CONCEPT ANALYSIS

Mindfulness in nursing: an evolutionary concept analysis

Lacie White

Accepted for publication 15 May 2013

Correspondence to L. White: WHITE L. (2014) Mindfulness in nursing: an evolutionary concept analysis.

e-mail: lwhit025@uottawa.ca Journal of Advanced Nursing 70(2), 282–294. doi: 10.1111/jan.12182

Lacie White BScN RN

PhD Student
School of Nursing, Faculty of Health
Sciences, University of Ottawa, Ontario,
Canada
Abstract
Aim. To report an analysis of the concept of mindfulness.
Background. Mindfulness is an emerging concept in health care that has
significant implications for a variety of clinical populations. Nursing uses this
concept in limited ways, and subsequently requires conceptual clarity to further
identify its significance, use and applications in nursing.
Design. Mindfulness was explored using Rodgers evolutionary method of concept
analysis.
Data Sources. For this analysis, a sample of 59 English theoretical and research-
based articles from the Cumulative Index to Nursing and Allied Health Literature
database were obtained. The search was conducted between all-inclusive years of
the database, 1981–2012.
Review Methods. Data were analysed with particular focus on the attributes,
antecedents, consequences, references and related terms that arose in relation to
mindfulness in the nursing literature.
Results. The analysis found five intricately connected attributes: mindfulness is a
transformative process where one develops an increasing ability to ‘experience
being present’, with ‘acceptance’, ‘attention’ and ‘awareness’. Antecedents,
attributes and consequences appeared to inform and strengthen one another over
time. Mindfulness is a significant concept for the discipline of nursing with
practical applications for nurse well-being, the development and sustainability of
therapeutic nursing qualities and holistic health promotion.
Conclusion. It is imperative that nurse well-being and self-care become a more
prominent focus in nursing research and education. Further development of the
concept of mindfulness could support this focus, particularly through rigorous
qualitative methodologies.

