Pathway linking dispositional mindfulness to fatigue in oncology female nurses: Exploring the mediating role of emotional suppression

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Abstract

Purpose

Fatigue is a physical and emotional state associated with certain aspects of nursing practice. The current study aimed to investigate the indirect effect of dispositional mindfulness on fatigue via emotional suppression in oncology female nurses.

Methods

In a cross-sectional study, 137 female oncology nurses were recruited from several hospitals to complete baseline questionnaires. Emotional suppression, dispositional mindfulness and fatigue were assessed with the Weinberger Adjustment Inventory (WAI), Five Facet Mindfulness Questionnaire (FFMQ) and the Multidimensional Fatigue Inventory (MFI) respectively. A Mediation model was tested using structural equation modelling.

Findings

Dispositional mindfulness was negatively associated with emotional suppression (β = −0.69, p = 0.000). In addition, emotional suppression was positively associated with fatigue (β = 0.32, p = 0.014). The mediation path was significant with emotional suppression fully mediating the relationship between dispositional mindfulness and fatigue (b = -0.20 [CI: −0.01, −0.25].

Discussion

These results support the proposed model, and the assumption that emotional suppression may help facilitate the onset of fatigue or maintain it in female oncology nurses. The findings have implications for the use of brief mindfulness interventions aimed at the effective regulation of emotion in oncology nurses to aid in well-being and optimal nursing practice.

Introduction

Fatigue is an overwhelming state of tiredness, energy depletion or exhaustion (Epstein et al., 2020; Knupp et al., 2018). In the field of nursing, fatigue becomes problematic for the effective care of patients and for the well-being of the nurse. Three types of fatigue have been identified in nursing practice, these being cognitive fatigue, emotional fatigue and physical fatigue (Drake and Steege, 2016; Epstein et al., 2020). Cognitive fatigue is evident when the nurse has problems concentrating, has memory problems (eg. remembering the patient's care plan or medication schedule) or difficulty making decisions. Emotional fatigue is displayed as unengaged nursing, emotional sensitivity, or feelings of unhappiness. Physical fatigue is exhibited as exhaustion, tiredness or symptoms of headache, aches and pains, or general malaise.

Fatigue is more common under certain nursing environmental conditions such as high workloads, staff shortages, shift combinations (such as an evening shift followed by a morning shift ie. quick returns) and lack of sleep (Epstein et al., 2020). Fatigue has been found to be associated with the greater number of hours worked, fewer hours of sleep and a recent distressing patient event (Bae and Fabry, 2014; Han et al., 2014; Knupp et al., 2018). While fatigue is experienced irrespective of the nature of the nursing, it would be expected that nursing within certain wards such as within oncology or nursing terminally ill patients may be more deleterious because of compassion fatigue (Figley, 1995). Oncology nurses may experience compassion fatigue through empathy with the suffering of the patient, and may feel guilt and distress when unable to prevent trauma and pain (Duarte and Pinto-Gouveia, 2017). In a study of Spanish oncology nurses (Arimon-Pages et al., 2019), compassion fatigue as measured by burnout and secondary traumatic stress was reported to be highly prevalent. Burnout manifested as emotional exhaustion has been found to be higher in surgical oncology nurses compared to general surgery nurses (Ksiazek et al., 2011).

Despite nurses being vulnerable to fatigue, several factors both within individual nurses and within the nursing practice environment have been found to mitigate the effects of fatigue associated with nursing (Epstein et al., 2020; Knupp et al., 2018). In Epstein et al‘s (2020) study, newly graduated nurses who engaged in proactive strategies to prevent fatigue, such as having a rest period before a night shift or a lie-in before a morning shift, reported less fatigue. Other nurses engaged in reactive strategies to cope with fatigue such as resting or not catching up with friends after a quick return. Within the nursing practice environment better nurse manager ability, leadership and support have been associated with lower nurse fatigue (Knupp et al., 2018).

The ability to accurately identify emotional states and regulate emotion is essential for psychological adjustment and well-being (Koole, 2009). Weinberger et al. (1979) identified six social-emotional adjustment types: Reactive, Sensitized, Oversocialized, Undersocialized, Assured and Repressive. The last of these adjustment types, namely Repressive and their use of emotional suppression as a way of coping with unpleasant thoughts and emotional experience (Geraerts et al., 2006; Myers, 2010) is the focus of the current research. Suppression as an emotion regulation strategy involves the inhibition of emotional expression, and would seem to explain the relationship between mindfulness and nursing fatigue. According to Weinberger et al. (1979) repressors have low trait anxiety and high levels of defensiveness. A repressive coping style has been associated with diminished physical health (Myers, 2010), reduced quality of life and distress (Costanzo et al., 2006). Within oncology nursing practice, one would expect that where negative emotional states associated with the cancer patient's trauma, suffering, pain and eventual dying are suppressed in order to attend to the demands of patient care, this may result in sustained fatigue.

