key: cord-0999590-2cu0jdzq
authors: Kostovich, Carol T.; Bormann, Jill E.; Gonzalez, Beverly; Hansbrough, Wendy; Kelly, Brendan; Collins, Eileen G.
title: Being present: Examining the efficacy of an Internet Mantram Program on RN-delivered patient-centered care
date: 2021-02-08
journal: Nurs Outlook
DOI: 10.1016/j.outlook.2021.01.001
sha: 572838daf9330679185f95732e99c0282477bb73
doc_id: 999590
cord_uid: 2cu0jdzq

BACKGROUND: The COVID-19 pandemic highlighted nurses’ compassionate presence during stressful conditions. Strategies to reduce workplace stress are needed. PURPOSE: The purpose of this study was to evaluate a stress reduction strategy, an Internet-based Mantram Repetition Program (MRP), for nurses caring for hospitalized Veterans. METHODS: A one group pre-/post-test design was used to assess change in nurses’ perceived outcomes after participating in the MRP. A post-test-only design was used to assess hospitalized Veterans’ perceptions of nursing presence and satisfaction with care. Qualitative interviews were used to supplement quantitative data. FINDINGS: Patients perceived high levels of presence and satisfaction with care. Post MRP, nurses perceived increased mindfulness, compassion satisfaction, spiritual well-being, and nursing presence. Increased mindfulness was associated with greater compassion satisfaction and less burnout. DISCUSSION: For nurses working on the front lines of patient care, the potential for experiencing stress and burnout is a reality. Participating in a MRP could lessen these effects and facilitate nursing presence.

The COVID-19 pandemic challenged health care systems worldwide. Material resources, including personal protective equipment, ventilators and ICU beds were in short supply; access to COVID-19 testing was limited. Nurses and physicians were working extra shifts, often times out of their comfort zone as units were transformed to care for patients with COVID-19; and more ICU beds were added to accommodate the high influx of critically ill patients (Beresford, 2020) . In addition to the daily workload demands, The U.S. Department of Veterans Affairs (US Department of Veterans Affairs, 2020) (VA) noted several sources of work-related stress in health care workers as a result of the COVID-19 pandemic, including the physical strain of prolonged wearing of personal protective equipment, physical isolation, and vigilance in maintaining strict infection control measures. Personal stressors follow, including fear of contracting the virus and infecting family members, possible separation from family, others' fear of interacting with those treating COVID-19 patients, and inner conflict about competing needs and demands (US Department of Veterans Affairs, 2020). News stories began to emerge highlighting the mental health consequences of being a frontline health care provider. Emotional stress (Thompson, 2020) , anxiety, depression, post-traumatic stress disorder and burnout (Occupational Health & Safety, May 19, 2020) were being identified in frontline workers. Registered nurses (RNs) shared stories of being present with their patients as they said their final goodbyes to family members via videoconferencing because family were not allowed to visit (Hewings-Martin, 2020) . Nurses were there to comfort and pray with their patients who were afraid but had no family at their bedside (Esposito, 2020) .

While the focus on the physical and emotional impact of providing direct patient care has been brought to the forefront by the COVID-19 pandemic, this has long been a reality for RNs. Exposure to human suffering, physical exertion, and long work hours have contributed to RN stress in the workplace (Jennings, 2008) . Burnout, characterized as emotional exhaustion, depersonalization, and decreased personal accomplishment (Maslach & Jackson, 1982) , is described as an employee's reaction to chronic stress (Freudenberger, 1974) . Burnout has been linked to RN perceptions of decreased patient safety (Halbesleben et al., 2008; Liu et al., 2018) , decreased nurse workplace engagement ("PRC National Nursing Engagement Report," 2019), disruptive behaviors (Rehder et al., 2020) , short staffing and worklife imbalance (Boamah et al., 2017) , and health care acquired infections (Cimiotti et al., 2012) . Strategies to reduce RN burnout are essential to enable nurse-delivered patient-centered care (PCC) . RNs who are present for their patients are better able to establish therapeutic nurse-patient relationships so that care can be personalized and patient-centered (Frampton & Charmel, 2009 ).

