Certified Nursing Assistants' Wellbeing (CNA)

Mindful Self-Compassion Training to Improve Retention, Job Satisfaction, and Attitudes Toward Dementia Among Long-Term Care Nursing Assistants

Certified nursing assistants (CNAs), who provide the majority of care to persons with chronic disease and/or cognitive impairment from Alzheimer's disease and related dementias, face tremendous job and home stress, and as a result absenteeism and job turnover are high. This is a preliminary study that will tailor Mindful Self-Compassion (MSC) - a promising new program designed to cultivate greater self-care, and strengthen resilience and coping skills - for the CNA population and study its effectiveness. If results are favorable, MSC could be incorporated into CNA training programs, thereby helping contribute to a more effective and stable long-term care workforce.

Study Overview

• Status: Completed
• Conditions: Stress and Burnout
• Intervention / Treatment: Behavioral: 8-Week Mindful Self-Compassion (MSC); Behavioral: 6-Week Mindful Self-Compassion (MSC)

Detailed Description

U.S. nursing homes (NHs) serve 1.6 million older persons, all of whom have significant physical and/or cognitive impairment, and the majority of whom have Alzheimer's disease or a related cognitive disorder. In these settings the vast majority of hands-on care is provided by an estimated 634,000 certified nursing assistants (CNAs) - paraprofessional caregivers who are racially diverse, largely female, and an annual income equivalent to the poverty threshold for a family of four. Despite the crucial role of CNAs in providing care for the long-term care population and efforts to recruit and retain a stable workforce, absenteeism rates are high and annual turnover averages 65%, with adverse impact on the quality of care provided to NH residents, making CNA retention a policy priority.

CNAs have significant life stressors that affect their ability to work, such as single parenthood, poor physical health, difficulty finding childcare, and transportation problems. They also face emotionally and physically demanding job tasks, particularly when working with persons with Alzheimer's disease and related dementias, and many lack helpful strategies for dealing with stress, negative feelings, and burden.

A newly developed, standardized Mindful Self-Compassion (MSC) intervention may have particularly high impact and relevance for the high-stress lives of NH CNAs. MSC training has been shown to increase wellbeing, compassion for others, and stress-coping skills. However, little is known about the impact, feasibility and acceptability of MSC training in low-educated, stress-burdened paraprofessional populations such as CNAs, or whether it can impact outcomes such as burnout, absenteeism, and turnover.

This preliminary study will modify, refine, and test a MSC training intervention for CNAs, to be known as the CNA Wellbeing Program, who care for nursing home residents. The researcher teams' goal is to increase CNA coping skills and well-being, thereby reducing intent to leave the job, reducing burnout, and improving job satisfaction and attitudes toward people with dementia. The proposed research will be conducted in 3 similarly rated and structured community NHs. In Aim 1 the investigators will assess intervention feasibility and acceptability in one NH, using the knowledge they gain to tailor an evidence-based MSC program specifically for CNAs. In Aim 2 the investigators will pilot test the MSC training program with 30 CNAs who work in 2 similarly rated and structured NHs, evaluating the fidelity of the revised training and exploring trends in immediate, 3-month, and 6-month outcome measures in order to inform power calculations for future trials.

The specific aims are:

Aim 1. Determine the feasibility, acceptability, and necessary adaptations of MSC training needed to meet the diverse cultural background, limited literacy, and job and family challenges of the nursing home CNA workforce, including the unique challenges of caring for persons with dementia, and of the data collection methods.

1. Conduct a field trial of the standardized 8-week MSC training program with 15 CNAs within a single community NH. Evaluation will focus on: (a) participation (including home practice adherence); (b) attendee evaluation of the training; (c) barriers to and facilitators of participation; (d) use and retention of class material by participants; and (e) recommendations for improvement of training.
2. Field test the feasibility and acceptability of our study recruitment and evaluation strategy.
3. Use data collected from the field test to modify recruitment strategies, protocols, and course structure, content and materials so as to be maximally feasible, acceptable and effective in a CNA population.

Aim 2. Conduct a pilot test of the adapted protocols and intervention in a sample of 30 CNAs from 2 similarly rated and structured community NHs to reexamine feasibility and acceptability, identify trends in key intermediate and long-term outcomes, and estimate effect size in preparation for a future randomized trial.

