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Secondary Traumatic Stress: Mental Health Professionals’ Silent Illness

Kamani Odina-Herbert
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Kamani Odina-Herbert is a graduate student and teaching assistant with the Edson
College of Nursing and Health Innovation at Arizona State University. She has been a pediatric
psychiatric nurse for three years.
I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Kamani Odina-Herbert,
Edson College of Nursing and Health Innovation, Arizona State University, 550 N. 3rd Street,
Phoenix, AZ 85004
Email: kodinahe@asu.edu

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Abstract
On average, 50% of mental health professionals experience secondary traumatic stress (STS)
which has led to burnout and worsening the mental health provider shortage. Those with STS can
have traumatic memories, emotional outbursts, and may avoid clients or work after constantly
being exposed clients’ traumas. Burnout is an occupational phenomenon combining emotional
exhaustion, work depersonalization, and diminished accomplishment in the workplace. Burnout
has led to decrease in organizational committed, absenteeism, and even physical illness. A
literature review was conducted to determine the role of mindfulness-based interventions in
preventing burnout. The project was completed with four psychiatric mental health nurse
practitioners (PMHNP) at a telepsychiatry clinic in the southwestern region of the US. The
international review board approved the project prior to implementation. The providers were
asked to complete a survey known as the Maslach Burnout Inventory to measure their level of
burnout before and after the five senses grounding technique. It was to be completed at least
once during their work week for eight weeks. The results are still being collected and analyzed at
this time. It hypothesized that the participants in the project have decreased levels of burnout
after participating in the intervention. This project will be able to show that burnout can be
prevented and mitigated at an individual level utilizing mindfulness techniques that many of the
PMHNP encourage their patients to use. A cost-effective and efficient way to decrease burnout,
reduce STS, and prevent more PMHNP and other mental health professionals from leaving the
workforce.
Keywords: secondary traumatic stress, burnout, mental health, mindfulness-based
interventions

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Secondary Traumatic Stress: Mental Health Professionals’ Silent Illness
Secondary traumatic stress (STS) is well-studied but not considered a priority for many
mental health organizations. As part of their jobs, mental health professionals work closely with
those who have experienced trauma. The emotional and cognitive content of their individualized
work with clients places mental health providers at increased risk for developing STS. Many
mental health professionals struggle to continue working in the mental health field due to the
overwhelming nature of their jobs without reprieve. Improving their mental health will lead to
career longevity so that they may continue to help others.
Problem Statement
Mental health workers are unknowingly putting themselves at risk of developing
secondary traumatic stress disorder. This problem results from knowing about another
individual's traumatic event (Potocky and Guskovict, 2020). Every day they listen to their
patient's stories with empathy to individualize treatment. The symptoms closely resemble
posttraumatic stress disorder with the following similaries; intrusive thoughts, traumatic
memories, emotional outbursts, irritability, changes in sleep, poor concentration, avoidance of
clients and work, and hypervigilance (Potocky and Guskovict, 2020). Roughly 50% of mental
health workers have shown at least one symptom of this stress disorder, and those with high
levels of empathy reported more symptoms (Brown et al., 2022; Yazici and Ozdemir, 2022).
Secondary traumatic stress among mental healthcare workers leads to burnout,
correlating to workers switching jobs or leaving the healthcare field entirely. About 24% of
adults and 17% of youth experience mental health, with more than 40% living in areas
throughout Arizona with a mental health shortage (Koch et al., 2020; Reinart et al., 2022). There

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is a continual demand for mental health services. Due to its damaging effects, mental health
professionals have been leaving the mental health field, further impacting the ability to meet the
rising demand for mental health services in the community.
Purpose and Rationale
Burnout is a recognized phenomenon within the workforce. The source and cause of
burnout vary among careers but is manifested by secondary traumatic stress within the mental
health field. Compounding stress from interacting with multiple traumatized clients leaves
mental health workers with overwhelming stress levels. Secondary traumatic stress has been
widely researched; however, implementation of the evidence is still lacking. This paper aims to
acknowledge the prevalence of secondary traumatic stress among mental health workers and
propose an efficient intervention.
Background and Significance
Secondary traumatic stress disorder was brought to the world’s attention by Charles
Figely in 1993, who recognized that clinicians and educators could develop trauma from
exposure to another individual’s trauma (Ogińska-Bulik et al., 2021). Since its popularization,
multiple studies have been conducted among nurses, paramedics, and mental health personnel to
demonstrate the prevalence of developing STS when working with trauma victims (OgińskaBulik et al., 2021).
Theoretical models were developed to explain this particular phenomenon, such as the
Ecological Framework of Trauma and the Constructivist Self-Development Theory (OgińskaBulik et al., 2021). The Ecological Framework of Trauma focuses on personal and environmental
factors and their relationship to secondary trauma (Ogińska-Bulik et al., 2021). The
Constructivist Self-Development Theory emphasizes vicarious trauma and its relationship to