Models of care have been developed to encourage nurses to be present with their patients as a means of providing PCC (Frampton & Charmel, 2009 ). In 1976, Paterson and Zderad published their Humanistic Nursing Theory (Paterson & Zderad, 1976) which promoted the nurse's physical "doing for" and emotional "being with" patients. They noted that, "This essential interhuman dimension of nursing is beyond and yet within the technical, procedural, or interactional elements of the event. It is a quality of being that is expressed in the doing" (Paterson & Zderad, 1976, p. 13 ). Subsequently, periodic writings on nursing presence began to appear in the literature. Benner (1984) identified that expert nurses use "presencing" in their care. As part of the University of Iowa Classification of Nursing Intervention study, Gardner (1985) proposed presence as a nursing intervention. McKivergin and Daubenmire (1994) developed a course to teach nurses how to be present to their patients which included meditation, centering, and intentionality as strategies. The literature provides numerous examples of the value of nurses being present for their patients (Dunniece & Slevin, 2000; Finfgeld-Connett, 2006; Melnechenko, 2003; Osterman et al., 2010; Snyder et al., 2000; Wilson, 2008) . Two scales were developed to measure nursing presence: The Presence of Nursing Scale (PONS) (Kostovich, 2012) was developed to measure patients' perceptions of nursing presence; and the Presence of Nursing Scale-RN Version (PONS-RN) (Kostovich et al., 2016) was developed to measure nurses' perceived ability to be present to their patients. Consistently being present for patients is often a challenge for RNs who provide bedside care. Adverse working conditions have been associated with changes in nurse job satisfaction and emotional exhaustion (Gelsema et al., 2006) . Higher patient acuity, increased reliance on technological advances, and physical and emotional demands contribute to stress and burnout among the RN workforce making it difficult for nurses to be present with their patients. Nurses often prioritize caring for others but participate in minimal self-care, including practicing stress reduction activities (Melnyk et al., 2018; Melnyk, 2020) . Despite the deleterious effects of nurse stress and burnout on quality of patient care, few stress reduction strategies are available in the workplace, and only a limited number have been empirically tested for their efficacy in reducing burnout in nurses. Further, no known strategies have been tested to facilitate nursing presence. The purpose of this study was to examine the efficacy of an Internetbased Mantram Repetition Program (I-MRP) for RNs caring for hospitalized Veterans and explore its influence on RNs' and Veterans' perceptions of nursing presence. The research questions to be answered were: R1: What is the efficacy of an Internet-based mantram repetition program for nurses caring for hospitalized Veterans? R2: What is the impact of the Internet-based Mantram Repetition Program on nurses and the care they provide?

The Mantram Repetition Program (MRP) is a mindbody-spiritual approach to stress management. The stress reduction strategies of MRP include mantram (sacred word) repetition, slowing down, and onepointed attention. Participants self-select a word or phrase with a spiritual meaning that is repeated silently throughout the day to train attention and redirect unwanted thoughts. By doing so, the thinking process slows and allows one to "pause," be mindful and attentive in the present moment. One-pointed attention or doing one thing at a time, supports being present in the moment and participants are taught the value of monotasking rather than multitasking. Further, for busy RNs, the MRP tools of mantram repetition, slowing down and one-pointed attention can be practiced almost continually throughout the day and between activities. The MRP is portable and can be practiced anywhere; no special equipment, device applications, or specific practice locations are required.

There is a growing body of research that demonstrates the benefits of the MRP in a variety of patient and non-patient groups. Uncontrolled studies have shown reductions in perceived stress, anxiety, anger, and improvements in quality of life and existential spiritual well-being in Veterans with chronic illness (Bormann et al., 2005) and health care workers (Bormann et al., 2006a; Borman, et al., 2006c) . MRP was also found to decrease family caregiver burden in those taking care of Veterans with dementia (Bormann et al., 2009) .

