Introduction

Mindfulness or state of mindfulness is fostered from one's consistent and deliberate choice to take cognizance of what is happening on the inner and outer worlds, exercising the ability to be fully involved in the present moment without diverting one's attention to past or future events.^1-2It is consciousness that arises when one pays attention in a specific way, that is, with the purpose of perceiving the present moment without judgment.²

While individual differences may occur in the natural degree of mindfulness between people, this kind of meta-cognitve skill can be developed with training.¹Such techniques aim to develop a perspective for thoughts and feelings in which they are recognized as mental events or as accurate reflections of reality.²

Commonly, people and critics tend to associate mindfulness with meditation practice. However, this practice brings together a variety of methods such as yoga, focused breathing, body awareness and meditation. Studies expand the possibilities of practicing mindfulness, which would be through the arts, literature and even through daily activities. All of these practices have physiological origins and effects and are employed to strengthen awareness and pursue well-being.^1-2

In health care, the practice of mindfulness helps to cultivate in the professional a desire to know and understand the feelings and needs of patients and family, developing the ability to be fully present with attention focused on the other, patient and / or family.² The nurse's “presence” is a critical element for effective support to the patient who experiences some physical or mental imbalance. Acting as assistants, teachers and researchers, nurses can use mindfulness-learning techniques to actively engage in the events that occur in their surrounding contexts.²

In this sense, different approaches to intervention programs in mindfulness have been employed in these different contexts. Among them, the Mindfulness Stress Reduction Program (MBSR) stands out³The eight-week session, which brings together various meditation techniques to promote quality mindfulness, aims to teach people to approach stressful situations consciously so that they can respond assertively rather than react automatically. Mindfulness-based stress reduction practices have shown promising positive results in several clinical populations, in which nursing is considered one of the most prominent professions, justified by its prominent position in the management and delivery of health care in loco.

According to the intention of the presented texts, the question is: what would be the limits and potentialities of mindfulness for nursing care? Reflecting on mindfulness is important because it shows a fertile field of exploration for nursing, providing consistent foundations for approaching their practices as an instrument for improving care and the implementation of comprehensive care. Thus, the objective is to reflect on the limits and potentialities of mindfulness practices for nursing care, exploring the available scientific evidence, its use in health care and nursing care.

Mindfulness and Scientific Evidence

To understand how mindfulness practice affects individuals, groups, and institutions, a consistent body of scholars has been devoted to describing the effects of this state of mind on basic human functions that include attention, cognition, emotion, behavior, and physiology.⁴ The impacts of mindfulness cultivation on attention report better stability (sustaining attention on something present and a less vague mind), better attention control (ability to focus on something selected), and better attention efficiency (economic use of cognitive resources).⁴

Improved quality of care provides better cognitive performance in two main aspects: capacity and flexibility. Cognitive ability was considered in relation to memory and intelligence flow from performance in storing and processing experiences and information. Progression in cognitive flexibility leads to improved adaptability through the creation of new responses and perspectives to the situations presented, associating mindfulness with creativity and convergent and divergent thinking.⁵

As for emotions, studies reveal the impact on reactivity and emotional tone. Through qualified attention, cultivating mindfulness can influence the selection of emotional stimuli for observation and change how they are evaluated, shaping emotional reactions. The practice is associated with less negative and more positive emotional tones, accelerating the recovery of negative emotions and shortening the time for emotional reaction to an adverse situation.⁶

In terms of behavior, the reduction of automaticity stands out, as it allows greater awareness of automatic and habitual operations, which occur when there is involvement in effortless behavior without conscious supervision of their operational details. It also promotes activation in higher brain regions associated with behavioral self-control, increasing an individual's ability to recognize the occurrence of automatic behaviors whose responses may be poorly adaptive, such as compulsions and addictions in general.^6-7

From the physiological perspective, the scientific evidence produced has emphasized the role of mindfulness cultivation in stress, showing that the practice is related to several neurobiological mechanisms responsible for stress regulation. Among the findings are its beneficial effects on cortisol, sleep quality, aging process, immune system, inflammatory processes and brain tissue structure.⁴

