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Practicing Mindfulness in Critical Care

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Julia Sarazine, DNP, APN, FNP-BC

Mindfulness seems to be everywhere now; it is used frequently to refer to a way of doing, thinking, and being. It originally came to the United States in the 1970s but gained significant traction when Jon Kabat-Zinn developed mindfulness-based stress reduction (MBSR). MBSR’s standardized design allowed researchers to demonstrate the intervention’s effectiveness, and it is now offered on six continents. Its eight-week curriculum comprises weekly two-and-a-half hour classes and 45 minutes of individual practice per day.

Defining Mindfulness
The mind naturally wanders from the present moment to the past or future. This is often referred to as autopilot.
  • Have you ever commuted to work and not remembered the drive or train ride?
  • Have you ever eaten something and not remembered tasting it?
  • Have you ever reacted to a situation and later regretted how you handled it?
These are all examples of mindlessness. In contrast, mindfulness focuses on being aware in the present.
There are multiple definitions of mindfulness, but the most commonly quoted is from Jon Kabat-Zinn: “paying attention on purpose in the present moment, nonjudgmentally.” Kabat-Zinn further explains, “It is not that mindfulness is the answer to all of life’s problems. Rather it is that life’s problems can be seen more clearly through the lens of a clear mind.”1
Mindfulness in Critical Care
The Critical Care Societies Collaborative’s call to action has helped raise awareness of the importance of addressing and preventing burnout syndrome (BOS) in critical care. The call to action summarizes the research and potential interventions for critical care professionals. Moss and colleagues discuss several environmental and individual strategies that may prevent or treat BOS. Mindfulness is listed as an intervention that may “help an individual cope with their environment.”2
Mindfulness Research and Healthcare Professionals
The research related to mindfulness as an intervention to prevent and treat BOS is growing. Two significant systematic reviews focus on healthcare providers. West and colleagues analyzed 15 randomized trials and 37 cohort studies and concluded that mindfulness was an effective intervention to decrease the symptoms of burnout in physicians, specifically decreasing scores in two of the three symptoms of BOS—emotional exhaustion and depersonalization.3
Additionally, Guillamie and colleages conducted a mixed-methods systematic review, analyzing data from 32 studies evaluating effects of mindfulness-based interventions on stress for nurses. They concluded that “mindfulness training may decrease nurses’ levels of anxiety and depression and benefit their psychological well-being and performance at work.”4
Two Types of Mindfulness
There are two categories of mindfulness: formal and informal. The formal practice is focused on setting aside time to meditate and develop the muscle of attention and awareness. The meditations can be focused on breathing, walking, and mindful movement or yoga. 
Informal mindfulness is being as present as possible with any activity by using your attention and senses to fully experience the moment. It does not take any extra time. These two practices build on each other
Developing a Formal Mindfulness Practice
To increase the ability to be present in our lives, it is helpful to set aside time each day for formal practice by meditating with a timer or using a guided meditation app for five to 10 minutes.
Developing an Informal Mindfulness Practice
Here are some strategies and tips to incorporate into your daily life through informal practice, especially at work, where stress levels can be elevated. Just as a reminder, it is important also to practice informal mindfulness in times of minimal stress since it is easier to focus on being present and will make it more accessible during times of higher stress. Remember, it does not take any more time to be mindful.
STOP is a mindful technique that can be used in any situation to slow us down and reconnect with ourselves. It can be used before entering a patient’s room, sending an e-mail, charting, speaking, or entering your home after work. The acronym STOP stands for:
  • Stop whatever you are doing to pause for a moment.
  • Take a deep breath or two.
  • Observe any specific thoughts, emotions, or body sensations.
  • Proceed with more awareness.
Two Feet, One Breath
This mindful technique can be used in times of stress to ground ourselves and create a little space from the stressful situation being encountered.
With both feet firmly on the ground, while either standing or sitting:
  1. Focus as much attention as possible on sensations in the sole of the left foot—perhaps pressure or sensations from contact with the sock or shoe.
  2. Then shift attention to sensations in the sole of the right foot, with as much attention as possible.
  3. Tune in to your breathing—just feeling the breath as it moves in and out.
  4. Now, continue whatever you are doing in a more grounded and present way.
Mindful Hand Washing
Use all the senses to bring awareness to the activity of washing the hands. Feel the temperature of the water and the sensations of the hands rubbing together, the smell of the soap, and the sound of the water running, and notice the bubbles forming from the soap. This awareness can be applied to any routine activity, such as brushing teeth, taking a shower, or typing an e-mail.
Mindful Eating
First, take time to appreciate everything involved in growing and preparing the food that is available to eat. Someone planted the seed; it received sunlight and water; someone picked the fruit or vegetable, loaded it onto a truck, cleaned and packaged it in a factory, transported it to the neighborhood grocery store, placed it on the shelf; and it was purchased with the assistance of a cashier at the store.
Second, when eating a meal or snack, use the senses to be as present as possible, even if it is just for a few bites. Look at the colors and shapes of the food, notice the smell, feel the texture of the food between your fingers or in your mouth, notice the taste of the food and, if possible, the sound of the food as you eat it. The focus is on just feeling gratitude and being as present as possible.
In mindfulness practice, quotes are often offered to stimulate or deepen our practice. Here are a few of my favorites:
“You can’t stop the waves, but you can learn to surf.”
–Jon Kabat-Zinn
“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”
–Viktor Frankl
“Thoughts are not facts.”
–Jon Kabat-Zinn 
1.      Kabat-Zinn J. Full Catastrophe Living. New York. New York, NY: Delacorte Press; 1990.
2.      Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An official Critical Care Societies Collaborative statement: burnout syndrome in critical care healthcare professionals: a call for action. Crit Care Med. 2016 Jul;44(7):1414-1421.
3.      West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016 Nov 5;338(10057):2272-2281.
4.      Guillaumie L, Boiral O, Champagne J. A mixed-methods systematic review of the effects of mindfulness on nurses. J Adv Nurs. 2017 May;73(5):1017-1034.‚Äč