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secondary trauma (Ogińska-Bulik et al., 2021). Studies have been conducted regarding the
occupational load, job satisfaction, social work environment, and their effects on secondary
trauma (Ogińska-Bulik et al., 2021).
The National Child Traumatic Stress Network has recognized the impact of secondary
traumatic stress on healthcare professionals, specifically those working directly with traumatized
clients (Introduction, 2018). Resources, interventions, and information has been available to
individuals and organizations to address the problem. However, prevention efforts have been
focused on education and self-care.
Mental Health Workers
Mental health professionals must schedule or interact with as many clients as possible
while providing individualized care. They have become severely busy due to heavy patient loads
affected by the mental health professional shortage (Ogińska-Bulik et al., 2021; Reinart et al.,
2022). For every 100,000 people that require mental health treatment, there are only 11
psychiatrists, 22 psychologists, and 155 counselors that vary in multiple fields within multiple
fields (Koch et al., 2020). Burnout tends to occur with an increased workload, long hours, and
poor social support (Garcia et al., 2019). It has been found that burnout has led to a decline in
patient safety, a decrease in patient satisfaction, and an increase in patient complaints (Garcia et
al., 2019).
Self-Care
The primary intervention for stress and anxiety is self-care, emphasizing prevention.
Most medical professionals recommend a form of self-care to maintain low-stress levels and a
healthy mind. Encouraging mental health workers to engage in healthy lifestyles and focus on
their health can prevent development of stress disorders (Steinlin et al., 2017). Despite self-care

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being the primary focus, many individuals do not partake in or follow through. Education
training focusing on self-care is attended but does not result in increased self-care (Sprang et al.,
2019). It has been found that many mental health workers are not provided with the appropriate
tools for self-care or are not supported by their organization (Jirek, 2020). Mindfulness is one of
the best self-care practices and highly recommended for feelings of stress. (Potocky and
Guskovict, 2020).
Coping
The coping skill tool kit is another intervention that allows mental health workers to deal
with the trauma exposure in the moment or soon after. Providing education about the differences
between positive and negative coping skills has a positive impact on symptom severity
(Marković and Živanović, 2022; Potocky and Guskovict, 2020). It is imperative to follow up
with mental health professionals to ensure they utilize positive coping skills appropriately and
avoid negative ones.
Organizational Changes
Systemic change in behavioral health organizations is another promising and promoted
intervention. Creating a culture that supports mental health workers and encourages self-care
allows mental health workers to focus on their health. Organizations are encouraged to reduce
caseloads to ensure proper debriefing and recovery from traumatic patients (Introduction, 2018;
Potocky and Guskovict, 2020).
Employee Assistance Program
Work stress and burnout are not exclusive to healthcare. It occurs across all career types.
The employee assistance program (EAP) was created to address decreased work performance
related to work stress and feelings of burnout (Chen et al., 2021; Doran, 2022). When

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implemented and utilized correctly, workers' stress and the likelihood of leaving the profession
decreases (Chen et al., 2021). It is free of charge across most organizations and is encouraged to
be used, yet, it is the most underutilized due to lack of time and misunderstanding (Doran, 2022).
Better Job Satisfaction and Less Burnout
The primary goal of most interventions is prevention. Due to the nature of mental health
professionals’ duties, interventions are embedded within the workday to mitigate the risk of
developing STS. When appropriately addressed, there will be increased job satisfaction,
decreased work stress, and less burnout (Chen et al., 2021; Introduction, 2018; Marković and
Živanović, 2022; Potocky and Guskovict, 2020). It is highly recommended that research focus on
identifying the various factors involved with secondary traumatic stress and developing best
practices to address it (Potocky and Guskovict, 2020; Sprang et al., 2019).
STS has been thoroughly defined throughout the research because it is commonly
interchanged with burnout and compassion fatigue (Leung et al., 2022; Potocky and Guskovict,
2020; Singh et al., 2020). Providing a definitive definition sets the tone for what the intervention
is meant to target. Organizations are a big part of the change, and researchers are working on
making cost-effective interventions that will lead to STS prevention (Potocky and Guskovict,
2020; Sprang et al., 2019). Secondary traumatic stress has been proven to impact mental health
workers; now, an effective intervention must follow.
Internal Data
Private mental health facilities are flexible in the services that they offer to varying
populations and with the increased usage of telehealth, they can reach individuals who are unable
to access mental health treatment in person. Current services offered include psychiatric
evaluations and follow ups, genetic testing, case management, online attention

