Research article critiquing

Order Description Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research. Part 1: quantitative research. British Journal Of Nursing, 16(11), 658-663. Please note you only have to address six of the elements outlined in the Coughlan et al article. You may choose any six items and based on the research article you selected determine if the authors adequately addressed the particular elements. Or Select a qualitative research study and critique using the guidelines in the following article Ryan, F., Coughlan, M., & Cronin, P. (2007). Step-by-step guide to critiquing research. Part 2: qualitative research. British Journal Of Nursing, 16(12), 738-744. RESEARCH CRITIQUING Students will develop a formalized critique of either a qualitative or quantitative study. Students may utilize one of the research articles that they will be using for their final project. Please follow the guidelines in the Coughlan et al. (2007) or Ryan et al. (2007) article below: (be sure to use the quantitative guideline or qualitative depending on your study. Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research. Part 1: quantitative research. British Journal Of Nursing, 16(11), 658-663. ~or Ryan, F., Coughlan, M., & Cronin, P. (2007). Step-by-step guide to critiquing research. Part 2: qualitative research. British Journal Of Nursing, 16(12), 738-744. Volume 40, No. 3, July - September 2013 11 Abstract Nursing is a stressful profession and takes its toll at the physical, emotional and mental levels. Many studies exploring work stress among professionals concluded that many nurses experienced high level of work stress. The harmful consequences of stress on nurses have been widely researched. The prevalence of stress and the negative outcomes that can result suggest that stress reduction is an important component for good health and quality of life. Meditation is one of the common coping strategies used by nurses to cope with their considerable stress. Research on meditation interventions to alleviate nurses’ work stress is still at the initial phase. This review was to look at literature related to various meditationbased programmes used by nurses to provide a summary on the current findings. The themes derived from the eight studies are: no standardised methods of meditation, limited control for variables, no uniform target groups, different duration, different style of reporting stress outcomes, and various instruments used to measure outcome. Introduction Nursing is a demanding career consisted of tension, heavy workload and enormous responsibility (Lim, Bogossian, & Ahern, 2010). A previous study exploring work stress among professionals reported that most nurses experienced high level of work stress (Lim et al., 2010). Growing evidence suggests that it might be increasing in severity. Stress is defined as a pattern of emotional states and physiological reactions occurring in situations when individuals perceive threats from the environment that are beyond their ability to manage (Lazarus & Folkman, 1984). The key stressors identified by nurses are: interpersonal difficulties with other healthcare professionals, increased workload and staff shortage, pressure from management and increasing demands from patients and their families (Lim et al., 2010; Richards, Oman, Hedberg, Thorsen, & Bowden, 2006). Most nurses also need to fulfil other caregiving roles outside their work. Correspondence to Maria Huibing LIM Tel: (65) 92975890 Email: [email protected] Keywords literature review; meditation; nurses; stress Evaluation of meditation programmes used by nurses to reduce stress: A literature review Maria Huibing LIM Bachelor of Science (Honours) (Nursing) Student, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore CHOW Yeow Leng Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Assistant Professor, Alice Lee Centre for Nursing Studies, National University Health System, Singapore Edward POON Director, Department of Nursing, Ang Mo Kio-Thye Hua Kwan Hospital Adjunct Associate Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Singapore Nursing Journal 12 The detrimental effects of stress on nurses have been widely documented. Studies have shown that stress affects nurses’ immune systems and health by weakening the body’s defence mechanism (Lim et al., 2010; Oman et al., 2006). Prolonged stress experiences have also been linked with acute and chronic health conditions such as hypertension and cardiovascular diseases, which may gradually lead to morbidity or death (McNeely, 2005). Stress can also increase risktaking behaviours such as poor diet and smoking (McNeely, 2005). There are evidences that higher level of work-related stress can negatively affect the quality of work and family relationships (Lim et al., 2010; Oman et al., 2006). Stress decreases cognitive