Keywords: concept analysis, evolutionary method, holistic, mindfulness, nursing,

presence, self-care

282 © 2013 John Wiley & Sons Ltd

JAN: CONCEPT ANALYSIS
Why is this research or review needed?
• Stress, burnout and high attrition rates in nursing are an
ongoing concern; the application of mindfulness in nursing
requires further exploration as one possible response to
addressing these concerns.
• Mindfulness is an emerging concept in health care and
research communities demonstrating significant value for
holistic health promotion, yet remains relatively undeveloped
in nursing.
• The concept of mindfulness has similar theoretical perspec-
tives to those of holistic nursing practices and requires con-
ceptual clarification for further development in the discipline.
What are the three key findings?
• The concept of mindfulness encompasses intricately connected
attributes: it is a transformative process, where one develops
an increasing ability to experience being present with aware-
ness, acceptance and attention.
• Mindfulness can support improving physical, emotional, psy-
chosocial and spiritual well-being, and can help translate
holistic health promotion from theory to practice.
• Integrating mindfulness into education and practice can
enhance therapeutic nursing qualities and support a shift from
a purely theoretical way of knowing to one that is more
embodied and holistic.
How should the findings be used to influence policy/
practice/research/education?
• With access to training, nurses can gain personal experience
of being and practising mindfulness, subsequently giving them
tools to promote holistic health practices across various clini-
cal settings and health populations.
• The mechanisms of mindfulness are poorly understood; quali-
tative research designs will contribute to the evolving science
of mindfulness and would help ground the concept in
nursing.
Introduction
Mindfulness is an emerging concept in health care that has
gained substantial interest in research communities in the
last two decades (Mindfulness Research Guide 2011).
Situated in 2,600-year-old Eastern Buddhist philosophy,
mindfulness was taught as a means to alleviate human
suffering (Matchim et al. 2011b) and cultivate compassion
(Ludwig & Kabat-Zinn 2008). The alleviation of suffering
is a universal concern, particularly relevant in the field of
health care where there is extensive contact with suffering,
© 2013 John Wiley & Sons Ltd
Mindfulness in nursing: a concept analysis
and additionally healthcare providers themselves struggle to
maintain their own health and well-being in the midst of
caring. Mindfulness is now being adopted in Western medi-
cine and psychology as a secular perspective with main-
stream application (Koerbel & Zucker 2007, Teixeira
2010). Empirical evidence is accumulating that mindfulness
programmes and practices can improve physical and psy-
chological health, and promote overall well-being in many
different health settings (Roth & Creaser 1997, Proulx
2003, Matchim et al. 2008). In addition, systematic reviews
of healthcare providers reveal that practitioners who incor-
porate mindfulness into their personal and professional lives
demonstrate an improved sense of well-being and ability to
employ self-care strategies (Irving et al. 2009, Escuriex &
Labbé 2011).
Despite growing attention, the concept of mindfulness
remains ambiguous and abstract (Tusaie & Edds 2009).
Proulx (2003) suggests that mindfulness practices promote
‘a holistic self-regulatory approach to health, congruent
with nursing values and beliefs’ (p. 201). With similar theo-
retical perspectives to that of nursing (Cohen-Katz et al.
2004, Smith et al. 2005, Poulin et al. 2008), mindfulness
has the potential to inform nursing education, practice and
research levels. However, to integrate mindfulness more
directly into the discipline of nursing, a clearer understand-
ing of the concept is required.
Background
The integration of mindfulness into Western healthcare
settings has been largely credited to Jon Kabat-Zinn who
developed the first standardized mindfulness-based pro-
gramme in 1979 at the University of Massachusetts Medi-
cal School (Baer 2010). This mindfulness-based stress
reduction (MBSR) programme involves eight 2
5-hour
weekly group sessions, a daylong silent retreat, and a
commitment to practice mindfulness activities for 45 min-
utes, 6 days a week. MBSR continues to predominate
interventions and outcome research related to mindfulness
(Poulin et al. 2008). Evidence suggests that mindfulness is
supportive of a variety of clinical populations, including
but not limited to, the improvement of chronic and
cancer-related pain, sleep disorders, eating disorders,
psoriasis and a variety of psychological disorders (Cohen-
Katz et al. 2004).
In addition, other variations of MBSR: mindfulness-
based cognitive therapy (MBCT; Segal et al. 2002), mind-
fulness-based relationship enhancement (MBRE; Carson
et al. 2004), mindfulness-based wellness education
(MBWE; Poulin et al. 2008), mindfulness-based eating
283
L. White
awareness treatment (MB-EAT; Kristeller & Hallett 1999)
and mindfulness-based medical practice (MBMP; Irving
et al. 2012) are emerging. Acceptance and commitment
therapy (ACT; Hayes et al. 1999) and dialectical behav-
iour therapy (DBT; Linehan 1993) also have mindfulness
processes embedded in them and are demonstrating empiri-
cal benefits (Lynch et al. 2007, Ruiz 2010). Although
appearing supportive to the growing movement of mind-
fulness in mainstream health promotion, the variety
between and in all of these programmes may be a contrib-
uting factor in the challenge to create a working definition
of mindfulness.
Abercrombie et al. (2007) suggest, ‘it is essential that
holistic nurses conduct and participate in research that is
relevant to their clinical practice’ (p. 33). Mindfulness as a
holistic intervention has many potential benefits for nurse
well-being and for the varied health populations they serve,
and subsequently requires nursing-directed research. This
cannot be undertaken without a clearly defined concept, as
concepts are the necessary foundation in building theory
(Rodgers 2000). However, a conceptual analysis of mind-
fulness is challenging as Sharpiro and Carlson (2009) high-
light that ‘attempting to write about mindfulness in an
academic and conceptual way is in some ways antithetical
to the very nature of mindfulness’ (p. 3), which is grounded
in an experiential process. Despite this, conceptual develop-
ment is important so that mindfulness can be fully inte-
grated into health care.
Rodgers evolutionary method (Rodgers 2000) was used
for the purpose of this concept analysis on mindfulness.
The philosophical perspective embedded in this method
views concepts as context-dependent, dynamic and con-
stantly evolving. The method is inductively focused and is
“a means of identifying a consensus or the ‘state of the art’
of the concept” (Rodgers 2000, p. 97). The purpose of this
method is not to arrive at a conclusion or definitive defini-
tion of the concept, but rather to describe the current use
of a concept for further development of nursing knowledge.
This iterative process is supported through six primary
activities (Table 1).
Data sources
To gain clarity on how the concept of mindfulness has
been integrated into the discipline of nursing, the leading
database for nurses, the Cumulative Index to Nursing and
Allied Health Literature (CINAHL) was used. This data-
base includes virtually all-nursing and allied health jour-
nals (Polit & Beck 2008) and, therefore, offers a
perspective on how mindfulness is being integrated specifi-
284
Table 1 Primary activities in evolutionary method of concept
analysis (Rodgers 2000).
• Identify concept of interest and surrogate terms.
• Identify and select: setting and sample.
• Collect data with focus on concept attributes, context of
concept use, interdisciplinary, sociocultural and temporal
variations.
• Analyse data.
• If available, identify exemplar of the concept.*
• Identify implications of analysis and future development of the
concept.
*Mindfulness is a subjective experience that has application across
many contexts; therefore, identifying an exemplar would risk limit-
ing understanding of its varied uses, and thus was omitted from
this analysis process.
cally into nursing. Mindfulness was not a major subject
heading in the database. No other search terms for this
concept were included in the final sample to provide a
clearer picture of its use separate from other concepts. The
dates searched were all-inclusive of the CINAHL database,
and fell between 1981 and 2012. Inclusion criteria
included English journal articles with theoretical or
research-based content. The key search terms and decisions
made to arrive at final sample are described in Figure 1.
The final sample for this analysis included 59 articles that
fell between 1994–2012.
All items in the sample were identified with a number
and read through once to support immersion in the
concept, and to gain a general tone of the individual and
collective works. Code sheets for the organization of data
were created individually for attributes, antecedents, conse-
quences, references, related terms and nursing-specific
implications for research, education and practice. Methodo-
logical and reflexive journals were started at the beginning
of this study to ensure rigour and to retrace steps as
necessary throughout the analysis.
Formal analysis was delayed until the completion of data
collection as Rodgers (2000) cautions: ‘there are few occur-
rences more detrimental in concept analysis than the
researcher getting stuck on a particular idea and, conse-
quently, being unable to allow the characteristics of the
concept to emerge from the data’ (p.94). Formal analysis
began with individually examining coding sheets to estab-
lish themes. In each category, common themes were orga-
nized and reorganized until trends were comprehensively
and clearly identified and subsequently labelled. This analy-
sis also focused specifically on the use, emerging trends and
future development of mindfulness in the context of
nursing.
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JAN: CONCEPT ANALYSIS Mindfulness in nursing: a concept analysis