Mindfulness is the state of nonjudgmental present-moment awareness (Brown et al., 2007). Jon Kabat-Zinn (1990) defined mindfulness as "paying attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment to moment" (p. 29). There is research evidence for mindfulness to be associated with enhanced mood (Johnson et al., 2013); reduced negative thinking (Feldman et al., 2010), improved attention (Jha et al., 2017) and enhanced problem-solving ability (Green and Black, 2017). Mindfulness practice can reduce stress, anxiety and depression (Hofman et al., 2010) and has been linked to psychological well-being (Schutte and Malouff, 2011) and emotional well-being (Menges and Caltabiano, 2019). Mindfulness has been reported to moderate the development of depression in oncology professionals (Di Giuseppe et al., 2019), and to be associated with lower nursing stress and better psychological well-being in nurses (Guillaumie et al., 2017; Said and Kheng, 2018; Schwarze and Gerler, 2015; Wang et al., 2017). Brief mindfulness with a focus on loving kindness meditation (where positive feelings and thoughts of love, compassion and kindness are directed to self and others) was found to be associated with enhanced positive affect and greater self-reported compassion for others (Polizzi et al., 2019).

One would therefore expect that mindfulness would be a protective factor for oncology nurses whose jobs require compassion for the suffering of patients, and which have been associated with fatigue under stressful conditions of excessive workloads and shift work. Nurses who have higher levels of mindfulness would be expected to be more attentive to patient needs, to be able to solve problems as they arise (Green and Black, 2017) and to experience less stress. Mindfulness or having a receptive awareness of the present moment (Brown and Ryan, 2003) would be conducive to the well-being of nurses and in turn to the optimal care of patients.

Further support for examining the interrelationships between trait mindfulness, emotional suppression and fatigue comes from research which has reported a link between trait mindfulness and better emotion regulation (Hill and Updegraff, 2012), and studies on the effects of mindfulness on fatigue (Clauss et al., 2018; Surawy et al., 2005). Research has found that persons with higher trait mindfulness engage in less maladaptive emotion regulation strategies such as emotional suppression (Tamagawa et al., 2013). This association has also been found in special populations such as those with multiple sclerosis (Schirda et al., 2015), where dispositional mindfulness has been linked to quality of life and lower emotion dysregulation. In persons with chronic fatigue syndrome, trait mindfulness has been associated with higher levels of life satisfaction and positive affect (Surawy et al., 2005). In a study of caregivers for the elderly (Clauss et al., 2018), emotional exhaustion and fatigue were found to decrease in the intervention group which received brief mindfulness with a focus on breathing, and engaged in a positive reflection exercise in relation to a work-related event. One would expect that nurses who are high on the trait of dispositional mindfulness would engage in less emotional suppression and experience less fatigue.

The aim of the study was to examine the interrelationships between mindfulness, emotional suppression and fatigue in oncology nurses. It was hypothesized that

  • 1.

    Dispositional mindfulness will negatively predict emotional suppression;

  • 2.

    Emotional suppression will positively predict fatigue;

  • 3.

    Emotional suppression will fully mediate the relation between dispositional mindfulness and fatigue.

Section snippets

Participants

In a cross-sectional study, 137 oncology female nurses were recruited from five general hospitals, three university teaching hospitals and one specialist cancer hospital in Tabriz, Iran through convenient sampling method. Descriptive information for the sample is reported in Table 1.

Data were collected over three months from December 2018 to March 2019. The eligibility criteria included: to be in front-line nursing practice roles and being female. Exclusion criteria included: A history of

Correlations

Pearson correlation analyses (See Table 2) revealed that nurses with higher levels of dispositional mindfulness had lower levels of fatigue. In addition, emotional suppression was positively correlated with fatigue. As emotional suppression decreased, fatigue decreased. The relation between emotional suppression and dispositional mindfulness is negatively significant which means that as emotional suppression increased, dispositional mindfulness decreased (and vice versa). Dispositional

Discussion

This study sought to examine the interrelationships between dispositional mindfulness, emotional suppression and fatigue in oncology nurses. All the proposed hypotheses were supported. Each of these will be discussed in turn highlighting the significance of the findings in terms of intervention strategies to better facilitate physical, cognitive and emotional adjustment in nurses and lessen fatigue.

The first hypothesis that dispositional mindfulness would negatively predict emotional

Conclusion

The current study found support for mindfulness being associated with less fatigue in oncology nurses through its effects on how emotions are regulated. This has implications for the use of mindfulness practice with a focus on emotion regulation, and self-compassion for others (loving kindness meditation) supported by implementation intentions or planning for meditation. Reducing fatigue in oncology nurses has benefits for the nurse's emotional well-being and for the safety and compassionate

CRediT author contribution statement

Rasoul Heshmati: Conceptualization, Methodology, Software, writing results, Writing - review & editing. Marie L. Caltabiano: Writing - review & editing, Writing Introduction and Discussion.

Declarations of competing interest

None declared.

Acknowledgement

We sincerely thank the oncology nurses who participated in this study.

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