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deficit/hyperactivity disorder (ADHD) testing, legal consultation, and emergency after hour
calls. These are offered indiscriminately to their clients with some of the services being covered
through health insurance.
The organization has two locations in Phoenix, one in Tempe, and one in Flagstaff. The
organization started as a telehealth only clinic and has recently offered in person appointments at
these locations through appointment only. The organization has plans to expand the clinic’s
reach by acquiring more healthcare providers.
The chief executive office and found had stated that as the demand for mental health
services increases, the organization finds themselves needing to increase their caseload. There is
concern that as the workload increase, the current employees will begin developing secondary
traumatic stress symptoms and burnout. Developing an intervention to prevent STS will decrease
burnout which will, in turn, prevent turnover and maintain the current retention rate.
PICOT Question
In mental health workers (P), how does the use of mindfulness-based interventions (I)
compared with nothing (C) impact the feelings of burnout (O)?
Search Strategy
A detailed review was conducted of current evidence to answer the PICOT question. The
three databases utilized in this search were CINAHL, PubMed, and PsycINFO. These databases
provided high levels of primary research relevant to burnout and mental health workers.
Keyword Selection
The main keywords utilized among the databases were burnout, mental health workers,
mindfulness, and interventions. Each keyword was partnered with additional words to help
expand searches. Burnout was typically used with stress, fatigue, secondary traumatic stress, and

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exhaustion. Mental health workers were typically used with mental health staff, mental health
professionals, therapists, social workers, counselors, and mental health providers.
Initial and Final Search Yields
CINAHL produced 33 articles when the keywords burnout, stress, fatigue, mindfulness,
mental health workers, mental health staff, therapists, counselors, or social workers were
utilized. PubMed produced 137 articles with the keywords burnout and mental health worker. It
was decreased to 50 with the addition of stress and mental health workers to the search. PsycInfo
produced 247 articles with the keywords mental health workers and burnout. It was decreased to
63 with the addition of the words intervention and mindfulness. Ten articles with high levels of
evidence were chosen from the three databases; eight were randomized controlled trials, one was
an exploratory study, and one was an interventional study.
Limitations, Inclusion, and Exclusion Criteria
During the search, several limitations were utilized to find articles relevant to the PICO
question. The search focused on clinical and randomized control trials (RCTs). It was further
limited to articles published within the last five years. Articles were chosen if they were relevant
to the mental health field or burnout in healthcare but did not discriminate on the type of
professional.
Critical Appraisal and Synthesis of Evidence
The quality and level of evidence of each study were determined utilizing the rapid
critical appraisal (RCA) tool (Melnyk & Fineout-Overholt, 2019). Quantitative studies are
among the highest levels of evidence, with systematic reviews being the gold standard (Melnyk
& Fineout-Overholt, 2019). Quantitative studies were the primary choice emphasizing
randomized control trials (RCTs) with a minimal bias to provide evidence regarding mindfulness

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and reduced burnout symptoms (see Appendix A, Table A1). Only one study had an overt bias,
as they were the author of the book utilized in the intervention (Hofer et al., 2018). The studies
were placed in a synthesis table to clearly display the interventions and outcomes (see Appendix
A, Table A2).
The participants were white women in their 40s with varied occupations in healthcare,
either in a hospital or clinic. The online studies still recruited participants from hospitals or
clinics. All studies used mindfulness to address feelings of burnout and quality of life. The
measurement tools were heterogeneous as they utilized different tools to measure stress, quality
of life, depression, and anxiety. Studies using Maslach's theory of burnout utilized the Maslach
Burnout Inventory (see Appendix A, Figure A1). Frameworks had a small degree of
homogeneity, the most common being Maslach's burnout theory. One study was added due to the
additional information on burnout prevalence among psychiatric professionals and the potential
positive impact of a mindfulness-based intervention. The most considerable difference among
the studies was the specific intervention utilized; while all were mindfulness-based, each focused
on a different type (see Appendix A, Figure A2).
Four of the ten studies focused on only nurses, while the others had a mix of occupations
(see Appendix A, Figure A2). All the studies had low attrition rates, but two had less than ten
participants (see Appendix A, Figure A2). Seven studies measured overall burnout, while the
others had a mixture of stress, quality of life, depression, and anxiety (see Appendix A, Figure
A2). Overall, there was a decrease in negative symptoms with an increase in quality of life and
wellness (see Appendix A, Figure A2). Most of the studies did three to six-month follow-ups.
They found that participants in the study continued to practice mindfulness and maintained
decreased burnout symptoms (see Appendix A, Figure A1).

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Discussion
Mindfulness has a significant impact on STS. Reducing stress, depression, and anxiety is
tied to introducing mindfulness, lowering the risk of stress and burnout. Though second to
organizational changes, implementing mindfulness on an individual level can be cost-effective
and personalized to the needs of each employee. With the increasing call for psychiatric services,
higher workloads and longer hours will lead directly to the development of STS. The evidence
clearly shows the feasibility of implementing mindfulness activities and the positive effects. It is
vital to include mindfulness and foster self-care within the organizational culture to lessen the
risk of STS and burnout.
A Multidimensional Theory of Burnout
A Multidimensional Theory of Burnout explains the three interrelated concepts of
burnout. The complex intermingling of emotional exhaustion, depersonalization, and reduced
personal accomplishment is the underlying cause of burnout (Maslach, 1998). Emotional
exhaustion is feeling emotionally overextended and drained of emotional resources (Maslach,
1998). Depersonalization is the negative response to others, usually seen as having a detached
response (Maslach, 1998). Lastly, reduced personal accomplishment is a declining sense of
competence and work productivity (Maslach, 1998).
Exhaustion is considered the central quality and main display of burnout, as it is the stress
component (Maslach, 1998). Chronic fatigue leads people to distance themselves from work
emotionally and cognitively to minimize its effect on their exhaustion; this is how
depersonalization develops (Maslach, 1998) (see Appendix B, Figure B1). A decline in feelings
of personal accomplishment occurs parallel to the other aspects (Maslach, 1998). The theory
further explores that occupational demands and lack of personal resources are critical to