Keyword searched: mindful*

A scan of abstracts from the 944 results from this search revealed that

944
mindfulness was not consistently a central theme within the articles.

Keyword searched: mindfulness, in the abstract or title.

Within these 557 results the concept of mindfulness in relation to the

557
nursing discipline appeared infrequently.

Keywords searched: mindfulness in the article abstract or title,

and nurs* anywhere within the article OR in the publication name

76
76 results relevant to the discipline of nursing obtained.

Filtering out book reviews, editorials, brief commentaries and

conference abstracts resulted in 59 journal articles.
Figure 1 Description of search terms 59
used and results obtained from the
CINAHL database.

the others and so there will be notable overlap in the

Results
discussion.

References
References describe the ways a concept has been applied
(Rodgers 2000). Table 2 presents a breakdown of the
research and theoretical based papers for this sample. The
use of mindfulness in this literature was divided into con-
text of use for varied health populations and separately for
its use directly with healthcare practitioners. In addition,
although the use of mindfulness in the CINAHL database
appears to be growing exponentially, the application of
mindfulness in nursing remains limited (Figure 2).
Attributes
The defining attributes of mindfulness are subtle (Caccia-
tore & Flint 2012) and intricately connected to one
another. The most frequently cited definition in the litera-
ture remains one from Kabat-Zinn (1994) who stated that
mindfulness is ‘paying attention in a particular way: on
purpose in the present moment, and nonjudgmentally’
(p. 4; Proulx 2003, Poss 2005, Matchim et al. 2008,
Stanton & Dunkley 2011). Through the analysis, five
defining attributes emerged to clarify the concept. The
‘experience of being present’ is one attribute of mindfulness
that is cultivated and sustained through three additional
attributes: ‘awareness’, ‘acceptance’ and ‘attention’. In addi-
tion, mindfulness can be understood as a ‘transformative
process’. Although each of the attributes will be addressed
in turn, one cannot be appreciated contextually without
Experience of being present
Mindfulness is difficult to understand outside the realm of
experience (Sitzman 2002). Poulin et al. (2008) posit that
learning mindfulness can lead to improved health and well-
being ‘through greater experiential understanding of the
interplay between mind, body and emotions’ (p. 78). Chal-
lenging current societal and cultural norms, which place
emphasis on completing tasks, remaining busy and ‘doing’
something at all times, this experience is associated with ‘a
way of being,’ (Proulx 2003), ‘being in the moment’
(Cohen-Katz et al. 2004) or engaging in ‘being mode’ (Day
& Horton-Deutsch 2004a). As an experience of being,
mindfulness is highly subjective (York 2007); but, in
general, it is the ability to be present moment-to-moment
(Day & Horton-Deutsch 2004a, Smith et al. 2005) while
sustaining qualities of awareness, acceptance and attention
through each moment.
Awareness
The ability to become deeply aware of self (Praissman 2008)
in the midst of moment-to-moment experiences is another
attribute of mindfulness. Tusaie and Edds (2009) explain that
awareness ‘is the background of consciousness, which is con-
stantly monitoring the environment’ (p. 359). Said another
way, awareness is ‘being with observations’ (Tusaie & Edds
2009), able to observe ‘the constant stream of thoughts, emo-