Randomized clinical trials (RCTs) have demonstrated that the MRP reduces anger and improves existential spiritual well-being in adults living with HIV/AIDS (Bormann et al., 2006b) and reduces PTSD symptom severity in Veterans Bormann et al., 2008) . Findings from these RCTs have been further validated using qualitative methods Bormann, et al., 2006c) that describe how the MRP strategies can be used in a variety of situations to regulate emotions and manage stress. Another RCT conducted with Korean nurse managers found that those in the MRP group reported greater reductions in burnout compared to the notreatment control group (Yong et al., 2011) . There are physiological mechanisms that may explain the calming effect of mantram repetition such as the relaxation response (Benson et al., 1975) , slower cardiovascular rhythms (Bernardi et al., 2001) , and brain deactivation (Berkovich-Ohana et al., 2015) .

Traditionally taught in a face-to-face format, the MRP was adapted to an Internet-based MRP format whereby VA employees could learn the MRP online at a time convenient for them. The I-MRP consists of asynchronous individual learning, time to practice techniques between sessions, and then reinforced learning with two online synchronous feedback sessions provided by an expert in MRP. The program was offered with the support of VA Employee Education System (EES) and the Office of Patient Centered Care. Research on this mode of delivery has demonstrated reductions in exhaustion, improvements in personal efficacy and mindfulness, and sustainability of practice in healthcare employees for up to three months post-treatment (Bormann et al., 2017) .

It is known that nurses' presence fosters relationships with patients so that care can be personalized and patient-focused (Frampton et al., 2003) ; nursing presence is positively associated with patient satisfaction (Hansbrough & Georges, 2019; Kostovich, 2012) ; and nursing presence can be taught using strategies that are very similar to MRP (McKivergin & Daubenmire, 1994) . The MRP has been found to improve mindfulness, existential spiritual well-being (Bormann et al., 2017) and reduce perceived stress and burnout (Yong et al., 2011) . What is not known, however, is the extent to which the I-MRP influences the nurse's ability to be present with patients.

This study employed a mixed methods design consisting of quantitative surveys and qualitative interviews. A one group, pretest/post-test design was used for assessing change in RNs followed by a one group, post-test only design with patients. To support the validity of the quantitative data, all RN and Veteran subjects were invited to participate in brief face-toface, audio-recorded, semistructured interviews. RNs were asked to share their perceptions of the I-MRP, including satisfaction with the program and its impact on the care they provide to patients. Veterans were asked to share their experiences of being a patient during their current hospitalization, and specifically, their experiences of care with their current nurse who practiced the strategies taught in the I-MRP.

The target population included RNs working on acute care units of a VA Medical Center in the Midwestern United States along with their patients. After approval was granted from the Institutional Review Board, a convenience sample of nurses was recruited from four medical-surgical units with the same model of care delivery and similar patient acuity. Nurses were

N u r s O u t l o o k 0 0 ( 2 0 2 1 ) 1 À1 1 included if they worked permanent full-time day or evening 8-, 10-, or 12-hour shifts; they were excluded if they were currently in orientation.

Patients were recruited after the nurses had completed their I-MRP training. Patients were included if they met the following criteria: (a) currently being cared for by a RN who received the I-MRP training, (b) anticipated discharge within 24 to 48 hours, (c) not in isolation, (d) alert and oriented to person, place, time, and (e) able to understand and answer the questions.

The I-MRP was provided to nurses in a series of six 1hour sessions (four individual, self-conducted modules and two synchronous group feedback sessions) completed over a three month period. As part of the program, participants received the book, "Strength in the Storm", by Eknath Easwaran (2013) . Participants accessed the modules through the VA learning management system while off duty. After each module, participants were asked content knowledge questions; between sessions, nurses were expected to practice MRP tools. During the feedback sessions, the facilitator addressed barriers and successes of the program, answered questions, and provided feedback and suggestions for application in the workplace.

After providing informed consent but immediately prior to beginning the I-MRP, RNs completed an emailed electronic survey that included the baseline assessments. Two months after completing the I-MRP, RNs completed the post-assessments. This 2-month time interval was selected because studies have demonstrated that participants continue to practice MRP tools up to three months after completing the course (Bormann, Thorp, et al., 2013) . A code number was assigned to maintain confidentiality. A screening question to determine if extended leave time was taken during the study period was asked prior to initiating the post-test surveys. Nurses who were on leave 3 weeks during the study time would be excluded and not required to complete the post assessments as their absence may have limited their opportunity to practice MRP. However, this did not impact any of the participants. After completion of the study, RNs were invited to participate in an audio-recorded semistructured interview conducted by a research assistant (RA) trained in qualitative interviewing.