processes and problem solving, which increase the risk for making errors and impact patient care (Brady, O’Connor, Burgermeister & Hanson, 2012). Therefore, it is important for nurses to effectively manage work stress (Lim et al., 2010; Richards et al., 2006). The reported common coping strategies used by nurses are problem solving, seeking social support and relaxation techniques (Ashker, Penprase, & Salman, 2012). Today, relaxation techniques such as meditation have drawn increasing attention as a modality for managing stress (Oman et al., 2006; Seaward, 2006). A growing body of evidence have suggested that meditation could be an effective strategy for nurses to manage stress and improve their professional effectiveness (Oman et al., 2006; Raingruber & Robinson, 2007). Meditation is a conscious mental process that induces a set of physiological changes termed as the relaxation response. Meditation has been shown to induce the parasympathetic nervous system (PNS) (Sapolsky, 2004). Following the activation of the sympathetic nervous system (SNS) produced by stress experiences, the PNS releases chemicals antagonistic to those produced by the SNS and the body returns to homeostasis (Sapolsky, 2004). Thus, meditation could be a beneficial coping strategy for nurses to manage their considerable stress. To date, there are no local studies conducted to examine the effectiveness of a nursing meditation programme as a stress reduction intervention for nurses working in Singapore. Furthermore, all the studies were conducted in the western countries which share a different culture from the local context. Therefore, a meditation-based programme which is sensitivity to the local context could be implemented to address the knowledge gap and improve clinical resources in Singapore. This review aims to provide a summary and discussion on the current findings about the various meditation-based programmes used by nurses, and to identify gaps in knowledge to inform future studies. Methods An extensive literature search was conducted from the databases of CINAHL, PubMed, Scopus and PsycINFO. The search terms included: “nurses”, “meditation”, “stress”, “chanting” “praying”, “healthcare professionals”, “mantra repetition”, “stress reduction”, “relaxation response”, “coping strategies” and “mind body therapy” and different combinations were used during the search. This search strategy resulted in 43 articles of potential relevance to this review. Each article was read in full and assessed for relevance to the review with reference to the following inclusion criteria: English language publications, primary research papers from year 2003 to 2012, research that used meditationbased programme, stress as one of the measured outcomes, and with nurses included as subjects. This review includes studies of qualitative, quantitative and mixed-method designs. Findings and discussion This review finds eight studies that meet the inclusion criteria. Among the eight studies, seven are quantitative with one mixed method study, which examined the effect of the meditation-based programme on stress reduction. Table 1 outlines the summary of the eight studies included in this review. Evaluation of meditation programmes used by nurses to reduce stress Volume 40, No. 3, July - September 2013 13 Table 1: Reviewed studies Authors Subjects Methods Findings Oman, Hedberg & Thoresen (2006) Physicians, nurses, chaplains and other healthcare professionals were randomised into the treatment group (n=27) and wait-list control group (n=31). RCT. Intervention: - 2-hour classes over 8 weeks. - Eight-Point Programme (EPP) - Competency of instructors was not assessed. - Measured adherence and showed that stress was mediated by adherence to practice. - Trained instructor. - 3 dropouts: schedule conflict (2), change in family situation (1). - Statistically significant reduction relative to pre-test was observed at post and all follow-ups. - Stress reduction in treatment group decreased ??60% of pre-test SD. - Stress reduction was greater at 1st and 2nd follow up. - Stress scores were measured using Perceived Stress Scale (PSS). Cutshall et al. (2011) All were nurses (n=11). Pre- and post-test experimental design Intervention: - Meditation programme consisting of 15 computer sessions. - Practice for 30 mins/session, 4 times/week for 4 weeks. - Followed 15 steps of guided training in sequence. - Used programme at the same time of day and days of each week to promote consistency. - Meditation was 20 minutes long. - Remainder time: Relaxation exercise under computer category. - Biofeedback data from each session submitted each week to track usage patterns of participants. 