Evidence shows changes in brain functional properties following the practice of mindfulness. Magnetic Resonance Imaging (MRI) investigating neuroplasticity in regions that regulate attention control showed greater effects on the anterior cingulate cortex, responsible for executive attention, flexibility for strategy change, and control in the presence of emerging conflicts.² Injuries in this region lead to impulsiveness and uncontrolled aggression; Impairing the connection of the anterior cingulate cortex to other brain regions results in poor mental flexibility performance, making decision making difficult.⁸

To date, eight consistently altered brain regions have been identified in groups of meditators, in addition to the anterior cingulate cortex, such as the fronto-polar cortex responsible for metaconsciousness; the sensory cortex and insula where body awareness of exteroceptive and interoceptive sensations occurs; increased hippocampal gray matter, the basis for memory consolidation and reconsolidation and stress control, as it is a region covered by cortisol receptors; the anterior and middle cingulate, and the orbitofrontal cortex that regulate the emotions and the ego; the superior longitudinal fascicle and the corpus callosum that regulate intra and interhemispheric communication.^8-9

This evidence shows that mindfulness practice affects brain areas that are important for knowing yourself and others. The results found so far are challenging and stimulating, which makes it licit to state that such practice is an important intervention tool for health care.

Mindfulness in Health Care

Several health professionals have used mindfulness-based interventions in different physical and mental conditions in clinical and therapeutic contexts. In pursuit of comprehensive care, it is necessary to develop an understanding of mindfulness practice at its interface with various levels of knowledge to properly assess its effects. Its use has been strengthened by the increasing use of non-pharmacological integrative and complementary practices for the management of acute and chronic clinical conditions influenced by stress and other health problems, reporting the benefits of these practices.³

There is strong scientific evidence that mindfulness-based interventions can improve a range of biological and psychological outcomes in illness, including acute and chronic pain, hypertension, type 2 diabetes, Acquired Immunodeficiency Syndrome / Human Immunodeficiency Virus (HIV / AIDS), depression and drug abuse.¹⁰ Such conditions are unquestionably present in the daily work of nursing and require interventions for the effectiveness of comprehensive care.

MBSR, one of the most researched programs in the scientific literature, is composed of formal and informal meditation practices. The formal encourages attention focused on breathing, body scan, open monitoring of the experience at the present moment without judgment and during walking and eating activities. The informal one is performed during daily activities, which consists in living these activities moment by moment with fullness and engagement.^2,11

This program enhances the ability to observe the content of immediate events, specifically the transient nature of thoughts, emotions, memories, mental images and physical sensations. It decreases the habitual tendency to react emotionally and to rummage transient thoughts or physical sensations, reducing the symptoms of depression and anxiety, strengthening the immune functions, emotional self-control, the volitional orientation of attention and, above all, the balance needed to deal with the stressors.¹²

Among the most worrying impacts of stress are, in addition to the direct damage to health and quality of life, impairment of skills and competence to work, and the adoption of non-adaptive behaviors such as psychoactive drug use. Therefore, it is considered relevant to search for a stress reduction intervention that aims to avoid continuous stress illness, especially among groups that have a high incidence of work stress and health problems strongly influenced by the stress experience, such as nurses, people exposed to violence and drug users.

Within the scope of drug use and substance abuse care, the Mindfulness-Based Relapse Prevention Program (MBRP) seeks to identify high-risk relapse-triggering situations in individuals with addictive behavior. Evidence regarding the integration of mindfulness practices with the traditional prevention of cognitive behavioral relapse suggests the possibility of developing a relationship of awareness and non-identification with thoughts and feelings, avoiding the emergence of thought patterns and behaviors that may lead to relapse.¹³

Through awareness, regulation, and tolerance of potential relapse triggers, mindfulness cultivation helps maintain the ability to deal with relapse precipitating factors, breaking the cycle of automatic psychoactive substance use behavior. It contributes to awareness and acceptance in cases of lapses in this process, helping the person to recognize and minimize the feeling of guilt, which also reduces the risk of relapse.¹³ The program was effective in reducing alcohol and other drug use by 31% over a period of up to one year after the intervention.⁴

For the prevention of relapse from depression, the Mindfulness-Based Cognitive Therapy (MBCT) program proved effective, contributing to the resolution of residual symptoms in people with recurrent depression, as its differential over other therapies is the incorporation of skills of mindfulness in everyday life.¹⁴ Thus, mindfulness cultivation was as effective as antidepressant in relapse prevention.