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L. White
Table 2 References to mindfulness in CINAHL nursing literature.
Context of use for varied health populations
Mindfulness meditation-based stress reduction:
experience with a bilingual inner-city program (Roth & Creaser
1997)
Cancer (Ando et al. 2009, Kvillemo & Br€anstr€ om 2011,
Weitz et al. 2012)
Cancer survivors (Lengacher et al. 2011, Matchim et al.
2011b)
Diabetic peripheral neuropathy (Teixeira 2010)
Healthy adults (Matchim et al. 2008)
HIV-infected patients (Ampunsiriratana et al. 2005)
Mental health (Day & Horton-Deutsch 2004a,b, Davis et al.
2007, York 2007, Kitsumban et al. 2009)
Minority children with depression and anxiety (Liehr &
Diaz 2010)
Multiethnic women with abnormal pap smears (Abercrombie
et al. 2007)
Pregnancy and maternal well-being (Beddoe et al. 2009)
Substance use disorder (Carroll et al. 2008)
School aged children (Wall 2005)
Theoretical discussions/literature reviews/practice implications of
mindfulness
Cancer: literature reviews (Smith et al. 2005, Matchim &
Armer 2007)
Cancer survivors: literature review
(Matchim et al. 2011a)
Chronic hepatitis C (Koerbel & Zucker 2007)
Mental health (Bashford 2011, Klainin-Yobas et al. 2012)
Paediatric clinical practice (Ott et al. 2002)
Psychological support for people with stomas
(Trunnell 1996)
Substance abuse disorder (Bankston 2008, Miller 2010, Lange
2011)
Varied populations (Proulx 2003, Praissman 2008, Stanton &
Dunkley 2011)
Veteran’s (Cuellar 2008)
Context of use for healthcare practitioners
Mindfulness-based intervention research
Human service professionals (Poulin et al. 2008)
Interdisciplinary stress/coping (McCracken &
Yang 2008)
Nurse stress/burnout (Cohen-Katz et al. 2005a,b, Mackenzie
et al. 2006, Pipe et al. 2009)
Student nurse stress/burnout (Young et al. 2001, Beddoe &
Murphy 2004, Kang et al. 2009)
Theoretical discussions/literature reviews/practice implications of
mindfulness
Certified Nursing Assistant stress in long-term care (Zeller &
Lamb 2011)
Interdisciplinary mindfulness bereavement model (Cacciatore &
Flint 2012)
Interdisciplinary stress/coping (O’Neal 1997, Klatzker 2006,
While 2010)
Nurse healing and transformation (Ott 2004)
Nurse leadership (Pipe 2008)
286
Table 2 (Continued).
Nurse practitioners (Poss 2005)
Nurse stress/burnout (Ott et al. 2002, Cohen-Katz et al. 2004)
Mindfulness/nursing theory (Sitzman 2002)
Palliative care communication model (Wittenberg-Lyles et al.
2010)
Psychiatric/mental health nursing (Hirst 2003, Horton-Deutsch
& Horton 2003, Tusaie & Edds 2009)
tions and body sensations’ (Roth & Creaser 1997, p. 152).
Day and Horton-Deutsch (2004a) described this as one
becoming a ‘detached witness.’ With this awareness, it is sug-
gested that individuals have a greater ability to reflect and
respond in healthy ways to their experience as it arises (Davis
et al. 2007).
Acceptance
Being able to accept what arises in ones awareness without
judging (Kvillemo & Br€ anstr€
om 2011), resisting (Cohen-
Katz et al. 2004) or avoiding (Cacciatore & Flint 2012) is
particularly important and is another defining attribute of
mindfulness. Instead of reacting in these ways, one develops
the ability to witness his/her experience, accepting moments
as they arise, and can learn ‘to respond rather than react to
[their] habitual ways of thinking, moving, and doing’ (Day
& Horton-Deutsch 2004a, p. 165). In addition, acceptance
can foster a more compassionate approach to self and other
in the midst of experiences that arise in phenomena (Ott
2004, York 2007), particularly those that may be uncom-
fortable or challenging. When one can accept what is occur-
ring moment-to-moment without evaluating it as ‘good’ or
‘bad’ (Matchim et al. 2011a), they may, as Pipe (2008)
suggests, be able to offer a more balanced presence through
‘nurturing a healthy regard for the emotions of self and
others’ (p. 121).
Attention
Awareness requires that one is also able to maintain his/her
attention on that which he/she is aware of. Attention,
another attribute of mindfulness, is the ability to stay in the
moment-to-moment experience (Wittenberg-Lyles et al.
2010, Matchim et al. 2011b). It is a shift in the mind from
habitually unconscious automatic functioning, worry and
rumination (Zeller & Lamb 2011) of past and future expe-
riences to focus on what is occurring in the present (Day &
Horton-Deutsch 2004a). Matchim et al. (2011b) summarize
attention as being ‘receptive to the whole field of aware-
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JAN: CONCEPT ANALYSIS Mindfulness in nursing: a concept analysis

120

100 Mindfulness in title or

abstract

80
Mindfulness in title or

# of results
abstract with nurs* in journal

per year
60 article or title of journal

40

20

Figure 2 Rate of growth for term 0

‘mindfulness’ in CINAHL Database rela-

94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
20
20
20
tive to application directly within nursing
discipline. Year

ness’ (p. 62) where one can maintain focus on what arises
without becoming distracted or lost in thought (York
2007).
Transformative process
and healing’ (as cited in Ott 2004, p. 24). Owing to
mindfulness as a process of continual development, the
ability to clarify the concept by antecedents, attributes, and
consequences becomes difficult as they all become inter-
twined (Tusaie & Edds 2009, Figure 3).