27% dropout rate: All 3 participants indicated feeling overwhelmed and lack of sufficient time for practice. Improvements in stress score: - Linear Analogue Self Assessment (LASA) scale was used to measure stress, however no information on validity and reliability was reported (higher scores=more stress). - Adherence is important to achieve optimal outcome. Bormann et al. (2006) 50% of the subjects (n=62) were nurses, 50% were hospital staff. Pre- and post-test, experimental design. Intervention: - Group meetings (1.5 hours) over 5 weeks. - Group discussion on how to incorporate mantram repetition in daily life and mantram practice during classes. - Concepts of one-point attention and slowing down taught to enhance mantram practice. - Encouraged participants to practise mantra repetition at home. - Mantram practices were measured using counters, papers and self-report questionnaires. - Used PSS to measure stress. - Significant pre to post-test reductions in perceived stress. - Positive association between stress and meditation because mantra contained spiritual meaning. Evaluation of meditation programmes used by nurses to reduce stress Singapore Nursing Journal 14 Andres & Gloria (2010) Subjects were mainly healthcare professionals including doctors, nurses and psychologists (n=29). Pre- and post-test, and follow-up at 3 months post-intervention. Intervention: - 8-week programme, 2.5 hours classes. - Practised meditation techniques (yoga, exercise that focus on attention, meditation). - Group debate about the strengths and difficulties that these techniques and coping strategies involve when they are applied in everyday life. - Classes cost money but participants were paid after finishing each evaluation. - Trained instructor. - Measured how often participants did the practice at home. - Daily home practice for 45 minutes. - Daily stress was evaluated using Survey of Recent Life Experiences (SRLE) and PSS in Spanish version but had high reliability. - Reduced perceived stress but was not statistically significant. - No power analysis was done. - High adherence Cohen-Katz et al. (2005) Participants were nurses from community based hospital. They were randomly assigned to treatment (n=14) and wait-list control group (n=13). Mixed method study 8-week programme, 2.5 hours classes. Intervention: - Formal didactic instructions on stress management strategies plus experiential exercises on mindfulness techniques (yoga, meditation and breathing exercises). - Practised mindfulness techniques 6 days/week at home. - Number of people showing elevated psychological distress decreased following Mindfulness Based Stress Reduction (MBSR) in treatment and wait list control group. - Measured psychological distress using BSI to distinguish levels of stress?? but Brief Symptom Inventory (BSI) was not sensitive. Shapiro et al. (2005) Healthcare professionals (nurses, physicians, social workers, physical therapists and psychologists) were randomly assigned to treatment (n=18) and wait-list control groups (n=20). No mentioning how randomisation was done. Intervention: - 2 hours session/week over 8 weeks. - Participants received training in sitting meditation, yoga, breathing exercises, loving-kindness meditation, body scan exercises. - Meditation was conducted in group and allowed participants to share their direct experience with the practices. - 2 open-ended evaluative questions. - Significant reduction in stress using PSS. - Did not perform intention to treat analysis despite high dropout rate. - High dropout suggested that nurses felt burdened with the long class hours of the programme. Evaluation of meditation programmes used by nurses to reduce stress Volume 40, No. 3, July - September 2013 15 Pipe et al. (2009) Nursing leaders from various healthcare organisations were randomised into treatment (n=16) and control (n=17) groups. RCT. Intervention: - Attended 2 hours weekly classes for 4 weeks. - Learnt about core MBSR principles, engaged in didactic and experiential instructions. - Committed to approximately 30 minutes of related practice and education. Control: - Leadership course. - Used Symptom Checklist 90-revised (SCL-90-R) but did not mention calculation of stress score. - Self-report measures of stress at post-intervention vs. baseline decreases. Brady et al. (2012) Subjects were healthcare professionals from the mental health setting (n=16). Pre- and post-test, experimental design. Intervention: - Learning and practised meditation. - Didactic presentation. - Group discussion and homework assignment. - Learnt sitting and walking meditation. - 30 minutes of daily home practice. - Self-report minutes of practice and practice using diaries which was checked by the instructor weekly. - Trained instructor. - High attrition rate due to varying work schedule demands of the unit. - Used Mental Health Professionals Stress Scale (MHPSS) to measure stress. - Overall decrease in stress scores but did not reach statistical significance. Evaluation of meditation programmes