Among healthcare users undergoing mindfulness and yoga-based relaxation programs,¹⁰ There was a 43% decrease in the utilization of services when compared to the previous year, showing that this type of intervention can represent a health saving. Thus, the focus of health care will tend to shift from over-utilization of the specialist clinic in treating advanced-stage users to a more individual-centered approach and care coordinated by teams that promote well-being, self-care, disease prevention and management.

Based on evidence about intervention programs, practitioners showed significant improvement in clinical symptoms, anxiety, and quality of life, making up an available strategy that contributes to the mental health of individuals. Thus, it can act more efficiently as its actions are supported by a comprehensive care model that recognizes health and disease states as complex and multi-causal.

Mindfulness in Nursing Care

Nursing involvement with non-pharmacological therapeutic measures supported by strong scientific evidence expands the possibilities for nurses to act and the effectiveness of health promotion and prevention actions.¹¹ In this sense, the use of these measures helps to avoid illnesses caused by continuous stress, as nurses guide their clients to recognize the body's negative response to prolonged stress and provide a resource for them to stop the negative impact of this response.

The use of mindfulness-based stress reduction interventions has been investigated and discussed as an appropriate non-pharmacological clinical tool, whose inclusion in the practice of nurses triggers the need for knowledge production from studies that investigate their effectiveness from the perspective of research in nursing.

The possibilities of mindfulness can be expanded even for self-care, because the nursing professional himself is subjected to stress-related risks. Responsibilities attributed to nursing are known to be situations of diverse tension. Additionally, outcomes such as anxiety, depression and muscle pain are associated with stress experienced by nursing team professionals, in which the chance of developing these problems is twice as high in professionals with high stress levels.^15-16

Although mindfulness can be taught and refined through training, mindfulness is challenging in terms of maintenance and strengthening, especially in the face of arduous and stressful stimuli. Constant practice results in compassion for oneself and others, for when the practitioner becomes more accustomed to accepting the moment as it is without judgment, a more realistic picture of the facts is constructed, contributing to better decision making or in interpersonal communication.

Mindfulness, awareness of the present moment, and compassion are intertwined and are important elements in interacting with each other's suffering. Empathy is important in this process by establishing a bridge that can be crossed to the territory of another individual's feelings, but it can be said that compassion is even more necessary because it is understood that the human tendency is to be empathetic only to their acquaintances or the like. In the care system, compassion goes further, as it is not limited to acquaintances and is less stressful than empathy.¹⁷

Compassion training through meditation has made the practitioner more likely to help each other with just two days of training. Constant practice, on the other hand, can induce a lasting change from compassion motivation, regardless of person or situation. Thus, it is clear that compassion training has an important influence on altruistic help, and it is important to implement it in nursing care.¹⁸

In this context, nursing can benefit from compassion, especially for its close relationship with users, whose actions include the recognition of stressful situations, the detection of coping strategies and the ability to intervene properly in reducing agents and of the effects of stress on individuals and also on the collectivity.¹⁹

Lack of compassion in nursing care was news in England when a patient association reported their negligence in long-term care facilities for the elderly. The government immediately demanded that universities implement higher standards of training in nursing courses. Some universities claimed a reduction in funding for nurse training, but discussions discussed the quality of training and the professional selection for health services. It was stated that qualification was poorly focused on users' needs, distancing nurses from the development of basic and essential interpersonal components.^20-21

To minimize such problems, the practice of mindfulness has been incorporated into the professional training of doctors and nurses. In the United States, about 79% of medical courses offer some form of mindfulness training, as well as mindfulness research and training centers have proliferated worldwide.²² Training in nursing students has shown that there has been improvement in some aspects of ethical decision making. However, despite all the evidence of the benefits of the technique, there are still few nursing courses that use this type of training in their curricula.²³

In Brazil, in order to take care and promote health beyond traditional practices, the Open Minded Center of the Federal University of São Paulo, in the city of Santo Amaro, was founded in 2011, working in Mindfulness-based professional practice. In 2016, at the University of São Paulo, the Center for Mindfulness and Integrative Therapies was opened at the Ribeirão Preto College of Nursing (EERP-USP), coordinated by nursing teachers and researchers in the mental health area. It is worth mentioning the existence of other centers of dissemination of recent and even older non-academic mindfulness practices.

