaluating and establishing proper extenuation of this stress is thus paramount. 

Similarly, Adriaenssens, De Gucht, and Maes (2012) report on another primary study designed to evaluate the stress factors and their impact on ER nurses making for a level II LoE. The study utilized a Cross-sectional data analysis study design with a sample of 302 nurses drawn from 15 hospitals who had undergone at least 6 months of practice in the ER. The outcomes assessed in the study was the possible extremities of symptoms that could take place if the stress factors associated with practicing nursing in the ER were not properly mitigated upon. Based on the results, there is a myriad of occurrences within the ER that acts as major stress factors for nurses, key among them being the death of a young patient. Male ER nurses had higher fatigue levels than female nurses (MD = 6.75, t = 2.15, p = .029) while working in the ER on a fulltime basis was more stressful than working on a part-time basis (MD = -0.14, t = -2.49, p = .014). Further, unless there is proper mitigation, the stress that the nurses experience in the ER can lead to clinical depression that manifests through symptoms such as substance abuse and even suicide ideation. The researchers thus concluded that practice in the ER was extremely stressful and the need for effective mitigation of the stress was paramount. 

A pre-test/post-test design level II LoE primary study was undertaken and reported in the journal article by Mahon, Mee, Brett, and Dowling (2017). The purpose of the study was to evaluate if a formal mindfulness-based approach would both alleviate stress amongst nurses and improve on their compassion. Stress alleviation and compassion are important for any ER nurse. The study had a sample of 90 nurses at its advent but only 64 of them remained to its completion. Self-assessed stress evaluation alongside Stress Scale and Compassion Scale testing was undertaken at the beginning and at the end of the study. Between the two tests, a formal and comprehensive mindfulness meditation intervention was undertaken. The results showed a significant reduction in self-evaluated stress from the sample that completed the tests as well as an increased compassion rate based on the Stress Scale and Compassion Scale testing. Time was a significant factor both for stress exercitation and mitigation F (1, 61)=18.369, p< .001, partial n 2 = .231. Post-compassion scores were (M=98.89, SD=8.80) as compared to the pre-compassion scores which stood at (M=92.58, SD=8.15). As reflected in the discussion and conclusion in the article, there was definitive evidence that mindfulness was effective in both mitigations of stress symptoms and enhancement of compassion among nurses. 

Westphal et al. (2015) report on a self-assessment survey designed to investigate the role played by mindfulness in assisting emergency room nurses to cope with the stress that comes with their specific nature of practice. This was a Level II-2 LoE study. The sample was limited to 50 nurses specifically employed by an urban teaching hospital situated in Zurich Switzerland. The results of the research based on data collection and analysis revealed the trend that the use of mindfulness was inversely proportional to anxiety (r¼.55, p o.001), depression (r¼.49, p o.001), burnout (r¼.37, p o.001) and finally (r¼.52, p o.001) for emotional exhaustion. However, no specific group or category of nurses, either through gender or religious affiliation, showed a higher propensity for the use of mindfulness over the others with p values being 4.05. Based on the discussion and conclusion from the study, it is clear that ER nurses undergo a lot of depression generally based on the nature of the work that they do and also on the work-family balance issues relating to practicing nursing in the ER. Secondly, the use of mindfulness to alleviate nursing is individual in nature and cannot be tied to a specific group or niche of practice. However, when mindfulness is used in the right way, it is definitively effective in the alleviation of stress, depression, anxiety, fatigue, exhaustion and burn out in ER nursing. 

Evaluation and Synthesis of Reviewed Evidence 

It is definitively clear from the research reported in the articles above that practice in any clinical healthcare profession in general and specifically nursing within the ambit of the emergency response is extremely stressful. Duffy, Avalos, and Dowling (2015) evaluate the various stress factors that come with practicing as a nurse in the ER. Further, Adriaenssens, De Gucht, and Maes (2012) reaffirm the existence of this stress factors then shows that unless proper mitigation for the stress caused by these factors is undertaken, they can have an adverse effect on the nurses and also their practice. Based on the above, establishing an effective mitigation for stress amongst ER nurses is paramount. Secondly, it is important to establish a form of mitigation that has minimum side effects and cost implications since stress and its adverse symptoms are the norm, rather than the exception for ER nurses. 