used by nurses to reduce stress Singapore Nursing Journal 16 Different meditation-based programmes The meditation-based programmes identified in the eight studies were: mindfulness based stress reduction (MBSR), eight point programme (EPP), mantra repetition programme, and a computer-guided meditation programme. All programmes in the eight studies were structured as they followed a planned curriculum (Andres & Gloria, 2010; Bormann et al., 2006; Brady et al., 2012; Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2005; Cutshall et al., 2011; Oman et al., 2006; Pipe et al., 2009; Shapiro, Astin, Bishop, & Cordova, 2005). The programmes commenced with an education phase in which participants received training on various meditation techniques through experiential exercises. Structure is needed for meditation programmes to align content to the learning objectives in order to achieve desirable outcomes (Van der Hek & Plomp, 1997). For religious components, only the study by Oman et al. (2006) has religious components in their programme. It has been found that engaging a spiritual-based focus for meditation could enhance motivation to persist in meditation, thereby promoting stress reduction (Bormann et al., 2006; Oman et al., 2006). Out of the set of eight practices that participants were required to learn, the first and second points of the EPP recommended participants to select and memorise materials from the readings of major religions (Oman et al., 2006). Participants without a religious faith could select materials from spiritual traditions (Oman et al., 2006). Hence, the programmes in the eight studies could be practiced by people of different religion or those without a religious background. There are differences in meditation techniques among the eight programmes. All programmes in the eight studies involved more than one type of meditation techniques. Two studies involved mantra repetition and focused attention (Bormann et al., 2006; Oman et al., 2006). Four studies on the MSBR programme used yoga, meditation and body scan exercises (Andres & Gloria, 2010; Cohen-Katz et al., 2005; Pipe et al., 2009; Shapiro et al., 2005). On top of MSRB, Shapiro et al.’s (2005) study also added breathing exercise and lovingkindness meditation. Although Brady et al.’s (2012) study is also a MBSR programme, it only comprised sitting and walking meditation. Cutshall et al.’s (2011) study involved breathing exercises and meditation. There is no clear evidence indicating that one type of meditation is far better than another. Nonetheless, it was found that many people preferred a simple and secular meditation technique as compared to formal meditation programmes, such as MBSR (Lane, Seskevich, & Pieper, 2007). Cohen-Katz et al. (2005) is the only study that engaged in mixed methods design. The other seven quantitative studies used different study designs. Three studies were randomised controlled trial (RCT) (Oman et al., 2006; Pipe et al., 2009; Shapiro et al. 2005). However, Shapiro et al.’s (2005) study may not be a true RCT as the study did not mention how randomisation was done. Four studies used pretest-posttest design without a control group (Andres & Gloria, 2010; Bormann et al., 2006; Brady et al., 2012; Cutshall et al., 2011). Only two out of the seven quantitative studies included openevaluative questions as an effort to further assess the subjective experiences of their participants, which may not be so comprehensively captured by quantitative instruments (Brady et al., 2012; Shapiro et al., 2005). It was suggested that studies that examined the effectiveness of an intervention should involve both qualitative and quantitative methods to provide a richer data on the physical and psychological health outcomes (Irving, Dobkin, & Park, 2009). A prominent limitation in the eight studies is the absence of research on potentially negative effects of meditation practices, such as mental and physical distress (Irving et al., 2009; Shapiro & Walsh, 1984). Such omission may reinforce the notion that meditation practices are beneficial for everyone. However, some studies have found that meditation could cause negative side effects. Limited control for confounding variables Van der Hek and Plomp (1997) suggested the importance to control confounding variables so that the intervention which brought about the intended effect in one study would bring about similar effect in another study. Group support is one of the confounding variables. Meditative classes in the seven studies were conducted in group sessions, except for Cutshall et al.’s (2011) study in which the participants practised individualised meditation at home, guided by a computer-based programme. It has been shown that Evaluation of meditation programmes used by nurses to reduce stress Volume 40, No. 3, July - September 2013 17 group