The Center for Mindfulness and Integrative Therapies of EERP-USP, constituted in the academic and research context in mental health nursing, integrates research, teaching and extension activities, seeking alignment with the National Policy of Integrative and Complementary Practices in Health (NPICP). approved by the Brazilian Ministry of Health through Ordinance No. 633 of 03/28/2017 and Ordinance No. 702 of 03/21/2018, whose objectives involve measures such as the incorporation and implementation of integrative practices in the Unified Health System (UHS) at all levels of health care, increases the solvability of UHS by expanding access to integrative practices, promotes health actions using innovative alternatives that contribute to the sustainable development of communities.^24-26

The integrative practices contemplated by NPICP, which started in 2006 with five recognized practices, 14 in 2017 and 10 in 2018, total a set of 29 practices, including meditation. In Ribeirão Preto, São Paulo, the Municipal Program for Integrative and Complementary Practices in Health (MPICPh) was approved by Municipal Law No. 72/2013, which complies with the terms of the Federal Policy for Integrative and Complementary Practices, including meditation based on in mindfulness.^24-26

Care nurses who incorporate mindfulness practice experience better overall well-being, less stress, lower anxiety levels and symptoms of depression through interventions that lasted from four weeks to eight weeks. It is emphasized that the positive impacts of the technique can be observed for both the professional and the organization.²⁸

By teaching the practitioner to experience present experiences with openness and without automatic judgments or classifications, an internal process of experiences and insight into the ways of thinking and attitudes in certain situations is created; Insights are important in the problems that arise in the world of leadership and they cannot be taught, but are present in everyday experiences.²⁷ Flexibility to everyday experiences is important for experienced nurses and leaders to avoid taking actions and decisions without the necessary attention in the situation.

Metacognitive improvement results in less distraction in the clinical setting, allowing the identification of sudden changes in clients' health status and improved performance, which can reduce errors during nursing procedures, thus contributing to patient safety. In the clinic, hospital procedures are improved when leaders create a more positive environment for nursing practice with significant reduction of adverse events such as nosocomial infection, pneumonia, postoperative complications, length of stay, among others.²⁸

In addition, communication with users and followers becomes more effective, avoiding crisis situations. Therefore, mindfulness has been used in the medical clinic to reduce medical errors, improve interpersonal relationships, prevent burnout and stress-related illnesses. In nursing, it can help in building skills that will enable user engagement in a meaningful, focused and unhurried manner.

By adopting a mindfulness-based therapeutic framework, nursing is ideally placed to use, recommend and guide these interventions for its clients, as these programs have already been implemented and tested in the most diverse populations. By participating in mindfulness-based programs, you can gain basic knowledge and exercises that can be disseminated to your clients.¹¹ For example, develop breathing techniques, acceptance and unjudgmental opening of thoughts about the experience of pain and fears in users experiencing the disease process.

This study suggests that the implementation of specific practices aimed at alleviating the suffering of individuals could be elected in the composition of fundamental nursing care. The intervention suggested here includes providing the client with education in recognizing the body's stress response and then providing mindfulness-based stress reduction resources by halting the negative impact of the prolonged stress response. These techniques provide tools for individuals to cope with the emotional experience and physiological impact of their illness, trauma, or hospitalization.

It is important to emphasize that there is no differentiation of the mindfulness practice itself, this differential will depend on the nature of the profession of the practitioner. In the case of nurses, as health professionals spend most of their time interacting and caring for individuals in a sick situation and seeking better health and well-being parameters, the feelings of compassion, empathy and stress control provided by Mindfulness practices are beneficial for both practitioner and user.

Nurses have a unique opportunity to work with individuals and help them utilize integrative practices in conjunction with traditional western medical practices. They should be able to think fully about the care provided and develop interventions that address the complexity of the human experience in the health-disease process. Nurses are also educators and have the opportunity to promote better health outcomes, expanding the quality of life through integrative techniques.