The literature refers frequently to mindfulness as a process

(O’Neal 1997, Cohen-Katz et al. 2005a, Mackenzie et al.
2006, Cacciatore & Flint 2012). The transformative process
of mindfulness as a defining attribute is clearly articulated
from different scholars. Ott (2004) discussed mindfulness as
a ‘life-affirming process.’ This view is echoed in a statement
from Poulin et al. (2008) that ‘being aware of our embodied
experiences is a crucial step towards living in a more inte-
grated way’ (p. 73). Kabat-Zinn et al. (1998) stated that
through mindfulness ‘we … gain immediate access to our
own powerful inner resources for insight, transformation,
Antecedents
Antecedents refer to those things which precede the concept
(Rodgers 2000). Formal and informal practices support one
in cultivating the attributes that encompass mindfulness
(Table 3). These practices are varied and used to differing
degrees based on individual need and preference (Smith
et al. 2005). Practices that focus on the breath are consid-
ered foundational as ‘it is always present, always changing,
and is the link between the body and the mind’ (Roth &
Creaser 1997, p. 152). Formal practices inform and

Attributes of mindfulness

Antecedents Consequences
n

Aw
tio

Present
ten

ar

Requirements for practice Moment Physical

en
At

Practices: formal Experience Psychosocial

es
s

informal Spiritual

Acceptance

Figure 3 Attributes, antecedents and Transformative process

consequences of mindfulness.