Data collection from patients began after the RNs completed the I-MRP. The RA identified patients cared for by an I-MRP-trained RN by reviewing the daily assignment board. After the charge nurse verified the patients met inclusion criteria and gave approval to approach them, the RA invited the patients to participate by completing the survey and participating in a face-to-face audio-recorded interview. Several steps were taken to minimize bias: (a) Data were collected on random days so nurses would not be able to anticipate when data collection would occur; (b) Data were collected at the end of the shift so nursing care would not be influenced by patient participation in the study; (c) To minimize missing or inaccurate data, the RA confirmed that the patient was able to distinguish between the care provided by the RN and other personnel before beginning data collection.

The independent variable in this study was the I-MRP for nurses. The dependent variables included (a) nurserelated professional quality of life, nursing presence, mindfulness, spiritual well-being, MRP utilization, I-MRP program satisfaction and, (b) patient-related nursing presence and satisfaction with nursing care. Demographic variables were recorded for both nurses and patients.

Professional quality of life was measured using the Professional Quality of Life Scale (ProQOL) (Stamm, 2010) . Professional quality of life is the value one feels related to their work as a helper. Both positive and negative aspects of job work influence the quality of one's professional life. The ProQOL (Stamm, 2010 ) is a 30-item instrument developed to measure these aspects. Comprised of three subscales, the ProQOL measures compassion satisfaction, compassion fatigue, burnout and secondary traumatic stress. On a 5-point Likert-type scale, respondents are required to rate the frequency of their experiences related to helping people, from 1 (never) to 5 (very often). Cronbach's alpha for the subscales ranged from 0.75 to 0.88 with evidence to support construct validity (Stamm, 2010) .

Nursing presence, the nurses' perceived physical and emotional availability to their patients, was measured by the Presence of Nursing Scale-RN Version (PONS-RN) (Kostovich et al., 2016) . This 30-item scale is comprised of two subscales: The "Doing For" subscale (18 items) and The "Being With" subscale (12 items). Using a 4-point Likert-type scale, nurses rate their level of agreement regarding their perceived availability to perform elements of nursing presence, from 1 (never had time) to 4 (always make time). A Rasch analysis supported the reliability and validity of the twodimensional structure (Kostovich et al., 2016) .

Mindfulness was measured using the Mindfulness Awareness Attention Scale (MAAS) (Brown & Ryan, 2003) . Mindfulness is the presence or absence of attention and awareness to events occurring at the present time. This 15-item self-report scale assesses the presence or absence of attention and awareness to events presently occurring. On a 6-point Likert-type scale, respondents rate the frequency of attention and

awareness they experience during daily activities, from 1 (almost always) to 6 (almost never). Cronbach's alpha has been reported to be 0.84, with evidence to support content, construct, divergent, and convergent validity (Brown & Ryan, 2003) .

Existential Spiritual Well-being (SWB) was assessed using the Functional Assessment of Chronic Illness Therapy Spiritual Wellbeing (FACIT-Sp) scale (Canada et al., 2008) , a 12-item measure that has been interpreted as a total score and as three subscales: (1) meaning, (2) peace, and (3) faith. Each item is scored on a 5-point scale ranging from 0 (not at all) to 4 (very much). Each of the three subscales contain four items such as "I feel a sense of purpose in my life," "I feel peaceful," and "My illness has strengthened my faith or spiritual beliefs". Cronbach's alpha has been reported to be 0.84 with evidence to support content, discriminant, convergent, and construct validity (Peterman et al., 2002) .

Nurse satisfaction with the I-MRP was assessed using the Client Satisfaction Survey (CSQ-8) The CSQ-8 is a unidimensional 8-item measure of client satisfaction with services using a 4-point Likert-type scale. The items for the CSQ-8 were selected on the basis of ratings by mental health professionals of a number of items that could be related to client satisfaction and by subsequent factor analysis. Cronbach's alpha has been reported to range between 0.92 and 0.93 with evidence to support face, content, criterion-related, and construct validity (Larsen et al., 1979) .