meditation increases practitioners’ commitment to the practice and brings about greater benefits as compared to individual meditation (Irving et al., 2009). Five out of the eight studies included group discussion during class, which allowed participants to share their experience of the practices (Andres & Gloria, 2010; Brady et al., 2012; Oman et al., 2006; Shapiro et al., 2005). This group component could have provided some forms of group support in facilitating stress reduction. The duration of practising meditation at home is another confounding variable. Lane et al. (2007) suggested that the frequency of meditation practice does affect the outcome. Six out of the eight studies required participants to engage in practice of meditation at home (Andres & Gloria., 2010; Bormann et al., 2006; Brady et al., 2012; Cohen-Katz et al., 2005; Oman et al., 2006; Pipe et al., 2009). However, there was no standardisation of timing for home practices in all the eight studies. The time period ranged from 30 minutes in Brady et al.’s (2012) study to 45 minutes in two other studies (Andres & Gloria, 2010; Cohen- Katz et al., 2005). Furthermore, only three of these six studies used self-report to measure the amount of meditative practice (Andres & Gloria., 2010; Bormann et al., 2006; Brady et al., 2012). No study examined the relationship between the total amount of practice and stress outcome. The qualification of the instructor could influence the effectiveness of the meditation interventions (Irving et al., 2009). Andres and Gloria (2010) suggested that the instructor’s experience could be a contributing factor to the high adherence rate. Only four studies explicitly mentioned the competency of the instructors (Andres & Gloria, 2010; Bormann et al., 2006; Pipe et al., 2009; Shapiro et al., 2005). The use of control groups could control for these confounding variables. RCT design is also another way to control confounding variables as the random assignment of participants reduces the threat of selection bias and increase the internal validity of the study (Richardson & Rothstein, 2008). There was no control group in four of the eight studies (Andreas & Gloria, 2010; Cutshall et al., 2011; Bormann et al., 2006; Brady et al., 2012). The remaining four studies with control groups were RCT. Three of these four studies used wait-list control group (Cohen-Katz et al., 2005; Oman et al., 2006; Shapiro et al., 2005). This means there was no active comparison to measure the efficacy of the meditation-based programme, compared to other forms of stress management programmes (Oman et al., 2006). Only Pipe et al.’s (2009) study could assert that the reduction in stress was due to the meditationbased programme. In their study, the control condition was also an educational series containing leadership strategies and stress management principles which were conducted over the same period time as the treatment group. Behavioural variables such as adherence to the meditation sessions should be measured as it contributes to sustainable effects (Cutshall et al., 2006; Irving et al., 2009). Only three of the studies assessed adherence to the programme (Andres & Gloria, 2010; Bormann et al., 2006; Oman et al., 2006). However, the self-reported adherence to the intervention in Oman et al.’s (2006) study declined gradually post-intervention while adherence in Andres and Gloria’s (2010) study remained high even after the programme. In Andres and Gloria’s (2010) study, participants were provided financial compensation and they measured adherence up to 12 weeks as compared to 19 weeks in Oman et al.’s (2006) study. The financial compensation could be the possible reason for the higher adherence to the programme in Andres and Gloria’s (2010) study. However, Andres and Gloria (2010) reported a slight decrease in participants’ adherence to the meditation practice from post-intervention follow-up. It was reported that participants found it hard to maintain the meditation practice as other obligations, such as family priorities, pre-empted a regular meditation schedule (Richards et al., 2006). Of the three studies that measured adherence, only Oman et al.’s (2006) study tested whether perceived stress was mediated by adherence. Their findings showed that specific programme points such as slowing down, focused attention and spiritual association were mediators of reduction in perceived stress. Yet, the findings slightly differed from Richards et al.’s (2006) study which suggested the use of mantram and putting others first were also influential points of the programme. Although both studies were examining the same programme, they differed in design and type of participants. Oman et al. (2006) is a quantitative study conducted with healthcare professionals while Richards et al. (2006) is a qualitative interview conducted on