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developing burnout (see Appendix B, Figure B1). It is proposed that exhaustion and
depersonalization result from lacking personal resources, while the decline in personal
accomplishments is related to occupational demand. It explains that the consequences of burnout
are displayed as job withdrawal, a decrease in patient quality of care, and a decline in overall
health (see Appendix B, Figure B1).
The theory provided the definitions and influenced the measurement tools utilized in the
studies gathered (see Appendix A, Figure A1). Stress, job satisfaction, quality of life, depression,
and anxiety were measured as they are typically part of the lack of resources, demands, or costs
for burnout (see Appendix A, Figure A2). Mindfulness-based interventions focus on replenishing
the individual's resources to combat burnout, while any organizational changes would affect the
demands. Though not all the studies utilized the multidimensional theory of burnout, its
influence affected the choice of interventions, outcome measurements, and measurement tools.
Clinical Scholar Model
The Clinical Scholar Model is an evidence-based practice (EBP) model created to
encourage nurses to implement quality improvement projects utilizing EBP (Strout et al., 2009).
This model guides individuals through identifying the problem, researching EBP, and
implementing the change (Honess et al., 2009). The model is broken up into seven steps:
observe, determine, analyze, synthesize, apply, evaluate, and disseminate (Strout et al., 2009)
(see Appendix B, Figure B2). The proposed project is focused on quality improvement for a
healthcare organization that supports the use of the clinical scholar model.
The first step is to observe and determine the force driving the need for change (Strout et
al., 2009). The need for change is staff-driven and data-driven (see Appendix B, Figure B2). The
key stakeholder in the project had noted the increase in turnover and frequent complaints of

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stress. The second step is to determine the significance of the problem, desired outcomes, and
feasibility (see Appendix B, Figure B2). The key stakeholder shared the significance of the
problem, emphasizing the overwhelming increase of staff leaving the organization and the need
for more staff. The desired outcome is to decrease the levels of turnover and stress felt
throughout the organization. The feasibility is possible as it does not take away from the
workload nor cost money.
The third step is analyzing external and internal evidence (see Appendix B, Figure B2).
The external evidence was gathered and critically appraised. It demonstrated the prevalence of
burnout and the positive effect of mindfulness-based interventions. The internal evidence comes
from the key stakeholder interviews but is missing raw data. The fourth step is synthesis which
involves putting together a proposal for the project, getting approval from the IRB, and educating
the organization about the upcoming intervention. IRB is necessary due to the study involving
the mental health workers within the organization, and educating the organization will be aided
by the key stakeholder. The fifth and sixth steps are applying the intervention and evaluating the
outcomes (see Appendix B, Figure B2). Utilizing the measurement tools for burnout and STS
before and after the intervention will determine the effect.
The final step is disseminating the findings (see Appendix B, Figure B2). With the help
of the key stakeholder, disseminating the results internally will help encourage the continuation
of the intervention. Disseminating the results externally by publishing a paper will assist other
organizations attempting to apply the intervention.
Methods
Ethical Considerations

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Three ethical principles will guide this project: respect for person(s), beneficence, and
justice. Respect for persons is treating an individual with autonomy and allows for protection for
individuals that lack the ability to make their own decisions (Office for Human Research
Protections, 1979). The project adhered to this principle by ensuring that clinical all subjects
participated voluntarily and with ample information (Office for Human Research Protections,
1979). Prior to recruiting participants, information regarding the study was shared by the
shareholder, Clinic Founder, in advance to assure the organization is aware. There was also
informed consent forms with information regards mindfulness, length of the project, and
information being recorded. Consent was collected prior to beginning the intervention and was
obtained online to maintain anonymity.
Beneficence is to avoid harm and maximize benefits while also minimizing any risk for
harm (Office for Human Research Protections, 1979). The project adhered to this principle by
researching the possible risks to participants and implementing ways to minimize the risk (Office
for Human Research Protections, 1979). Surveys utilized in the project were deidentified and all
information collected is collected anonymously online.
Justice is the final principal and is the process of fairness distribution regarding the
benefits of the project (Office for Human Research Protections, 1979). The project adhered to
this principle by ensuring the subjects are selected due to their relevance to the problem being
addressed by the project rather than easy access to participants (Office for Human Research
Protections, 1979). The project specified the effect of burnout on mental health workers and the
benefit of preventing high turnover within the organization. The project ensured that vulnerable
participants are either excluded for provided extra explanation to their participation in the