The use of MRP tools by the RNs was evaluated using the researcher-developed Mantram Practice Questions document at I-MRP training completion and 2 months after completion. Fifteen questions in yes/no, Likerttype scale, and short answer format were asked of RNs upon completion of the program to determine when, where and how often they used mantram, slowing down, and one-pointed attention tools.

Nursing presence as perceived by patients was measured using the Presence of Nursing Scale (PONS) (Kostovich, 2012). This is a 24-item self-report instrument measuring patients' perceptions of the physical and emotional availability of the RN. On a 5-point Likerttype scale, patients rate the frequency that elements of presence were performed by the RN, from 1 (never) to 5 (always). Scores for all items are summed and higher scores indicate higher levels of perceived nursing presence. Cronbach's alpha has been reported at 0.96 with evidence to support content and construct validity (Hansbrough & Georges, 2019; Kostovich, 2012) .

Perceptions of nursing care were measured by the Schmidt Perception of Nursing Care Survey (SPNCS) (Schmidt, 2004) . This 15-item questionnaire asks patients to rate their satisfaction with nursing care provided by RNs, licensed practical nurses, and nursing assistants combined using a 5-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The survey is comprised of four subscales: (1) seeing the individual patient, five items; (2) explaining actions, three items; (3) responding to needs, three items; and (4) watching over patients, four items. Cronbach's alpha levels for the subscales have ranged from 0.84 to 0.92 with evidence to support construct validity (Schmidt, 2004) .

Sample To achieve a medium-large treatment effect size at the 0.05 significance level with at least 80% power, a sample of 20 RNs was needed to complete the pre-/posttest survey data. Within one month, the targeted enrollment of 23 RNs was recruited, which reflected 64% of the eligible participants. To account for missing data and attrition, 35 nurses were initially enrolled; 15 completed the study reflecting a retention rate of 41%. The majority of RNs withdrew from the study because of time constraints; one transferred to a unit not involved in the study. The online module format was noted to be both a facilitator and barrier to course completion as it allowed for self-paced learning but also was located behind the VA firewall which provided access challenges when not using a VA computer. A total of 22 patients completed the written surveys (Table 1) .

To be included in the study, RNs needed to complete both pre-and post-surveys and at least half of the online learning modules. Most RNs completed all four online modules (n = 13; 86%). The live synchronous sessions were most challenging for nurses to attend, with 66% (n = 10) attending both and the remaining 33% (n = 5) did not attend any live sessions. A total of 66% (n = 10) completed all online and synchronous sessions.

Two months post intervention, over half of the RNs continued to use the MRP tools. Nine RNs (60%) stated they continued to use their mantram with eight (53%) using it within the past week. Slowing down was used by 11 (n = 73%) of the RNs between daily to once/ month. Most (n = 9; 60%) practiced slowing down while at work. One pointed attention was practiced by nine RNs (60%) between daily to once/week, with 11 RNs (73%) using it while at work.

A Wilcoxon signed rank test was used to test for significant differences (alpha = 0.05 level) between variables pre-and postintervention. There was a significant increase in peace as a dimension of spiritual wellbeing, compassion satisfaction as a dimension of professional quality of life and mindfulness. While not

N u r s O u t l o o k 0 0 ( 2 0 2 1 ) 1 À1 1 significant, both being with and doing for dimensions of nursing presence and the meaning and faith dimensions of spiritual well-being increased. There was no change in burnout or secondary traumatic stress related to professional quality of life (Table 2) .

Spearman correlation coefficient, significant at alpha <0.05, was used to compare scales post RN intervention. There were four statistically significant relationships noted among the scales. The Compassion Satisfaction subscale of the ProQOL was moderately correlated with the Being With subscale of the PONS-RN (0.54) and the MAAS (0.50). The MAAS was also moderately correlated with the Meaning subscale of the FACIT (0.54). The Burnout subscale of the ProQOL showed a moderate-high negative correlation with the Peace subscale of the FACIT (À0.7) ( Table 3) .