1. Evaluate the fidelity and immediate impact of the modified training by measuring (a) training attendance; (b) satisfaction with the training; and (c) pre-and post-training measures of self-compassion, perceived stress, job satisfaction, job burnout symptoms, and attitudes towards persons with dementia.
2. Evaluate the sustained impact of the training by comparing baseline, 3-and 6-month post-training measurements of: intent to leave job, self-compassion, perceived stress, job satisfaction, job burnout symptoms, and attitudes towards persons with dementia.

• Study Type: Interventional
• Enrollment (Actual): 39
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • North Carolina
    • Chapel Hill, North Carolina, United States, 27599
      • University Of North Carolina At Chapel Hill

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Certified Nursing Assistant employed by one of 3 study Nursing Homes
• Aged 18 and over
• Speak English
• Work at least 20 hours as a CNA at one of our proposed Nursing Homes
• Expect to attend at least 75% of the intervention classes
• Expect to stay at least the course of the intervention on the job
• Score in the top 50% on the PSS-10 (Perceived Stress Scale) (if more than 20 participants interested)

Exclusion Criteria:

• Younger than 18
• Working fewer than 20 hours a week
• Unable to attend at least 75% of the intervention classes
• Expect to leave their position during the intervention

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: 8-Week Mindful Self-Compassion (MSC); CNAs in Aim 1 will participate in the standardized, 8-week Mindful Self-Compassion course. Each 8-week session will last for 2.5 hours. Also included is a half day retreat, that CNAs may attend if they are able.	Behavioral: 8-Week Mindful Self-Compassion (MSC); The 8-week MSC is a course of eight 2.5 hour weekly sessions that is based off self-compassion, a construct closely related to mindfulness. Self-compassion (SC) has three main interrelated components: self-kindness, common humanity, and mindfulness. MSC is an 8-session program that integrates SC and mindfulness. It includes the following components: Discovering Mindful Self-Compassion; Practicing Mindfulness; Practicing Lovingkindness; Discovering your Compassionate Voice; Living Deeply; Meeting Difficult Emotions; Exploring Challenging Relationships; Embracing Your Life
Experimental: 6-Week Mindful Self Compassion (MSC); CNAs from both nursing homes in Aim 2 will participate in the 6-week Mindful Self-Compassion course, that was shortened and customized to fit the needs of health care staff. Each 6-week session will last for 1 hour.	Behavioral: 6-Week Mindful Self-Compassion (MSC); The 6-week MSC is a course of six 1 hour weekly sessions that is based off self-compassion, a construct closely related to mindfulness. Self-compassion (SC) has three main interrelated components: self-kindness, common humanity, and mindfulness. MSC is an 6-session program that integrates SC and mindfulness. It includes the following components: What is Self-Compassion; Practicing Self-Compassion; Discovering your Compassionate Voice; Self-Compassion and Resilience; Self-Compassion and Burnout; Going Forward This program is a shortened version of the 8-week program, specifically created for the needs of health care staff.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Study Participant's Self-Rating of Likelihood to Leave Job in the Coming Year Over Time	The researchers will assess intent to leave job by asking "How likely is it that you will leave this job in the next year? "Would you say... 1 is Not at All Likely, 2 is Somewhat Likely, 3 is Very Likely." Minimum = 1 (best value), maximum = 3 (worst value). For the primary outcome analysis, intent will be evaluated by totaling the count of participants who responded "Somewhat Likely", "Very likely", or "Not at all likely." This was collected over the course of four time frames: Baseline, End-of Intervention interview, 3-Month Follow Up Interview, and 6-Month Follow Up Interview.	Participants will be followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Mean Score Over Time on Job Satisfaction Scale (JSS)	Job satisfaction will be assessed using the 3-item Job Satisfaction scale (JSS). Responses are provided using a 7-point Likert scale measuring how satisfied respondents are with their job. Minimum score = 0 (worst value). Maximum score = 6 (best value). Range of scores from 0 to 18, with higher values indicating better outcomes. Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants will be followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Approach to Dementia Questionnaire (ADQ) - Recognition of Personhood Subscale	Approach to Dementia Questionnaire (ADQ) - Recognition of Personhood Subscale is an 11-item instrument. Responses are indicated using a 5-point Likert scale. Minimum score (worst value) = 1. Maximum score (best value) = 5. Higher values represent a better outcome (range 11-55). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants will be followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Perceived Stress Scale (PSS)	Perceived Stress Scale (PSS) 10-item version. Perceived stress is defined as the degree to which individuals find their lives "unpredictable, uncontrollable, and overloading". Responses are indicated using a 5-point Likert scale. Minimum score (best value)=0. Maximum score (worst value)=4. Higher values represent a worse outcome (range 0 - 40). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants will be followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on PROMIS Depression Scale	PROMIS Emotional Distress Depression - Short Form (PROMIS) is an 8-item instrument. Responses are indicated using a 5-point Likert scale. Minimum score (best value) = 1/Never. Maximum score (worst value) = 5/Always. Lower values represent a better outcome (range 8-40). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Maslach Burnout Inventory (MBI) - Depersonalization Subscale	Burnout will be assessed via a modified Maslach Burnout Inventory (MBI) - Depersonalization Subscale (one of three subscales within the MBI), a 5-item scale. Items are measured on a 7-point Likert scale that asks how often respondents are feeling certain feelings. Minimum score (best value, never) = 0. Maximum score (worst value, every day) = 6. Analysis reports mean score rather than total score; range of the mean score is 0 to 6, with lower values representing better outcomes. Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Maslach Burnout Inventory (MBI) - Emotional Exhaustion Subscale	Burnout will be assessed via a modified Maslach Burnout Inventory (MBI) - Emotional Exhaustion Subscale (one of three subscales within the MBI), a 8-item scale. Items are measured on a 7-point Likert scale that asks how often respondents are feeling certain feelings. Minimum score (best value, never) = 0. Maximum score (worst value, every day) = 6. Analysis reports mean score rather than total score; range of the mean score is 0 to 6, with lower values representing better outcomes. Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants will be followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Maslach Burnout Inventory (MBI) - Personal Accomplishment Subscale	Burnout will be assessed via a modified Maslach Burnout Inventory (MBI) - Personal Accomplishment Subscale (one of three subscales within the MBI), a 7-item scale. Items are measured on a 7-point Likert scale that asks how often respondents are feeling certain feelings. Minimum score (worst value, never) = 0. Maximum score (best value, every day) = 6. Analysis reports mean score rather than total score; range of the mean score is 0 to 6, with higher values representing better outcomes. Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Self-compassion Scale-Short Form (SCS-SF)	The researchers will collect pre-post measures using the Self-compassion scale-short form (SCS-SF), a 12-item scale that includes the three components of self-compassion: self-kindness, common humanity, and mindfulness. This is done using a 5-point Likert scale. Minimum score = 1 (worst value). Maximum score = 5 (best value). Analysis reports mean score rather than total score (total range is 0.0 to 5.0), with higher values indicating better outcomes. Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants will be followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Self-compassion Scale-Short Form (SCS-SF) - Self-kindness Subscale	The researchers will collect pre-post measures using the Self-compassion scale-short form (SCS-SF) - Self-kindness Subscale (one of six subscales within the SCS-SF), a 3-item scale. Items are measured on a 5-point Likert scale. Minimum score = 1 (worst value). Maximum score = 5 (best value), higher scores indicating better outcomes. Analysis reports mean score rather than total score (total range is 0.0 to 5.0). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Self-compassion Scale-Short Form (SCS-SF) - Self-judgment Subscale	The researchers will collect pre-post measures using the Self-compassion scale-short form (SCS-SF) - Self-judgment Subscale (one of six subscales within the SCS-SF), a 3-item scale. Items are measured on a 5-point Likert scale. Minimum score = 1 (best value). Maximum score = 5 (worst value), with lower scores indicating better outcomes. Analysis reports mean score rather than total score (total range is 0.0 to 5.0). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Self-compassion Scale-Short Form (SCS-SF) - Common Humanity Subscale	The researchers will collect pre-post measures using the Self-compassion scale-short form (SCS-SF) - Common humanity Subscale (one of six subscales within the SCS-SF), a 3-item scale. Items are measured on a 5-point Likert scale. Minimum score = 1 (worst value). Maximum score = 5 (best value), with higher scores indicating better outcomes. Analysis reports mean score rather than total score (total range is 0.0 to 5.0). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Self-compassion Scale-Short Form (SCS-SF) - Isolation Subscale	The researchers will collect pre-post measures using the Self-compassion scale-short form (SCS-SF) - Isolation Subscale (one of six subscales within the SCS-SF), a 3-item scale. Items are measured on a 5-point Likert scale. Minimum score = 1 (best value). Maximum score = 5 (worst value), with lower scores indicating better outcomes. Analysis reports mean score rather than total score (total range is 0.0 to 5.0). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Self-compassion Scale-Short Form (SCS-SF) - Mindfulness Subscale	The researchers will collect pre-post measures using the Self-compassion scale-short form (SCS-SF) - Mindfulness Subscale (one of six subscales within the SCS-SF), a 3-item scale. Items are measured on a 5-point Likert scale. Minimum score = 1 (worst value). Maximum score = 5 (best value), with higher scores indicating better outcomes. Analysis reports mean score rather than total score (total range is 0.0 to 5.0). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Change in Mean Score Over Time on Self-compassion Scale-Short Form (SCS-SF) - Over-identification Subscale	The researchers will collect pre-post measures using the Self-compassion scale-short form (SCS-SF) - Over-identification Subscale (one of six subscales within the SCS-SF), a 3-item scale. Items are measured on a 5-point Likert scale. Minimum score = 1 (best value). Maximum score = 5 (worst value), with lower scores indicating better outcomes. Analysis reports mean score rather than total score (total range is 0.0 to 5.0). Measure was assessed at Baseline, at an End-of-Intervention Interview, a 3-month Follow Up Interview and at a 6-month Follow Up Interview.	Participants were followed for the duration of the intervention and 6 additional months after the intervention ends, an expected average of 8 months
Percent of Classes Attended by Participating CNAs	This will be reported as percent of classes attended by CNAs.	Participants will be followed for the duration of the intervention, an expected average of 6-8 weeks
Percent of Participants Attending All Intervention Sessions	This will be reported by percent of participants who attended every assigned intervention session (6 or 8 depending on intervention arm).	Participants will be followed for the duration of the intervention, an expected average of 6-8 weeks
Percent Intervention Minutes Attended by Participants	This will be collected by recording the number of minutes each participant spent per class in order to account for intervention missed due to participants' leaving early or coming late, and reporting percent of minutes attended by participants.	Participants will be followed for the duration of the intervention, an expected average of 6-8 weeks
Mean Number of Days Per Week Spent in Out-of-Class Informal Exercise	Based on participant completion of weekly surveys, the researchers will measure the number of days each week that class participants were able to practice learned informal techniques and exercises outside of class hours.	Participants will be followed for the duration of the intervention, an expected average of 6/8 weeks
Mean Number of Days Per Week Spent in Out-of-Class Formal Exercise	Based on participant completion of weekly surveys, the researchers will measure the number of days each week that class participants were able to practice learned formal techniques and exercises outside of class hours.	Participants will be followed for the duration of the intervention, an expected average of 6/8 weeks
Study Participant's Self-Rating of Satisfaction With the MSC Course	The researchers assess satisfaction of the MSC training using an 8-item, 5-point Likert Scale (0 = Strongly Disagree, 1 = Disagree, 2 = Neither Agree nor Disagree, 3 = Agree, 4 = Strongly Agree). Minimum = 0 (worst value), maximum = 4 (best value). Measure was assessed during the End-of-Intervention Interview.	At the conclusion of the week 6/8 class, during the End-of-Intervention Interview, participants were asked their satisfaction with the course