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project. The project’s methodology was reviewed by faculty mentors and received IRB approval
(see Appendix C, Figure C1).
Participants and Setting
The participants are employees within the organization that work directly with mental
health clients. Individuals that work with the mentally ill population are at a higher likelihood to
develop STS symptoms and feelings of burnout (Brown et al., 2022). The following employees
accepted will be, nurse practitioners, psychiatrists, psychologists, therapists, social workers, case
workers, registered nurses, and other mental health professionals that regularly work directly
with behavioral health clients. Exclusion criteria will be leadership and any employee that does
not work directly with mental health clients most of their workdays. Anyone that regularly
participates in mindfulness activities will also be excluded. The exclusion is necessary to ensure
that data isn’t skewed from people that are not very likely to develop symptoms or already
utilizes the proposed intervention.
Recruitment will be done with assistance of the stakeholder. It will involve sending out a
recruitment email with a flyer attached (see Appendix C, Figure C2). The flyer will explain the
eligibility requirements and what is expected of their participation. The flyer also holds ways to
contact the project head for more information. The flyer also contains a QR code that leads
individuals to the consent form (see Appendix C, Figure C3). The consent adds details of what is
expected of individuals that was shown in the flyer. Most importantly, the consent document
outlines that participation is completely voluntary and that all information collected is
deidentified.
Project Description

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The project aims to determine whether using a mindfulness grounding technique will
reduce feelings of burnout. Recruitment will be allotted a week, to provide ample time for
anyone to asks questions and take the time to decide if they want to join. During recruitment, the
consent document will be read, completed, and returned. During this time, the demographic
survey will also be sent to be completed by participants (see Appendix C, Figure C4). At the
beginning of week two, questionnaires will be sent out to emails provided by the stakeholder.
The survey will be the Maslach Burnout Inventory (MBI) for medical personnel. The MBI is a
22-item questionnaire about burnout symptoms (see Appendix C, Figure C5). Participants will
not be expected to calculate their own scores.
Education materials on the mindfulness technique, five-senses, will be sent to the email
individuals provided in the demographics survey at the beginning of week three (see Appendix
C, Figure C6). The five-senses technique is when an individual takes the time to recognize their
environment utilizing each of their sense. They will identify five things they can see, four things
they can touch, three things they can hear, two things they can smell, and one they can taste
(Smith, 2018). It is expected that the technique is utilized at least once during the workday, but
there isn’t a maximum amount.
The following eight weeks will include weekly email reminders to the participants to
complete the mindfulness along with a link to confirm they complete the mindfulness activity
(see Appendix C, Figure C7). During those eight weeks, there will be an assumption that
participants are completing the five-sense technique at least once a day while they are at work.
During week 12, MBI will be sent out again to the participants to collect new data regarding their
feelings of burnout. The project is estimated to take a total of 12 weeks, including recruitment
and data collection.

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Data Collection Plan
The demographics survey and MBI were the instruments chosen to complete the project.
They were chosen due to their relevance to the outcomes as well as their relation to the
theoretical framework. Demographics collected will allow to determine potential differences
when identifying symptoms of burnout. MBI focuses on burnout and directly tied to the
theoretical framework of the project. The multidimensional theory of burnout explains the
factors contributing to burnout and the MBI allows those factors to be measured.
The demographic survey created by the project lead will collect age, gender, role within
the organization, and experience in mental health (see Appendix C, Figure C4). The email is
utilized to send out reminders about the intervention and send out the follow up surveys at the
end of the intervention. The email will be promptly removed from the survey at the end of the
intervention stage of the project as it is not needed to analyze data.
The MBI for human services tailored to medical personnel (MBI-HSS-MP) is a 22-item
questionnaire that focuses on measuring the symptoms of burnout (see Appendix C, Figure C5).
The survey was created shortly after the creation of the Maslach Multidimensional Theory of
Burnout to be able to measure burnout in individuals (Maslach, 1998). Though it has multiple
versions, the MBI-HSS-MP has its own psychometrics for validity and reliability. Reliability was
measured using Cronbach’s alpha that measured values between 0.733 and 0.844 (Lin et al.,
2022). Validity was measured using Rasch analyses and questions were found to have good fit
statistics (Lin et al., 2022).
Data collection will be done utilizing a website named Qualtrics. It allows for the
creation of multiple questionnaires and surveys to be delivered electronically. Qualtrics will also
provide anonymity by not collecting IP addresses or personal data that can be found on personal