Patients' perceptions of nursing presence as demonstrated by their MRP-trained RN were very high. The potential total score on the PONS ranges from 24 to 120. In this sample, the mean score was 109.92 (SD = 12.04) with a median of 112.16 (range 107À115.33). Patients also demonstrated high levels of satisfaction with overall nursing care. Scores on the SPNC potentially range from 15 to 75. In this sample, the mean score on the total scale was 67.33 (SD = 4.49) with a median of 68.5 (range 67À69.67). A Spearman's Rho correlation was used to determine the relationship between nursing presence and overall satisfaction with nursing care. All four subscales of the SPNC Survey were positively correlated with the PONS at a significance level of at least 0.05 (Table 4 ).

Semi-structured Interviews were conducted with eight of the nurses who participated in the I-MRP. Eleven Veterans who received care from RNs in the program were also interviewed. All interviews were recorded and transcribed verbatim by the RA. Two of the researchers met to conduct an interpretative analysis of the data using an iterative dialogical process (Crist & Tanner, 2003) . Prefer not to answer 3 (13.6%)

Transcripts were read independently, central ideas were discussed, followed by a re-reading with coding of meanings. These were compared and grouped into themes to address the research questions. A second grouping organized the identified themes under the larger concepts of PCC and nursing presence. 

N u r s O u t l o o k 0 0 ( 2 0 2 1 ) 1 À1 1

The RNs described the impact of the I-MRP on their ability to be present with patients. A theme of being able to focus attention on one patient was evident. One RN stated, "I'm able to approach the patient with more mindfulness with being set and organized and concentrating on that patient at that time." Another theme related to connecting with the patient on a deeper level. One RN recalled, "It is such a reward for me and for them. I go home and tell my husband, 'you know what? I had these few moments with this patient'. Another RN related an exchange with an older patient who was adjusting to living alone and said, "I could see tears in his eyes and I had tears in my eyes so we connected." This theme was echoed by a Veteran who felt more closely bonded to a nurse who shared a personal story with him.

The Veteran data also revealed nursing presence in a theme of being watched over and cared for. Veterans talked about nurses responding quickly when called, checking back, easing anxiety, and doing more than what was needed. One Veteran commented, "You are secure. You are not here by yourself." Another noted, "It felt like he came in when he really didn't have to. He could have been doing something else. And, he makes you feel like you are part of the family."

Themes related to PCC were evident in the Veterans' data. These included the nurse being knowledgeable to explain care and answer questions. One Veteran described the nurse as "totally involved with what my needs were as well as the reason why [the nurse was] interacting at that particular time." Patient advocacy was another theme repeated by Veterans who needed action taken on their behalf. One patient described needing home care equipment which was not readily available, and the nurse who "stayed on the case to make sure" it was obtained so the Veteran could go home. These qualitative findings support the validity of the quantitative results.

A mind-body-spiritual approach to stress management, the I-MRP, was implemented with 15 RNs at a VA hospital. The rapid recruitment of the targeted enrollment suggests that RNs were eager to learn a stress reduction strategy. The retention rate over a 3month period was 41%. Compared to other I-MRP studies conducted with health care workers within VA, (Bormann et al., 2017; Leary et al., 2018) this is substantially lower. However, this study included only RNs, with the most common reasons for attrition being time commitment to participate and juggling participation with working 12-hour shifts. This was confirmed with only 66% (n = 10) completing both synchronous live learning sessions. The possibility that the RN role, when compared with other healthcare workers, has unique stressors that challenge time for self-care activities warrants further investigation. While the online modules facilitated completion of the I-MRP because they were self-paced, the ability to access modules while not at the VA was a barrier to completion. To enable the ability to complete the I-MRP, the development of a shorter, all asynchronous and more easily accessible I-MRP could be considered. Two months after I-MRP training, 60% (n = 9) of participants were still using the MRP tools, with between 60% and 73% (n = 9À11) using the tools at work. In addition to its sustainability, this supports the portability of the MRP as a stress reduction strategy with RNs while at work.

After completing the I-MRP, RNs demonstrated a significant increase in mindfulness and the peace subscale of the FACIT-Sp. These findings are consistent with a previous study of 39 health care workers, the majority of whom were RNs (39%) (Bormann et al., 2017) and with a sample of 273 Veterans (Buttner et al., 2015) .