Collaborators and Investigators

• Sponsor: University of North Carolina, Chapel Hill
• Collaborators: National Institute on Aging (NIA)
• Investigators: Principal Investigator: Philip D Sloane, MD, MPH, University of North Carolina, Chapel Hill

Publications and helpful links

General Publications

• Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983 Dec;24(4):385-96. No abstract available.
• Lee EH. Review of the psychometric evidence of the perceived stress scale. Asian Nurs Res (Korean Soc Nurs Sci). 2012 Dec;6(4):121-7. doi: 10.1016/j.anr.2012.08.004. Epub 2012 Sep 18.
• Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction With Life Scale. J Pers Assess. 1985 Feb;49(1):71-5. doi: 10.1207/s15327752jpa4901_13.
• Raes F, Pommier E, Neff KD, Van Gucht D. Construction and factorial validation of a short form of the Self-Compassion Scale. Clin Psychol Psychother. 2011 May-Jun;18(3):250-5. doi: 10.1002/cpp.702. Epub 2010 Jun 8.
• Khoury B, Sharma M, Rush SE, Fournier C. Mindfulness-based stress reduction for healthy individuals: A meta-analysis. J Psychosom Res. 2015 Jun;78(6):519-28. doi: 10.1016/j.jpsychores.2015.03.009. Epub 2015 Mar 20.
• Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013 Jan;69(1):28-44. doi: 10.1002/jclp.21923. Epub 2012 Oct 15.
• Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. Vital Health Stat 13. 2009 Jun;(167):1-155.
• Barbarotta L. Direct Care Worker Retention: Strategies for Success.; 2010.
• Castle NG, Ferguson-Rome JC. Influence of Nurse Aide Absenteeism on Nursing Home Quality. Gerontologist. 2015 Aug;55(4):605-15. doi: 10.1093/geront/gnt167. Epub 2014 Jan 7.
• Castle NG, Engberg J, Men A. Nursing home staff turnover: impact on nursing home compare quality measures. Gerontologist. 2007 Oct;47(5):650-61. doi: 10.1093/geront/47.5.650.
• Lerner NB, Johantgen M, Trinkoff AM, Storr CL, Han K. Are nursing home survey deficiencies higher in facilities with greater staff turnover. J Am Med Dir Assoc. 2014 Feb;15(2):102-7. doi: 10.1016/j.jamda.2013.09.003. Epub 2013 Oct 15.
• Trinkoff AM, Han K, Storr CL, Lerner N, Johantgen M, Gartrell K. Turnover, staffing, skill mix, and resident outcomes in a national sample of US nursing homes. J Nurs Adm. 2013 Dec;43(12):630-6. doi: 10.1097/NNA.0000000000000004.
• Cook G, Brown-Wilson C. Care home residents' experiences of social relationships with staff. Nurs Older People. 2010 Feb;22(1):24-9. doi: 10.7748/nop2010.02.22.1.24.c7492.
• Squillace MR, Remsburg RE, Harris-Kojetin LD, Bercovitz A, Rosenoff E, Han B. The National Nursing Assistant Survey: improving the evidence base for policy initiatives to strengthen the certified nursing assistant workforce. Gerontologist. 2009 Apr;49(2):185-97. doi: 10.1093/geront/gnp024. Epub 2009 Apr 1.
• Dill JS, Morgan JC, Marshall VW, Pruchno R. Contingency, employment intentions, and retention of vulnerable low-wage workers: an examination of nursing assistants in nursing homes. Gerontologist. 2013 Apr;53(2):222-34. doi: 10.1093/geront/gns085. Epub 2012 Aug 8.
• Lachs MS, Rosen T, Teresi JA, Eimicke JP, Ramirez M, Silver S, Pillemer K. Verbal and physical aggression directed at nursing home staff by residents. J Gen Intern Med. 2013 May;28(5):660-7. doi: 10.1007/s11606-012-2284-1. Epub 2012 Dec 8.
• Chappell NL, Novak M. Caring for institutionalized elders: Stress among nursing assistants. J Appl Gerontol. 1994;13(3):299-315.
• Morgan DG, Stewart NJ, D'Arcy C, Forbes D, Lawson J. Work stress and physical assault of nursing aides in rural nursing homes with and without dementia special care units. J Psychiatr Ment Health Nurs. 2005 Jun;12(3):347-58. doi: 10.1111/j.1365-2850.2005.00846.x.
