please see the attached 

Using the article, the PICO question, and the mindfulness research appraisal, write a two page paper responding to the following questions:

1. Describe something new you learned from the article about mindfulness training or mindfulness meditation.

2. Do you feel the article provides information to help answer the clinical question presented (PICO question)?

3. Did you notice any discrepancies in the appraisal tool about the article or its contribution to answering the PICO question?

4. Do you think there is a more appropriate clinical question that would be supported by the article presented? If yes, post your proposed PICO question explaining how the article better supports the new question, if no, explain why with rationale and support from the literature. 

5. After reading the article, what questions still remain regarding mindfulness

CONCEPT ANALYSIS

Mindfulness in nursing: an evolutionary concept analysis

Lacie White

Accepted for publication 15 May 2013

Correspondence to

L. White

:

e-mail: lwhit025@uottawa.ca

Lacie White BScN RN

PhD Student

School of Nursing, Faculty of Health

Sciences, University of Ottawa, Ontario,

Canada

W H I T E L . ( 2 0 1 4 ) Mindfulness in nursing: an evolutionary concept

analysis.

Journal of Advanced Nursing 70(2), 282–294. doi: 10.1111/jan.12182

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

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,

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

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.

© 2013 John Wiley & Sons Ltd 283

JAN: CONCEPT ANALYSIS Mindfulness in nursing: a concept analysis

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-

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.

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.

284 © 2013 John Wiley & Sons Ltd

L. White

Results

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

the others and so there will be notable overlap in the

discussion.

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.

Aw

areness

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-

Keyword searched: mindful*

Keyword searched: mindfulness, in the abstract or title.

76 results relevant to the discipline of nursing obtained.

Filtering out book reviews, editorials, brief commentaries and
conference abstracts resulted in 59 journal articles.

5
9

7
6

5
5
7

9
4
4

Keywords searched: mindfulness in the article abstract or title,
and nurs* anywhere within the article OR in the publication name

Within these 557 results the concept of mindfulness in relation to the
nursing discipline appeared infrequently.

A scan of abstracts from the 944 results from this search revealed that
mindfulness was not consistently a central theme within the articles.

Figure 1 Description of search terms
used and results obtained from the

CINAHL database.

© 2013 John Wiley & Sons Ltd 285

JAN: CONCEPT ANALYSIS Mindfulness in nursing: a concept analysis

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-

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)

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)

286 © 2013 John Wiley & Sons Ltd

L. White

ness’ (p. 62) where one can maintain focus on what arises

without becoming distracted or lost in thought (York

2007).

Transformative process

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,

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).

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

A
tte

nt
io

n A
w

areness
Acceptance
Antecedents

Requirements for

practice

Practices: formal

informal

Consequences

Physical
Psychosocial

Spiritual

Present
Moment

Experience

Transformative process

Attributes of mindfulness

Figure 3 Attributes, antecedents and
consequences of mindfulness.

0

20

40

60

80

100

120

19
94

19
95

19
96

19
97

19
98

19
99

20
00

20
01

20
02

20
03

20
04

20
05

20
06

20
07

20
08

20
09

20
10

20
11

#
o

f
re

su
lts

p
e
r

ye
a
r

Year

Mindfulness in title or
abstract

Mindfulness in title or
abstract with nurs* in journal
article or title of journal

Figure 2 Rate of growth for term
‘mindfulness’ in CINAHL Database rela-

tive to application directly within nursing

discipline.

© 2013 John Wiley & Sons Ltd 287

JAN: CONCEPT ANALYSIS Mindfulness in nursing: a concept analysis

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

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).

Table 3 Antecedents.

Engaging in the practice of mindfulness

Requirements of practice Types of practice

Capacity

Desire and commitment to

practice

Time to practise

Patience

Persistence

Non-striving – Non-goal

oriented

Formal practices*

Breath

Yoga

Sitting meditation

Walking meditation

Body scan

Mindful eating

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.

288 © 2013 John Wiley & Sons Ltd

L. White

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

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

© 2013 John Wiley & Sons Ltd 289

JAN: CONCEPT ANALYSIS Mindfulness in nursing: a concept analysis

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

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

290 © 2013 John Wiley & Sons Ltd

L. White

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

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)]:

© 2013 John Wiley & Sons Ltd 291

JAN: CONCEPT ANALYSIS Mindfulness in nursing: a concept analysis

• 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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evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance

and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original

research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Jour-
nal Citation Reports © (Nursing (Social Science)).

• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 3,500 in developing countries with free or low cost access).

• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

294 © 2013 John Wiley & Sons Ltd

L. White

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accuracy of the copy. Users should refer to the original published version of the material.