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L. White
Table 3 Antecedents.
Engaging in the practice of mindfulness
Requirements of practice Types of practice
Capacity Formal practices*
Desire and commitment to Breath
practice Yoga
Time to practise Sitting meditation
Patience Walking meditation
Persistence Body scan
Non-striving – Non-goal Mindful eating
oriented Informal practices
Practice of being present in
moment-to-moment experience
while in daily activities
i.e. washing dishes, sitting with
patient
*Formal practices of mindfulness are not an exhaustive list; how-
ever, they are the most discussed within this analysis of the nursing
literature.
strengthen informal ones, as it is easier to practise in calm
moments than during more active and stressful times (Pipe
2008). Through the development of being present with
attention, awareness and acceptance in formal practices,
one is more able to cultivate and sustain qualities of mind-
fulness informally in their day-to-day activities (Day &
Horton-Deutsch 2004a).
Mindfulness practices, although seemingly simple, are
quite challenging (Young et al. 2001, Sitzman 2002) and
therefore notable characteristics are required for one to be
with the practices in an engaged and healthy way. Despite
being mentioned relatively infrequently, the capacity to be
present to and endure uncomfortable experiences as they
arise is acknowledged as a necessary antecedent to partici-
pate in mindfulness practices (Davis et al. 2007, Tusaie &
Edds 2009). This is particularly significant as there are con-
flicting discussions regarding ‘who’ can practice mindful-
ness. Some scholars offer the view that anyone can practise
mindfulness (Ott 2004, Cacciatore & Flint 2012), while
others raise caution against introducing mindfulness
interventions to those with certain psychological diagnosis
(i.e. those experiencing psychosis or who are actively
suicidal; Poss 2005, Smith et al. 2005).
It is consistently stated that commitment, dedicated time
to practise, patience, and persistence with which one is will-
ing to return to the practices over and over again are
needed to successfully develop mindfulness (Roth & Crea-
ser 1997, Young et al. 2001). It is also identified that these
practices need to be done without attachment to outcome
(Ott 2004, Weitz et al. 2012). Pipe (2008), in a theoretical
288
paper discussing leadership and mindfulness in nursing,
suggests that practice is by its nature not goal-oriented, but
‘rather with the objective of continually becoming more
conscious of how we approach ourselves and those we lead’
(p. 119).
Consequences
Consequences are identified themes that arise from the con-
cept (Rodgers 2000). Consequences of mindfulness are
improved physical and mental health as well as changes in
personal behaviours (Proulx 2003). Participants in one
study identified sleeping better, having more vitality and a
reduction in pain levels (Kvillemo & Br€ anstr€
om 2011).
Lower levels of stress, anxiety, depression and burnout
are also noted outcomes in many mindfulness-based
intervention studies with specific health populations, and
for the healthcare practitioner themselves (Cohen-Katz et al.
2005b, York 2007, Ando et al. 2009, Kang et al. 2009,
Pipe et al. 2009). Also, for some participants in mindfulness
programmes, there may be a possible increase in distress
and anxiety that can occur as one cultivates the ability see
themselves, their thoughts and behaviour patterns more
clearly (Davis et al. 2007, Klainin-Yobas et al. 2012). How-
ever, there is also indication that as a result of practising
and cultivating mindfulness, one of the outcomes, consistent
with mindfulness as a process, is that antecedent qualities
are strengthened and one has increasing capacity for these
experiences (Tusaie & Edds 2009).
Behavioural and trait characteristics noted by participants
engaged in the process of mindfulness include feeling a
sense of calm (Day & Horton-Deutsch 2004b), peace
(Young et al. 2001, Cohen-Katz et al. 2005a, Matchim
et al. 2008), equanimity (Horton-Deutsch & Horton 2003)
increased levels of empathy and compassion for self and
other (Beddoe & Murphy 2004, Cohen-Katz et al. 2005a,
Davis et al. 2007, Kvillemo & Br€ anstr€
om 2011), new or
increased engagement with spirituality (Young et al. 2001,
Weitz et al. 2012) and improved health awareness and
self-care practices (Matchim et al. 2008). In addition, a
frequently discussed outcome in the literature is that mind-
fulness practices teach one to self-regulate his/her experi-
ence (Wall 2005, Wittenberg-Lyles et al. 2010, Matchim
et al. 2011a). Individuals are empowered to move from
unconscious and automatic internal and external reactions
to a more conscious relationship with them (Koerbel &
Zucker 2007, Pipe et al. 2009). Furthermore, as reactions
to situations change and transform, personal and profes-
sional relationships can also improve (Horton-Deutsch &
Horton 2003, Cohen-Katz et al. 2004).
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JAN: CONCEPT ANALYSIS
Related concepts
To clarify a concept further, Rodgers (2000) encourages the
identification of related concepts which ‘bear some relation-
ship to the concept of interest but do not seem to share the
same attributes’ (p. 92). Presence, awareness and attention
are all attributes embedded in the concept of mindfulness
and can be considered also to be related concepts. In addi-
tion, Tusaie and Edds (2009) highlight and discuss some of
the other related concepts of mindfulness: metacognition,
reflection, reflective practice and meditation. Although all
of these appear to be directly synonymous with mindful-
ness, they do not wholly encompass the concept.
Discussion
One of the most significant contributions that the evolu-
tionary method of concept analysis provides is a heuristic
tool for further inquiry, development and research (Rodgers
2000). Theories in the humanistic caring paradigm
espoused by Watson, Newman, Parse (Sitzman 2002, Amp-
unsiriratana et al. 2005, Pipe 2008, Pipe et al. 2009) and
Orem (Smith et al. 2005) can be appreciated as a theoreti-
cal match between nursing theory and practice, and mind-
fulness (Mackenzie et al. 2006). Despite this match, the
ability to fully operationalize and engage with the concept
of mindfulness in the discipline of nursing has remained
limited.
Mindfulness as a concept based on experience may
remain abstract and ungrounded in practical application if
its association remains solely in meta and grand theories
(which are themselves abstract in nature; Higgins & Moore
2009). Development of a middle range theory for mindful-
ness could offer greater ability to integrate its applications
and processes in practice, education and research. The
implications and potential directions for development of