Due to the COVID-19 pandemic, the risk for burnout of frontline nurses has increased (Ross, 2020 ; US Department of Veterans Affairs, 2020). In a study of ICU nurses in VAs, greater than 30% experienced symptoms of burnout (Swamy et al., 2020) . Burnout has been related to absenteeism and poor work performance (Dyrbye et al., 2019) . However, VA health care workers (Bormann & Abraham, 2019; Leary et al., 2018) participating in MRPs have experienced decreased burnout.

Overall professional quality of life includes compassion satisfaction and compassion fatigue, which is comprised of burnout and secondary traumatic stress. Finding ways to increase compassion satisfaction while decreasing compassion fatigue, and subsequently burnout and secondary traumatic stress, are essential. This study found a significant increase in compassion satisfaction in RNs post-I-MRP. Compassion satisfaction was moderately and significantly correlated (0.54; p < .05) to the Being With subscale of the PONS-RN and mindfulness (0.50; 0.05).

Mindfulness and meditation techniques allow one to become more self-aware and present in the moment (Kelly, 2020) . In this study, pre-post PONS-RN Being With subscale scores were trending toward significance (p = .10) even with a sample size that was underpowered. The MRP specifically teaches participants to slow down and be present in the moment, which directly relates to the nurses' ability to be present to their patients. Therefore, it is recommended that additional studies with a larger sample size be conducted to further explore this relationship.

In this study, patients perceived high levels of nursing presence and overall satisfaction with nursing care. Each of the four SPNC subscales demonstrated significant (p > .05) positive relationships to patients' perceptions of nursing presence. Because hospital reimbursement rates are, in part, related to patient satisfaction (Mazurenko et al., 2017) , creating a positive patient experience has implications for the financial status of the institution. Thus, identifying strategies to facilitate nursing presence becomes even more vital.

This study had many strengths, including the use of instruments with evidence of reliability and validity, initiation of several procedures to minimize bias during data collection, feedback sessions conducted by an international expert on MRP, and interviews conducted to validate quantitative data. However, this study is limited by subjects self-selecting to participate as they may have been more open to the effects of the MRP. No comparison group was included in the study, which limits the ability to determine the outcome if no MRP was used. The sample size was small and included only Veteran patients and RNs working on acute care units of a single VA hospital. Further, a more diverse sample of both RNs and Veterans could improve the generalizability of findings. Future research related to MRP and nursing presence should be considered with a focus on recruiting a larger sample size from multiple sites. This study focused on perceived patient satisfaction with nursing care as a nurse-sensitive patient outcome of nursing presence. Future studies should consider exploring the relationship between nursing presence and other patient outcome variables, such as patient falls, perceived pain, pressure injury prevalence, hospital acquired infections, and medication errors.

This is the first study to examine the use of an I-MRP to facilitate the ability of nurses to be present with their patients. Nurses' perceived ability to be present with their patients is positively associated with professional quality of life, mindfulness and spiritual well-being. Patients cared for by nurses who practiced the mantram repetition tools perceived high levels of nursing presence and overall satisfaction with nursing care. Findings from this study suggest that RNs are willing to learn portable stress reduction techniques which have the potential to minimize burnout and increase their presence with patients.

This study was funded by the US Department of Veterans Affairs, Office of Nursing Service, Nursing Research Initiative Grant, NRI 13-353; Award number 1 IK3 HX001426-01A1. 

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Measuring spiritual wellbeing in people with cancer: The functional assessment of chronic illness therapy-spiritual wellbeing scale (FACIT-sp)

Utilizing the PRC Nursing Quality Assessment Inventory

Associations between a new disruptive behaviors scale and teamwork, patient safety, worklife balance, burnout, and depression

The exacerbation of burnout during COVID-19: A major concern for nurse safety

Patients' perceptions of nurse staffing, nursing care, adverse events, and overall satisfaction with the hospital experience

Use of presence in the critical care unit

Concise ProQOL manual

Characterizing trends in ICU nurse burnout in VA and relation to outcomes

Nurses already facing severe stress over coronavirus

Managing healthcare workers' stress associated with the COVID-19 virus outbreak

There's just something about Ron

Effects of a spirituality training program on the spiritual and psychosocial well-being of hospital middle manager nurses in Korea