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devices. The results for each survey will be in a central location that will only be accessed by the
project lead through a locked laptop. The data collected through this website will only be stored
for a year for potential external publication.
To answer the project question, the symptoms of burnout will be measured among the
participants. Scores prior to starting the mindfulness intervention and after will be compared to
determine significance. The logic model displays the expected outcomes of the project (see
Appendix D). Expected short term outcomes are increased knowledge on the topics of burnout,
mindfulness as well as comfortability using mindfulness while at work. Expected long term
outcomes are proficient understanding of mindfulness, consistent use of mindfulness while at
work, and decrease symptoms of burnout. The long terms goals will be assessed with the MBI.
Data Analysis Plan
The data will be analyzed with the Intellectus statistics software. The specific test being
run will be the Paired t-test or Wilcoxon Signed-Rank test and Descriptive statistics. The test is
utilized to assess differences between variables that utilize the same scale (Intellectus Statistics
Team, 2021). At least three complete cases are required to run the test with the assumption that
data will be normally distributed. The Wilcoxon test can be run in place of the t-test if the rules
are not met for the Paired t-test. Descriptive statistics test is utilized to analyze the participants
and identify relationships in relation to the data provided (Intellectus Statistics Team, 2021).
Budget
The project had direct costs and indirect cost but did not get outside funding (see
Appendix E). The direct costs are specific for recruitment and providing information to potential
project participants. Recruitment and education were done online and did have any direct costs.
The direct costs also include utilization of the data collection instrument. Permissions and license

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are needed to utilize them. The cost is $2.50 per test with a minimum of 50 tests needing to be
purchased. The direct costs will be funded by the DNP student.
The indirect costs are what are needed to operate the project. Canva is a website that
allows for the creation of media materials such as flyers and brochures. The subscription allows
for unlimited access to all their creation materials. The gas is for travel between locations to
deliver flyers. The internet is for a fully functioning computer to complete everything necessary
for the project. The total cost is done over six months to account for prepping for the project and
the active implementation.
The funding is inaccessible. However, it’s important to note that there is federal funding
for high turnover among health care workers (Assistant Secretary for Public Affairs, 2022). Over
the potential savings are over $30-45,000 per employee each year. That is the average price to
hire a new employee due after losing one (Enrich, 2016). The organization has roughly 13
mental health workers equating to $390,000 - $585,000 in savings a year.
Results
Five participants completed the consent form and three of those participants completed
all the required surveys. Of the three participants, two of them identified as female. All the
participants were nurse practitioners within the clinic and had master’s degrees. Most of the
participants had anywhere from two to five years of experience working in mental healthcare
(see Appendix F, Table F1). The average age of the participants is 39.33 years old (see Appendix
F, Table F2).

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The Shapiro-Wilk test was conducted to determine whether the differences in in the pre
and post survey could have been produced by a normal distribution (Intellectus Statistics Team,
2021). The alpha value was 0.05 suggesting the possibility of normal distribution. A two-tailed
paired sample t-test was completed to determine the significance between the pre and post
surveys the participants completed. Statistical significance is found when the p-value is less than
0.05 (Intellectus Statistics Team, 2021). The MBI survey results break down into three sections:
emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) (see
Appendix F, Table F3). Three separated statistical tests were completed to compare the scores
from each section individually.
The results of the two-tailed paired samples t-test for emotional exhaustion was not
significant based on an alpha value of .05, t(2) = -0.34, p = .764, indicating that there was not a
decrease in feelings of emotional exhaustion after the intervention. The result of the two-tailed
paired samples t-test for depersonalization was not significant based on an alpha value of .05,
t(2) = -0.46, p = .691, indicating there was not a decrease in feelings in depersonalization after
the intervention. The result of the two-tailed paired samples t-test for personal accomplishment
was not significant based on an alpha value of .05, t(2) = 0.95, p = .441, indicating there was not
an increase in feelings of personal accomplishment (see Appendix F, Table F4).
The results do not allow for correlation between the intervention and maintaining low
feelings of burnout. The intervention has proven to have limited impact on both the participants
and overall, for the clinic. The intervention, however, can still be sustained through the providers
that participated in the project. The key stakeholder also has access to the materials provider to
the participants allowing for continual distribution for newer employees.
Discussion

SECONDARY TRAUMATIC STRESS

21

Burnout is a combination of feelings of emotional exhaustion, depersonalization, and
personal accomplishment. The participants showed low burnout before and after the intervention
was introduced. The mindfulness grounding technique did not have any effect on the participants
burnout. Many factors were involved to produce these specific findings. The key stakeholder and
owner of the telepsychiatry clinic reported wanting involvement in the project as a preventative
measure for STS and burnout. There was concern for potential burnout, but the owner did not
have data showing burnout and the pre-survey results confirmed low burnout among the
participants. Though the intervention did not further decrease overall feelings of burnout, it did
not significantly increase burnout allowing the grounding technique to still be a viable
preventative method.
There were multiple limitations within the study. The first limitation is a lack of face-toface interaction with the participants. The clinic is mostly done over telehealth with widely
varying schedules among the employees. There was not a central hub to allow for proper
recruitment with flyers or luncheon. Education material and instructions were all provided
electronically, depersonalizing the project, and potentially preventing potential participants from
being comfortable asking questions.
The second limitation is self-reporting and self-education. The project relied on the
honesty of the participants. It was possible for participants to have not read the education
materials or have understood how to complete the surveys. Due to the self-reporting nature of the
surveys, each question could have been interpreted differently for each participant causing
inconsistency in results. There is also the potential that participants did not complete the
mindfulness technique as they were instructed too.