mindfulness in nursing will be discussed in four themes:
education for self-care and nurse well-being, development
of therapeutic nursing qualities, support at practice levels
for varied health populations and research directions.
Education for self-care and nurse well-being
Significant attention in nursing literature and research has
been placed on the incidence and implications of stress, burn-
out (Poulin et al. 2008), compassion fatigue and vicarious
trauma (Sabo 2006), while there is limited focus on preven-
tion and reduction of these concerns (Young et al. 2001,
Poulin et al. 2008). Cohen-Katz et al. (2004) identify that
although ‘caring and compassion for ‘the patient’ have been
© 2013 John Wiley & Sons Ltd
Mindfulness in nursing: a concept analysis
held up as the nursing ideal, self-care has not been socialized
into nurses’ ways of thinking or into their work environ-
ments’ (p. 306). Nursing curriculum does not adequately
prepare nurses for their work and offers little insight into
self-care practices beyond reinforcing that it is practitioners’
responsibility to engage in them (Christopher et al. 2006).
This concern needs to be addressed more directly as nurses
often understand the importance of self-care and healthy cop-
ing strategies, but are not confident in their own capacity to
implement and use these strategies (Glass & Rose 2008).
Mindfulness has been identified theoretically and in a
limited way through research (Young et al. 2001, Beddoe
& Murphy 2004, Cohen-Katz et al. 2005a, Poulin et al.
2008, Kang et al. 2009) as an approach to closing this gap
between stress and well-being in nursing practice. The
reduction of student and clinical nurse stress, anxiety, and
burnout can be cautiously appreciated in the context of this
analysis, given the dearth of research studies to support this
claim. Consistent with mindfulness as a transformative pro-
cess, Cohen-Katz et al. (2005a) noted in their study that
nurses who engaged in mindfulness practices ‘began to
develop greater self-kindness and reported a dramatic shift
in their capacity to care for themselves’ (p. 85). In another
study, salient perspectives from student nurse participants
in a comprehensive mindfulness programme were offered;
one participant expressed feeling their experience helped
them to ‘understand health promotion from theory to prac-
tice’ (Young et al. 2001, para 12), and others felt that
mindfulness training should be incorporated into nursing
programmes.
Development of therapeutic nursing interactions
In addition to supporting nurse well-being, mindfulness has
the potential to enhance the development of less tangible
aspects of nursing (Sitzman 2002). Tusaie and Edds (2009)
posit that mindfulness can support transforming therapeutic
nursing interactions ‘from an intellectual activity to an
actual experience’ (p. 364). Based on current literature pres-
ence, empathy, patience, awareness (of self and other) and
compassion have been conceptualized as particularly impor-
tant to nursing practice and nurse–patient relationships.
There are indications through this analysis that mindfulness
can serve as a practical approach to cultivating these quali-
ties to develop a more embodied nursing practice. Cohen-
Katz et al. (2005a) found that after a mindfulness-based
stress reduction programme, nurse participants described
being more fully present and empathetic in their relation-
ship with others. Although these findings require further
investigation through ongoing research, mindfulness has the
289
L. White
potential to support the cultivation of holistic nursing
practices.
To be present with another in the midst of life challenges
and suffering is considered fundamental to nursing practice
(Ferrell & Coyle 2008). Despite this, multiple studies
describe nurses using distancing and avoidance strategies to
protect themselves from these experiences (Chang et al.
2006, Blomberg & Sahlberg-Blom 2007, Timmermann et al.
2009). In addition, scholars suggest that the phenomenon of
distancing is detrimental to the nurses’ well-being and the
therapeutic clinical process (Chang et al. 2006, Blomberg &
Sahlberg-Blom 2007, Iglesias et al. 2010). Through this
analysis, a possible response and prevention to these avoid-
ance strategies appeared in the form of emerging care models
that hold mindfulness as a central component (Wittenberg-
Lyles et al. 2010, Cacciatore & Flint 2012). With the
emphasis on mindfulness in care practices, nurses are offered
a way of cultivating a greater capacity to be in these chal-
lenging moments with sustained presence. This may help not
only to therapeutically support the client but also to ‘help
insulate providers from the long-term effects of others’
suffering’ (Cacciatore & Flint 2012, p. 68).
Support at practice level for varied health populations
The positive implications of mindfulness-based programmes
for nurses and their practice are evident. Despite this, mind-
fulness as a concept has been explored to a greater degree
with other varied health populations, but remains minimally
integrated into the discipline of nursing. The theoretical
discussions and research results offer a promising perspective
on the benefits of mindfulness in mainstream health care to
promote well-being in various clinical and non-clinical
populations. However, there is overwhelming agreement by
many scholars in this analysis that for mindfulness to be
successfully integrated into a supportive clinical practice, the
‘teacher’ must also have a mindfulness practice of their own
(Poss 2005, Klatzker 2006, Davis et al. 2007, Lengacher
et al. 2011).
The subtleties and challenges of mindfulness can only be
offered in an authentic and realistic way if taught by those
who have experience of being in the practice (Roth & Crea-
ser 1997, Stanton & Dunkley 2011). Poulin et al. (2008)
posit that for the successful integration of mindfulness into
health care, ‘health service professionals are a critical
population for mindfulness training because as they begin
to embody this learning, and experience benefits in their
own lives, they also bring this education to the people they
are working with’ (p. 78). Without nurses themselves
learning to practise and integrate mindfulness into their
290
own lives, they will be unable, skillfully, to offer it as a
holistic practice and perspective to those health populations
they serve. Placing attention on how to integrate mindful-
ness into nursing education and practice would strengthen
their ability to offer this knowledge to others.
Directions for research
As an emerging concept in nursing, mindfulness has great
potential to support practitioners, and subsequently the
health populations they serve. However, rigorous methodo-
logical research designs are needed to ground this concept
in nursing practice. There are significant gaps and directions