• Schaefer JA, Moos RH. Effects of work stressors and work climate on long-term care staff's job morale and functioning. Res Nurs Health. 1996 Feb;19(1):63-73. doi: 10.1002/(SICI)1098-240X(199602)19:13.0.CO;2-J.
• Cooper SL, Carleton HL, Chamberlain SA, Cummings GG, Bambrick W, Estabrooks CA. Burnout in the nursing home health care aide: A systematic review. Burn Res. 2016;3:76-87.
• Astrom S, Nilsson M, Norberg A, Sandman PO, Winblad B. Staff burnout in dementia care--relations to empathy and attitudes. Int J Nurs Stud. 1991;28(1):65-75. doi: 10.1016/0020-7489(91)90051-4.
• Moyle W, Murfield JE, Griffiths SG, Venturato L. Care staff attitudes and experiences of working with older people with dementia. Australas J Ageing. 2011 Dec;30(4):186-90. doi: 10.1111/j.1741-6612.2010.00470.x. Epub 2010 Oct 8.
• Zimmerman S, Williams CS, Reed PS, Boustani M, Preisser JS, Heck E, Sloane PD. Attitudes, stress, and satisfaction of staff who care for residents with dementia. Gerontologist. 2005 Oct;45 Spec No 1(1):96-105. doi: 10.1093/geront/45.suppl_1.96.
• Bauer-Wu S, Fontaine D. Prioritizing Clinician Wellbeing: The University of Virginia's Compassionate Care Initiative. Glob Adv Health Med. 2015 Sep;4(5):16-22. doi: 10.7453/gahmj.2015.042. Epub 2015 Sep 1.
• Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov-Dec;12(6):573-6. doi: 10.1370/afm.1713.
• Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness in Everyday Life. New York: Hyperion; 1994.
• Gotink RA, Chu P, Busschbach JJ, Benson H, Fricchione GL, Hunink MG. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PLoS One. 2015 Apr 16;10(4):e0124344. doi: 10.1371/journal.pone.0124344. eCollection 2015.
• Li G, Yuan H, Zhang W. The Effects of Mindfulness-Based Stress Reduction for Family Caregivers: Systematic Review. Arch Psychiatr Nurs. 2016 Apr;30(2):292-9. doi: 10.1016/j.apnu.2015.08.014. Epub 2015 Aug 28.
• Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness-based stress reduction (MBSR). Complement Ther Clin Pract. 2009 May;15(2):61-6. doi: 10.1016/j.ctcp.2009.01.002. Epub 2009 Feb 28.
• Lamothe M, Rondeau E, Malboeuf-Hurtubise C, Duval M, Sultan S. Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies. Complement Ther Med. 2016 Feb;24:19-28. doi: 10.1016/j.ctim.2015.11.001. Epub 2015 Nov 27.
• Smith SA. Mindfulness-based stress reduction: an intervention to enhance the effectiveness of nurses' coping with work-related stress. Int J Nurs Knowl. 2014 Jun;25(2):119-30. doi: 10.1111/2047-3095.12025. Epub 2014 Feb 26.
• Cohen-Katz J, Wiley SD, Capuano T, Baker DM, Kimmel S, Shapiro S. The effects of mindfulness-based stress reduction on nurse stress and burnout, Part II: A quantitative and qualitative study. Holist Nurs Pract. 2005 Jan-Feb;19(1):26-35. doi: 10.1097/00004650-200501000-00008. Erratum In: Holist Nurs Pract. 2005 Mar-Apr;19(2):78. Kimmel, Sharon [added].
• Mackenzie CS, Poulin PA, Seidman-Carlson R. A brief mindfulness-based stress reduction intervention for nurses and nurse aides. Appl Nurs Res. 2006 May;19(2):105-9. doi: 10.1016/j.apnr.2005.08.002.
• Baker C, Huxley P, Dennis M, Islam S, Russell I. Alleviating staff stress in care homes for people with dementia: protocol for stepped-wedge cluster randomised trial to evaluate a web-based Mindfulness- Stress Reduction course. BMC Psychiatry. 2015 Dec 21;15:317. doi: 10.1186/s12888-015-0703-7.
• Zeller JM, Lamb K. Mindfulness meditation to improve care quality and quality of life in long-term care settings. Geriatr Nurs. 2011 Mar-Apr;32(2):114-8. doi: 10.1016/j.gerinurse.2010.11.006. Epub 2011 Jan 15.
• Raab K. Mindfulness, self-compassion, and empathy among health care professionals: a review of the literature. J Health Care Chaplain. 2014;20(3):95-108. doi: 10.1080/08854726.2014.913876.