nurses. Evaluation of meditation programmes used by nurses to reduce stress Singapore Nursing Journal 18 No standardised target groups Standardisation of target group is one important criterion for results to be generalised. Five of the eight studies reviewed were conducted mainly on healthcare professionals working in hospitals (Andres & Gloria, 2010; Bormann et al., 2006; Brady et al., 2012; Oman et al., 2006; Shapiro et al. 2005). The participants of the other three studies were nurses of different ranks and working in various settings. Participants in Cutshall et al.’s (2011) study were nurses from acute hospital while Cohen-Katz et al.’s (2005) study were nurses from community-based hospitals. Pipe et al. (2009) sampled nursing leaders from various healthcare organisations. Irving et al. (2009) suggested that it was more appropriate for research to be conducted with more homogenous samples such as nurses only, because the nature of workload and stress varied across and within disciplines of health care settings. This was supported by Cutshall et al.’s (2011) study which demonstrated that nurses working in different departments within the same hospital settings could experience varying levels of stress. Hence, the programme conducted needs to meet the specific demands of the different groups in order to achieve optimal reductions in stress. No fixed duration The time periods for the mediation practices and programmes varied among the eight studies. The periods of implementation ranged from four weeks in three studies (Brady et al., 2012; Cutshall et al., 2011; Pipe et al., 2009) to almost six months in Oman et al.’s (2006) study. The reason for the long period of implementation in Oman et al.’s (2006) study was the additional follow-up of 19 weeks after the eight weeks post-intervention. Their purpose for the long followup was to assess whether changes in stress reductions were sustainable. Andres and Gloria’s (2010) study also included a follow-up at three months to assess the maintenance in stress changes, and found that stress scores continued to decrease until the time of follow-up. Although Cohen-Katz et al. (2005) included a follow-up, it focused on assessing the changes of the other outcome measure (i.e. burn-out scores) which was more significant. Hence, it was unsure whether effects of stress reductions measured at post-intervention could sustain in the five studies that had no follow-up. The duration of the practices for the eight studies ranged from 30 minutes in Cutshall et al.’s (2011) study to 2.5 hours in Andres and Gloria’s (2010) study. This information is important for considering the costs and time impact of the programmes on the work-flow of nurses (Shapiro et al., 2005). Shapiro et al.’s (2005) study highlighted that the long class hours with home practices would add additional strain on the already demanding schedule of most nurses. Hence, there are more likely to have higher attrition of participants due to time and scheduling issues. This was supported in Cutshall et al.’s (2011) study which showed that the significant dropout rate was because nurses felt overwhelmed and lacked sufficient time for practice. Many nurses reported that they were able to better manage shorter meditation practice (i.e. 10-15 minutes) ranging from three to five days a week (Richards et al., 2006). This was supported by Richardson and Rothstein’s (2008) study which showed that stress management interventions of shorter interventions were more effective than longer ones. Therefore, meditation-based programme offered to nurses should comprise frequent practice sessions of short duration to derive maximum benefits (Shapiro et al., 2005). Different instruments used to measure stress outcome Seven studies measured the amount of stress by calculating the total stress scores using various instruments, except for Cohen-Katz et al.’s (2005) study which measured the level of psychological distress using the Brief Symptom Inventory (BSI). BSI may not be sensitive to identify mild symptoms of stress typically experienced by nurses as the scale measures significant psychological symptoms of stress. Of the seven studies that used total stress scores, three used the Perceived Stress Scale (PSS) (Bormann et al., 2006; Oman et al., 2006; Shapiro et al., 2005). The three studies showed that PSS has adequate validity and reliability. Although Andres and Gloria’s (2010) study also used the PSS, it has been translated into the Spanish language. Furthermore, the study also used another scale, Survey of Recent Life Experiences (SRLE), to evaluate daily stress. These two scales have shown high reliability (Andres & Gloria, 2010). The other four studies measured total stress scores using different instruments which have reported adequate reliability and validity, except for the linear analogue