SECONDARY TRAUMATIC STRESS

22

The final limitation, and most significant, is the small sample size. The clinic had nine
providers at the time consent for the project was sent out and 12 when the intervention officially
started. However, of the original nine, only five had completed the consent and three completed
the intervention. This prevents the project results from being generalized, regardless of the
significance of the results.
A significant challenge with the project is only have one project champion supporting
and pushing the project. Potential participants could only hear the information from the key
stakeholder and project lead, and information was only provided via email. Information could
have easily been overlooked and the project viewed as insignificant with minimal people
advocating for participation. Communication with the key stakeholder was also difficult due to
maintaining an online only format for the project. For the same reason, participants could have
missed key information, the stakeholder had minor delays with responses with could have
impacted the project.
Mindfulness-based interventions have been shown to improve feelings of burnout with
the effect being the most significant with emotional exhaustion (Salvada et al., 2021). Among
studies that had small sample sizes utilizing mindfulness-based interventions, showed limited to
no improvement regarding burnout (Reyes Ortega et al., 2019; Watanabe et al., 2019). Robust
mindfulness-based interventions, such as regular face to face sessions, had the most positive
effect on burnout and STS among healthcare professionals (Strauss et al., 2021; Xie et al., 2020;
Cascales-Perex et al., 2021).
There is potential for future research and studies to continue focusing on mindfulnessbased interventions specifically for mental health professionals. Choosing a setting that can
support in-person recruiting and/or intervention sessions could improve the sample size. If the

SECONDARY TRAUMATIC STRESS

23

clinic is primarily online, scheduling education sessions via online platforms to in-person
engagement and ensure each participant thoroughly understands the intervention. Increasing the
survey to weekly, to track a trend instead of just two points of time could be a more accurate
representation of the burnout. Finally, adding a post-survey to the entire study or project will can
show subjective impact of an intervention versus just objective.
Secondary traumatic stress is a phenomenon that is experienced by few professions with
the potential of being overrepresented in mental healthcare due to the nature of the occupation.
Developing symptoms can lead to the current occupational phenomenon of burnout. Burnout is
the culmination of emotional exhaustion, depersonalization, and personal accomplishment
caused by increased work demands, decreased organization support, and lack of personal stress
resources. Mindfulness-based interventions provides personal stress resources which is only one
section of the overall burnout phenomenon. Mindfulness-based intervention has limited impact
with low engagement and participation but has the potential to prevent the consequences of STS
and burnout. Mental health professionals recommend mindfulness to many of their patients,
failing to use it themselves. It is imperative that mental health professionals take care of
themselves with the tools they offer to others in order to continue to make differences in the lives
of others.

SECONDARY TRAUMATIC STRESS

24
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Appendix A
Evaluation and Synthesis Tables

Table A1
Evaluation Table for Quantitative Studies
Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Sampson, M., et al.
(2020) The
MINDBODYSTR
ONG Intervention
for New Nurse
Residents

Cognitive
Behavioral
Theory

Design: RCT

N= 89

IV1:
MINDBODYSTRON
G

Tools:
Perceived Stress
Scale

Statistical
Tests Used:

DV1:
Decreased

DV1: Stress levels

Generalized
Anxiety Disorder
Scale (GAD-7)

IBM SPSS
Statistics

DV2:
Decreased

Country: USA
Funding: None
Reported
Bias:
Hired the new
grads and then
utilized them in the
study
Did not expand to
new grads that
were hired recently
before

Purpose: Evaluate
the effects of
MINDBODYSTRO
NG on mental
health, job
satisfaction, and
health lifestyle
behaviors

Demographics:
New Grad Nurses
hired at the
hospital
Setting:
Midwestern
Academic Medical
Center
Exclusion:
Non-new grad
nurses
Attrition:
17% for 6 month
follow-up
19% - control
17% - intervention

DV2: Depressive
symptoms
DV3: Anxiety
Symptoms
DV4: Job satisfaction
DV5: Health lifestyle
behaviors
Definitions: N/A

PHQ-9
Job Satisfaction
Scale
Healthy Lifestyle
Behaviors Scale
Validity/
Reliability:
Yes

ANOVA
Independent
Sample ttests

DV3:
Decreased
DV4:
Improved
DV5:
Improved

Level of
Evidence;
Application to
practice;
Generalization
Level of Evidence:
2
Strengths:
Measured both
short and long term
effects
RCT for
controlling internal
validity
Valid tools the
Weakness: Small
sample
Nonrandom
sample(all were
new grads and new
hires)

Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS
Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

32
Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice;
Generalization
Feasibility:
Slightly
Application:
Program is
applicable for new
grads

Günüşen, N.P., et
al. (2021) The
effect of a nurseled intervention
program on
compassion
fatigue, burnout,
compassion
satisfaction, and
psychological
distress in nuses: A
randomized
controlled trial.
Country: Turkey
Funding: None
Bias: Only
included those that
scored high risk for
CF

Cognitive
Behavioral
Theory

Design: RCT
Purpose: Evaluate
the effect of a nurseled intervention on
psychological
distress