• Egan H, Mantzios M, Jackson C. Health Practitioners and the Directive Towards Compassionate Healthcare in the UK: Exploring the Need to Educate Health Practitioners on How to be Self-Compassionate and Mindful Alongside Mandating Compassion Towards Patients. Heal Prof Educ. 2016:9-11.
• Neff KD, Dahm KA. Self-Compassion: What It Is, What It Does, and How It Relates to Mindfulness. (Robinson M, Meier B, Ostafin B, eds.). New York: Springer; 2015.
• Zessin U, Dickhauser O, Garbade S. The Relationship Between Self-Compassion and Well-Being: A Meta-Analysis. Appl Psychol Health Well Being. 2015 Nov;7(3):340-64. doi: 10.1111/aphw.12051. Epub 2015 Aug 26.
• MacBeth A, Gumley A. Exploring compassion: a meta-analysis of the association between self-compassion and psychopathology. Clin Psychol Rev. 2012 Aug;32(6):545-52. doi: 10.1016/j.cpr.2012.06.003. Epub 2012 Jun 23.
• Leary MR, Tate EB, Adams CE, Allen AB, Hancock J. Self-compassion and reactions to unpleasant self-relevant events: the implications of treating oneself kindly. J Pers Soc Psychol. 2007 May;92(5):887-904. doi: 10.1037/0022-3514.92.5.887.
• Wiklund Gustin L, Wagner L. The butterfly effect of caring - clinical nursing teachers' understanding of self-compassion as a source to compassionate care. Scand J Caring Sci. 2013 Mar;27(1):175-83. doi: 10.1111/j.1471-6712.2012.01033.x. Epub 2012 Jun 27.
• Mills J, Wand T, Fraser JA. On self-compassion and self-care in nursing: selfish or essential for compassionate care? Int J Nurs Stud. 2015 Apr;52(4):791-3. doi: 10.1016/j.ijnurstu.2014.10.009. Epub 2014 Oct 25. No abstract available.
• Gerber Z, Tolmacz R, Doron Y. Self-compassion and forms of concern for others. Pers Individ Dif. 2015;86:394-400.
• Duarte J, Pinto-Gouveia J, Cruz B. Relationships between nurses' empathy, self-compassion and dimensions of professional quality of life: A cross-sectional study. Int J Nurs Stud. 2016 Aug;60:1-11. doi: 10.1016/j.ijnurstu.2016.02.015. Epub 2016 Mar 4.
• Durkin M, Beaumont E, Hollins Martin CJ, Carson J. A pilot study exploring the relationship between self-compassion, self-judgement, self-kindness, compassion, professional quality of life and wellbeing among UK community nurses. Nurse Educ Today. 2016 Nov;46:109-114. doi: 10.1016/j.nedt.2016.08.030. Epub 2016 Aug 30.
• Beaumont E, Durkin M, Hollins Martin CJ, Carson J. Compassion for others, self-compassion, quality of life and mental well-being measures and their association with compassion fatigue and burnout in student midwives: A quantitative survey. Midwifery. 2016 Mar;34:239-244. doi: 10.1016/j.midw.2015.11.002. Epub 2015 Nov 6.
• Bluth K, Gaylord SA, Campo RA, Mullarkey MC, Hobbs L. Making Friends With Yourself: A Mixed Methods Pilot Study of a Mindful Self-Compassion Program for Adolescents. Mindfulness (N Y). 2016 Mar 1;7(2):479-492. doi: 10.1007/s12671-015-0476-6. Epub 2015 Dec 19.
• Bluth K, Eisenlohr-Moul TA. Response to a mindful self-compassion intervention in teens: A within-person association of mindfulness, self-compassion, and emotional well-being outcomes. J Adolesc. 2017 Jun;57:108-118. doi: 10.1016/j.adolescence.2017.04.001. Epub 2017 Apr 14.
• Friis AM, Johnson MH, Cutfield RG, Consedine NS. Kindness Matters: A Randomized Controlled Trial of a Mindful Self-Compassion Intervention Improves Depression, Distress, and HbA1c Among Patients With Diabetes. Diabetes Care. 2016 Nov;39(11):1963-1971. doi: 10.2337/dc16-0416. Epub 2016 Jun 22.
• McPherson S, Hiskey S, Alderson Z. Distress in working on dementia wards - A threat to compassionate care: A grounded theory study. Int J Nurs Stud. 2016 Jan;53:95-104. doi: 10.1016/j.ijnurstu.2015.08.013. Epub 2015 Sep 3.