that nursing can explore to contribute to the science of
mindfulness.
To date, mindfulness research has been explored mainly
through quantitative research designs. A frequently cited
limitation of quantitative studies on mindfulness is that they
have insufficient statistical power (Young et al. 2001, Mac-
kenzie et al. 2006). In addition, many scholars also critique
the self-selection method as a limitation in study designs as
it leads to biased results (Beddoe & Murphy 2004, Pipe
et al. 2009). However, as a key determining factor in one’s
ability to practise and integrate mindfulness is his/her will-
ingness and capacity to participate, this should be taken into
consideration when designing education and research proto-
cols.
Furthermore, appreciations of the contextual subtleties of
mindfulness have not been captured through the empirical,
quantitatively driven designs that dominate the current
research. There are now multiple tools to measure mindful-
ness and appreciate outcomes of mindfulness-based prac-
tices (Baer 2011). Despite these measurements, the
mechanisms of mindfulness are not well understood (Kvill-
emo & Br€ anstr€
om 2011). This may be partly because it is
difficult to expand the understanding of how mindfulness
truly affects participants outside the predetermined concep-
tualizations derived from these validated tools. Brown et al.
(2007) suggest that a greater appreciation of the mecha-
nisms of mindfulness and the use of a theoretical model to
ground research could support the development of sound
knowledge about mindfulness.
Given the experiential and subjective nature of mindful-
ness, qualitative approaches to researching mindfulness
would be beneficial (Proulx 2003, York 2007). In this
analysis, there were only a handful of qualitative studies;
this is consistent with concerns that there is a lack of quali-
tatively focused research designs in the study of mindfulness
(Smith et al. 2005). In this respect, nursing could present a
unique contribution to the development of mindfulness in
© 2013 John Wiley & Sons Ltd
JAN: CONCEPT ANALYSIS
health care and health promotion as their research practices
include a strong grounding in qualitative research method-
ologies. In particular, knowledge gained from phenomeno-
logical and grounded theory research could offer important
insight into the concept.
In research designs, attention to variables, such as inter-
ventions offered, the amount one practices (dose) and
which practices they gravitate towards, is needed, as there
are significant variations on these aspects of mindfulness
research and subsequent outcomes. Beddoe and Murphy
(2004) found that there was a correlation between the
amount of mindfulness practice one engaged in and the
positive outcomes evident as a result of those practices.
Also, some believe that longer programmes are necessary to
appreciate the subtleties of the mindfulness process, while
other studies show that even small dose interventions offer
positive outcomes to participants (Mackenzie et al. 2006).
This is particularly relevant in the nursing profession where
demands on many nurses in their professional lives are stag-
gering (Cohen-Katz et al. 2004). It is therefore important to
research what interventions, over what period of time, and
at what dose could offer positive outcomes to nurses who
are interested in practising mindfulness. In addition, longi-
tudinal studies are being encouraged (Mackenzie et al.
2006) to gain insights into the practitioner’s experience of
integrating mindfulness into their lives overtime.
Limitations
Based on inclusion criteria, an anglophone bias is a limitation
to this sample selection. Although this analysis served to sup-
port the current use of mindfulness in nursing literature, it
does not completely capture how the concept has been inte-
grated into the discipline without reviewing educational pro-
grammes and nursing texts. Exclusion of multiple conference
abstracts regarding mindfulness (e.g. Mindfulness of practice:
mind to care – 35th international mental health conference;
Petrie 2009) does reveal that mindfulness is becoming inte-
grated into healthcare practices. In addition, the discussion
of mindfulness in nursing texts is also appearing (Spross
2009, Reed & Shearer 2011). The research and development
of mindfulness in other disciplines is also in its infancy, but
continues to gain momentum, and highlights the need for this
concept. A cross-disciplinary analysis could further situate
and expand this concept for the discipline of nursing.
Conclusion
The development of mindfulness in nursing lags behind other
disciplines that have been more engaged with integrating the
© 2013 John Wiley & Sons Ltd
Mindfulness in nursing: a concept analysis
concept and its significant benefits into their respective
practices. This may speak of a larger sociocultural problem
that fails to address self-care promotion and support for
nurse well-being in the face of their challenging work. To
move the concept of mindfulness forward in nursing, there
first needs to be a global shift in perspective that identifies the
health of nurses as a priority in education and research
initiatives. Mindfulness can offer practical tools for health
promotion and lends itself to holistic practices and perspec-
tives on nursing care. Furthermore, as nurses experience
mindfulness themselves, they will have additional knowledge
available to promote it as a holistic health practice in their
various clinical settings.
Finally, mindfulness can support an ontological orienta-
tion to nursing knowledge development. Specifically, the
concept of mindfulness has significant potential to enhance
cultivating and sustaining qualities considered imperative to
therapeutic nursing practice. The current emphasis on task-
oriented approaches to care and evidence-based practices
has limited the ability to foster other avenues of knowing
in nursing education and practice. Consequently, value
must be placed on other forms of knowing, such as per-
sonal and embodied knowledge. Integrating mindfulness
more intentionally into nursing education, practice and
research can assist nurses to develop a particular way of
being present for themselves and others, and can create a
shift from a purely theoretical way of knowing to one that
is more embodied and holistic.
Acknowledgements
I offer sincere gratitude to Professor Marilou Gagnon PhD
RN ACRN at the University of Ottawa who encouraged
the development of this manuscript and provided invaluable
guidance throughout the process.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the author.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/ethical_1author.html)]:
291
L. White
• substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content.
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