Available research as presented above is split when it comes to the efficacy of mindfulness for stresses in ER nursing. A segment of the studies shows that mindfulness is effective for stress symptoms alleviation on a short-term basis but only as effective as other mitigation measures (Goyal et al., 2014). Even among alternative therapy approaches such as yoga, mindfulness-based therapies were still found to be superior (Wolever et al., 2012). Other studies, however, albeit agreeing that mindfulness is effective for short duration mitigation of the symptoms of stresses emanating from ER practice also indicate that mindfulness is also a better intervention than the other available options (Khoury, Sharma, Rush, & Fournier 2015). Based on the above, it is clear beyond peradventure that mindfulness can be effective in alleviating the symptom of stress in nurses within a short duration such as the two months within which the hypothesis for the instant research paper was based. However, it is still not clear whether the efficacy of mindfulness-based mitigations is superior in effectiveness than that of other interventions. To resolve the impasse, it would be necessary to evaluate the other factors about mindfulness that have been presented in the articles synthesized above. For a start, mindfulness comes with a minimal cost in both time and money and with no tangible side effects as and when compared with other interventions such as the use of medication (Williams, Simmons, & Tanabe, 2015). The cost and side effects implications are critical since ER practice presents high levels of stress hence intervention will be necessary on a constant basis. Other secondary factors that manifested in the implementation of mindfulness for stress mitigation included the enhancement of compassion and the extenuation of fatigue and burnout (Mahon, Mee, Brett, & Dowling, 2017). Finally, mindfulness-based therapy still maintains its effectiveness and even improves on it when used on an online basis as per Wolever et al.(2012). These secondary factors, when added to the actual effectiveness of mindfulness in stress mitigation makes it more suitable for ER nurses than any other available mitigation. 

Recommendation for Implementation of Practice Change 

Based on the research and analysis above, it would be recommended that as a policy, all nurses who practice in the ER be trained and prepared for the stresses that come with this specific area of practice. The special preparation is necessary since even within a best-case scenario, practicing as a nurse in the ER is bound to be stressful. Secondly, the training for stress-management in the ER should, on a compulsory basis include mindfulness-based interventions for stress. Online platforms for mindfulness-based therapy can also be made available for ER nurses. The recommendation is based on the fact that mindfulness is effective, cost-effective, and also comes with a lower risk of side effects when compared to any other form of intervention available to the nurses. The use of mindfulness for stress symptom mitigation for nurses will not only protect the practitioners from stress and the adversities it poses but will also improve the profession by increasing positive characteristics such as resilience and compassion. 

Conclusion 

The research and analysis undertaken above confirm the hypothesis that for the mitigation of stress symptoms for ER nurses within the period of two months, mindfulness-based interventions are as effective as other interventions from the specific perspective of results, but more effective when considered from a general perspective . Working in the ER is bound to be stressful for nurses irrespective of how well-trained and resilient they might be. Further, due to the nature of the job, manifestation of stress factors may happen on a regular basis and can have adverse effects on their efficacy as ER nurses. There is, therefore, the need for a cost-effective solution for stress that also does not have tangible side or adverse effects as it shall be used regularly. Mindfulness-based stress extenuation fits the requirements as outlined above and should thus, be utilized by ER nurses and given preference over other available options. Training on mindfulness both online and in-person is thus recommended for ER nurses. 

References 

Adriaenssens, J., De Gucht, V., & Maes, S. (2012). The impact of traumatic events on emergency room nurses: Findings from a questionnaire survey. International Journal of Nursing Studies , 49 (11), 1411-1422 

Duffy, E., Avalos, G., & Dowling, M. (2015). Secondary traumatic stress among emergency nurses: a cross-sectional study.  International Emergency Nursing ,  23 (2), 53-58 

Goyal, M., Singh, S., Sibinga, E. M., Gould, N. F., Rowland-Seymour, A., Sharma, R., ... & Ranasinghe, P. D. (2014). Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Internal Medicine , 174 (3), 357-368 

Hersch, R. K., Cook, R. F., Deitz, D. K., Kaplan, S., Hughes, D., Friesen, M. A., & Vezina, M. (2016). Reducing nurses' stress: A randomized controlled trial of a web-based stress management program for nurses. Applied Nursing Research , 32 , 18-25. 

Ireland, M. J., Clough, B., Gill, K., Langan, F., O'Connor, A., & Spencer, L. (2017). A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Medical Teacher , 39 (4), 409-414 

Khoury, B., Sharma, M., Rush, S. E., & Fournier, C. (2015). Mindfulness-based stress reduction for healthy individuals: A meta-analysis.  Journal of Psychosomatic Research ,  78 (6), 519-528 

Mahon, M. A., Mee, L., Brett, D., & Dowling, M. (2017). Nurses' perceived stress and compassion following a mindfulness meditation and self-compassion training.  Journal of Research in Nursing ,  22 (8), 572-583 

Westphal, M., Bingisser, M., Feng, T., Wall, M., Blakley, E., Bingisser, R., & Kleim, B. (2015). Protective benefits of mindfulness in emergency room personnel.  Journal Of Affective Disorders ,  175 79-85. doi:10.1016/j.jad.2014.12.038 

Williams, H., Simmons, L. A., & Tanabe, P. (2015). Mindfulness-based stress reduction in advanced nursing practice: a nonpharmacologic approach to health promotion, chronic disease management, and symptom control.  Journal of Holistic Nursing ,  33 (3), 247-259 

Wolever, R. Q., Bobinet, K. J., McCabe, K., Mackenzie, E. R., Fekete, E., Kusnick, C. A., & Baime, M. (2012). Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial. Journal of occupational health psychology , 17 (2), 246-258 

Wong, K. F., Teng, J., Chee, M. W., Doshi, K., & Lim, J. (2018). Positive Effects of Mindfulness-Based Training on Energy Maintenance and the EEG Correlates of Sustained Attention in a Cohort of Nurses. Frontiers in human neuroscience , 12 , 80.