self-assessment (LASA) scale used in Cutshall et al.’s (2011) study. Therefore, the significant improvements in stress reported in Cutshall et al.’s (2011) study had to be interpreted with caution. Pipe et al.’s (2009) Evaluation of meditation programmes used by nurses to reduce stress Volume 40, No. 3, July - September 2013 19 study used the Symptom Check-list 90-Revised scale and Brady et al.’s (2012) study used the Mental Health Professionals Stress Scale (MPHSS). Only Brady et al.’s (2012) study used a specific instrument, which was specially designed to measure the levels of stress among healthcare professionals in the mental health setting. Different reporting style of stress outcome Three of the eight studies compared the levels of perceived stress between the participants and general population at pre-intervention, and found that healthcare professionals including nurses had higher level of stress than the general population (Bormann et al., 2006; Oman et al., 2006; Pipe et al., 2009). Six studies reported a reduction in stress (Andres & Gloria, 2010; Bormann et al., 2006; Brady et al., 2012 Oman et al., 2006; Pipe et al., 2009; Shapiro et al., 2005). However, the extent of stress reduction differed among these six studies. Three studies achieved statistically significant reduction in stress levels (Bormann et al., 2006; Oman et al., 2006; Shapiro et al., 2005). However, the result of Shapiro et al.’s (2005) study had to be interpreted with caution because they did not perform intentionto- treat analysis despite the significant dropout rate which could increase the risk of type II error. The other three of the six studies that reported a reduction in stress score did not reach statistical significance (Andres & Gloria, 2010; Brady et al., 2012; Pipe et al., 2009). For Andres and Gloria’s (2010) and Brady et al.’s (2012) studies, it could be due to small sample size and there was no power analysis to determine the sample size. As for Pipe et al.’s (2009) study, it could be because the tool used did not demonstrate validity. Only Cutshall et al.’s (2011) study reported improvements in stress scores. The discrepancy in results could be explained by the different indications of the scores in the instruments. Although different tools were used among the six studies to measure stress, a higher total score calculated would indicate greater stress (Andres & Gloria, 2010; Brady et al., 2012; Oman et al., 2006). This differed from the LASA scale used in Cutshall et al.’s (2011) study, where a higher score on the LASA scale would indicate lower stress levels. Findings from Cohen-Katz et al.’s (2005) study demonstrated a decrease in psychological distress post-intervention, which indicated stress reduction at post-intervention. Knowledge gaps and implications Despite the promising results from the extensive research on meditation-based programmes as a strategy for work-related stress reduction for nurses, they were conducted in other countries which may not be applicable to local context. At present, there are no such local studies. As local nurses also experience high levels of work-related stress, it will be interesting to explore the effectiveness of a meditation-based programme for stress reduction among local nurses and foreign nurses from neighbouring countries working in Singapore. From the findings, research initiatives with a mixed methodology, more homogenous target group and sessions of shorter duration for meditation-based programme for stress reduction are recommended. A meditation-based programme which is sensitive to the local context could be implemented to help nurses in Singapore manage work-related stress, thereby making them more productive in their work. This may in turn enhance nursing practice and patient care as well as help in staff retention. Conclusion The introduction of this paper has outlined causes and consequences of stress on nurses. The high levels of stress experienced by nurses could affect their health and performance, and could be one of the main reasons for the high turnover rates in the profession. Relaxation techniques such as meditation have been used by nurses to cope with their stress. The present review of literatures has given an overview of the meditationbased programmes used by nurses and how meditation affects stress. The findings from the eight studies have shown that all the meditation programmes differed in their methods of meditation, target group, duration and the instruments used to measure stress outcome. Furthermore, these programmes did not have good control over the confounding variables. Nonetheless, the findings suggested that meditation-based programme can serve as a viable tool for promoting stress reduction among nurses. References Andrés, M. A., & Gloria, G. B. (2010). 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