• Allen AB, Leary MR. Self-Compassion, Stress, and Coping. Soc Personal Psychol Compass. 2010 Feb 1;4(2):107-118. doi: 10.1111/j.1751-9004.2009.00246.x.
• Abercrombie PD, Zamora A, Korn AP. Lessons learned: providing a mindfulness-based stress reduction program for low-income multiethnic women with abnormal pap smears. Holist Nurs Pract. 2007 Jan-Feb;21(1):26-34. doi: 10.1097/00004650-200701000-00006.
• Rosen J, Stiehl EM, Mittal V, Leana CR. Stayers, leavers, and switchers among certified nursing assistants in nursing homes: a longitudinal investigation of turnover intent, staff retention, and turnover. Gerontologist. 2011 Oct;51(5):597-609. doi: 10.1093/geront/gnr025. Epub 2011 Apr 15.
• Sloane PD, Williams CS, Zimmerman S. Immigrant status and intention to leave of nursing assistants in U.S. nursing homes. J Am Geriatr Soc. 2010 Apr;58(4):731-7. doi: 10.1111/j.1532-5415.2010.02781.x.
• Cohen S, Williamson G. The social psychology of health: Claremont symposium on applied social psychology. In: Perceived Stress in a Probability Sample of the United States. In: Spacapan S, Oskamp S, Eds. Newbury Park, CA: Sage; 1988.
• Roberti J, Harrington L, Storch E. Further psychometric support for the 10- item version of the perceived stress scale. J Coll Couns. 2006;9(2):135-147.
• Lintern T, Woods B, Phair L. Training is not enough to change care practice. J Dement Care. 2000;8:15-17.
• Lintern T. Quality in Dementia Care: Evaluating Staff Attitudes and Behaviour. 2001.
• Kada S, Nygaard HA, Mukesh BN, Geitung JT. Staff attitudes towards institutionalised dementia residents. J Clin Nurs. 2009 Aug;18(16):2383-92. doi: 10.1111/j.1365-2702.2009.02791.x.
• Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory. Palo Alto; 1986.
• Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol. 1986 May;42(3):488-92. doi: 10.1002/1097-4679(198605)42:33.0.co;2-s.
• Schaufeli WB, Bakker AB, Hoogduin K, Schaap C, Kladler A. on the clinical validity of the maslach burnout inventory and the burnout measure. Psychol Health. 2001 Sep;16(5):565-82. doi: 10.1080/08870440108405527.
• Diener E, Inglehart R, Tay L. Theory and validity of life satisfaction scales. Soc Indic Res. 2013;112(3):497-527.
• Cammann C, Fichman M, Jenkins D, Klesh J. Assessing the attitudes and perceptions of organizational members. In: Assessing Organizational Change: A Guide to Methods, Measures, and Practices. Vol 71.; 1983.
• McFarlin D, Rice R. The role of facet importance as a moderator in job satisfaction processes. J Organ Behav. 1992;13(1):41-54.
• Pearson C. An assessment of extrinsic feedback on participation, role perceptions, motivation, and job satisfaction in a self-managed system for monitoring group achievement. Hum relations.1991;44(5):517-537.
• Sanchez J, Brock P. Sanchez JI, Brock P. Outcomes of perceived discrimination among Hispanic employees: is diversity management a luxury or a necessity? Academy of Management Journal. 1996;39(3):704-719. Acad Manag Journal. 1996;39(3):704-719.
• Siegall M, McDonald T. Focus of Attention and Employee Reactions to Job Change. J Appl Soc Psychol. 1995;25(13):1121-1141.
• McLain DL. Responses to health and safety risk in the work environment. Acad Manage J. 1995 Dec;38(6):1726-43.
• Sanchez J, Kraus E, White S, Williams M. Adopting high-involvement human resource practices the mediating role of benchmarking. Gr Organ Manag. 1999;24(4):461-478.
• George J. Leader positive mood and group performance: The case of customer service. J Appl Soc Psychol. 1995;25(9):778-794.
• Fletcher S, Zimmerman S, Preisser JS, Mitchell C, Reed D, Gould E, Beeber A, Reed P. Implementation fidelity of a standardized Dementia Care training program across multiple trainers and settings. Alzheimers care today. 2010;11(1):51-60.