The potential of nursing mindfulness practice involves treating and preventing stress-related problems and promoting coping strategies considered more assertive. It is recommended to invest in the advancement of research that evaluates this type of intervention in the nursing team. Another recommendation that crosses the studies of the area is the need that the results of these interventions must be constantly monitored, allowing the improvement of techniques and forms of evaluation, in search of the best scientific evidence.²⁹

One of the limits pointed to the study is the ideal research design, because unlike pharmacological interventions, mindfulness-based interventions require longer protocols that require hours of training and engagement in practice. Therefore, it is suggested that the best design would be long-term, ie longitudinal, comparative cohort studies comparing three groups, for example treatment as usual, active control and intervention.²⁰

Also interventions promoted on an extension basis, that is, not necessarily delimited as a scientific investigation or for research purposes, can be monitored in the long term, contributing to program design focused on both users and family members of health services, as well as those of own nursing professionals.²⁹

The dissemination of these programs, as well as the exploration of their characteristics, their limits and potentialities, can be useful in the composition of practices increasingly aligned with the needs of each service and each group, within the general proposal that guides these interventions. Considering the reference culture of users and potential practitioners and the organizational conditions of health systems for the implementation of these proposals seems to be an aspect that can be better discussed in future studies, which may also foster greater representativeness of Brazilian publications.²⁹

The complexity of nursing education and the work environment generate many demands, requiring quick and ethical decisions, creativity, interpersonal skills and compassion. This study presents an alternative to deal with the stress and anxiety characteristic of this population and several users who need health care.

This reflection promotes the discussion of a new theme for nursing as a powerful device for the qualification of care and training in the Brazilian context, based on the knowledge produced about mindfulness in health and education. Nurses are challenged to pursue new approaches that improve their ability to bring about change and increase their resilience and care delivery as subjects and professionals in potentially stressful environments.

Final considerations

The reflections point to several potentialities in the practice of mindfulness both in self-care of nurses and in the care to users and family members. The benefits arising from the practice of mindfulness can be observed at physiological, psychological and social levels, supporting the expansion of scientific interest about these interventions. The products resulting from mindfulness-based practice can bring benefits to everyday stress management, building leadership and conflict resolution skills, compassionate care, empathic relationships, and more.

The limits for the use of mindfulness-based interventions range from the complexity of research design that addresses the complexity of interventions to the individual characteristics of each professional to the barriers of the health system itself. Considering the benefits already reported, it can be stated that more research in the area will still bring advances in the future, highlighting the role of nursing as an important protagonist in this construction.

Although the study has achieved its goal, there is a limitation regarding research on the benefits of mindfulness in the Brazilian context, but these are still scarce, which was an obstacle. But on the other hand, showing experimental and field research data highlights the immediate need to develop studies that address the benefits and the relationship between nursing and mindfulness. Second, there is a limitation of studies that address mindfulness in the field of nursing, which makes it difficult to assess the levels of evidence needed to offer a more structured nursing action proposition.

Summarizing the scientific evidence in this reflection may contribute to the development of new interventions and research based on the knowledge already produced and reflexively systematized here. Thus, making nursing aware of the potential benefits that this practice can bring to both professionals and users.

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Promotion

National Council for Scientific and Technological Development (CNPq) Universal MCTI / CNPq 01/2016 Process number 424062 / 2016-0

Corresponding author

Edilaine Cristina da Silva Gherardi-Donato

Email: gherardidonato@gmail.com

Address: Escola de Enfermagem de Ribeirão Preto USP

Av. Bandeirantes, 3900. Monte Alegre. Ribeirão Preto-SP, Brasil.

CEP: 14.040-902

Author Contributions

1 - Edilaine Cristina da Silva Gherardi-Donato

Article design and planning, data collection, writing, and critical review.

2 - Maria Neyrian de Fátima Fernandes

Article design and planning, data collection, writing, and critical review.

3 - Fabio Scorsolini-Comin

Writing and Critical Review.

4 - Ana Carolina Guidorizzi Zanetti

Data Collection, Writing and Critical Review.

How to cite this article

Gherardi-Donato ECS, Fernandes MNF, Scorsolini-Comin F, Zanetti ACG. Mindfulness: reflection on limits and potentialities for nursing care. J. Nurs. UFSM. 2019 [Acess in: Years Month Day];vol9, e52: P1-19. DOI:https://doi.org/10.5902/2179769233058