Helpful Links

• US Department of Labor, Bureau of Labor Statistics: Occupational Outlook Handbook.
• Nursing Home Compare
• Unscheduled Absence Survey: CCH Survey Finds Unscheduled Absenteeism Up in U.S. Workplaces.

Study record dates

Study Major Dates

• Study Start (Actual): March 27, 2019
• Primary Completion (Actual): June 2, 2020
• Study Completion (Actual): June 23, 2020

Study Registration Dates

• First Submitted: October 24, 2018
• First Submitted That Met QC Criteria: October 24, 2018
• First Posted (Actual): October 25, 2018

Study Record Updates

• Last Update Posted (Actual): April 29, 2021
• Last Update Submitted That Met QC Criteria: April 28, 2021
• Last Verified: March 1, 2021

More Information

Terms related to this study

• Keywords: Mindfulness; Long-Term Care; Certified Nursing Assistants; Staff Turnover; Mindful Self-Compassion
• Additional Relevant MeSH Terms: Behavioral Symptoms; Stress, Psychological; Burnout, Psychological
• Other Study ID Numbers: 18-2012; 1R21AG058133-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: Deidentified individual data that supports the results will be shared beginning 9 to 36 months following publication provided the investigator who proposes to use the data has approval from an Institutional Review Board (IRB), Independent Ethics Committee (IEC), or Research Ethics Board (REB), as applicable, and executes a data use/sharing agreement with UNC.
• IPD Sharing Time Frame: The data will be shared beginning 9 to 36 months following publication, and will be available for up to 7 years post publication.
• IPD Sharing Access Criteria: To access, interested parties will have to email Drs. Christine Lathren, lathren@email.unc.edu, and Philip D. Sloane, philip_sloane@med.unc.edu, or contact the study team through the Cecil G. Sheps Center for Health Services Research at (919) 966-5011.
• IPD Sharing Supporting Information Type: Study Protocol; Statistical Analysis Plan (SAP); Informed Consent Form (ICF); Clinical Study Report (CSR); Analytic Code

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No