N= 48
Even split for
control and
intervention group
Demographics:
34-36 y.o.
48 nurses
1 male
Setting: Public
Hospital in
Western Turkey
Exclusion:
Non-nurses, nurse
leadership, did not
complete the
questionnaire, at
low risk for CF,
less than 6 months
experience
Attrition: 8.3%

IV1: Nurse-led CBT
DV1: Compassion
Fatigue

Tools:
Demographic
Questionnaire

DV2: Burnout

ProQOL-IV

DV3: Compassion
Satisfaction

GHQ-12

DV4: Psychological
Distress
Definitions:
CF: stress of trying to
help someone who is
suffering

Validity/
Reliability: Yes

Statistical
Tests Used:
Kolmogorov
Zmirnov test

DV1: no
difference
between
the groups

Level of Evidence:
2

Yates’s
correction

DV2: no
difference
between
the groups

Clear definitions

Fisher’s
Exact Test
MannWhitney U
test
Wilcoxon
signed-rank
test with
Bonferroni
Correction

DV3: no
difference
between
the groups
DV4:
Decrease in
psychologi
cal distress

Strengths: Valid
scales

Weakness: only
done at one
hospital
small sample size
no even diversity
among nurses
potential of
breaking blindness
during the study
Feasibility:
Slightly
Application: Can
be replicated on a

Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS

33

Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice;
Generalization
larger scale for
generalization

Strauss, C. et al.
(2021) Reducing
stress and
promoting wellbeing in healthcare
workers using
mindfulness-based
cognitive therapy
for life

Cognitive
Behavioral
Theory

Design: RCT

N= 234
IV N=115
Control N=119

IV: Mindfulnessbased CBT

Tools:
DASS-21

DV1:
Decrease

Level of
Evidence: 2

DV1: Stress

Demographics:
42-44yrs old
Mostly female
Mostly white

SWEMWBS

DV2: Acceptability

DV2:
Increase

Strengths: Valid
scales

MBI-HSS

Statistical
Tests Used:
Mixedeffects
regression
model

iMTA PCQ

Cohen’s d

DV3:
Increase

Anonymity for
data collection

DV4:
Decrease

Large sample size

Country: UK
Funding: Health
Education England
and Welcome Trust
Bias: None

Purpose: Assess the
effectiveness of
mindfulness CBT in
reducing stress

Setting:
Completed online,
but recruited from
4 Healthcare
organizations
under NHS
Exclusion:
No listed exclusion
criteria
Inclusion: Work
for NHS,
understand
English, be older
than 18, and no
currently on leave
Attrition:
18% = IV

DV3: Effects on
wellbeing
DV4: Depression
DV5: Anxiety
DV6: Burnout
Definitions: None

SOCS
FFMQ-SF

DV5:
Decrease

Validity/
Reliability: Yes

DV6: No
change

Weakness:
Control group was
not an active
comparison
Participants mostly
white and female
Lack of long term
follow-up
Feasibility: Yes
Application: Yes
while addressing
specific
organizational
structure affecting
burnout

Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS
Citation

Xie, C. et al.,
(2020) Education
intervention versus
mindfulness-based
intervention for
ICU nurses with
occupational
burnout: A parallel,
controlled trial
Country: China
Funding: Sichuan
University doctoral
research funds
Bias: None

Theoretical/
Conceptual
Framework

Theory of
Mindfulness
Therapy

Design/ Method/
Purpose

Design: A
randomized parallel,
controlled trial
Purpose: Evaluate
the effectiveness of
mindfulness-based
intervention on
burnout

34
Sample/Setting

3% = Control
N= 106
Even split between
the groups
Demographics:
All females
27 y.o.
Setting: ICU
Hospital
Exclusion:
Worked less than
one year, were on
vacation or leave,
have been part of
of a mindfulness
program in the last
6 months
Attrition: 13.2%
Control
3.8% IV

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice;
Generalization

IV: Mindfulnessbased intervention

Tools:
Maslach Burnout
Inventory

Statistical
Tests Used:

DV1:
Increased

Level of Evidence:
2

MAAS

independent
t-tests

DV2:
Decreased

Strengths: Valid
tool for burnout

DV2: Emotional
Exhaustion

AAQ-II

Chi-square
tests

DV3:
Decreased

Large sample size

DV3:
Depersonalization

Validity/
Reliability: Yes

ANOVA

DV4:
Increased

DV1: Level of
Mindfulness

Weakness:
Limited to ICU
Nurses

DV4: Sense of
Personal
Accomplishments

Randomization
was limited to unit
not participant

Definitions:

Only 3-month
followup

Occupational
Burnout: the
combination of
emotional exhaustion,
depersonalization and
sense of personal
accomplishments

Feasibility: Yes
Application:
Yes, but needs to
be opened to other
healthcare workers

Depersonalization:
unfeeling and
impersonal response
toward recipients of
one’s service
Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS

35

Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Kiley, K. A. et al.
(2018) The
Effectiveness of
Guided Imagery in
Treatment
Compassion
Fatigue and
Anxiety in Mental
Health Workers

The
Professional
Quality of Life
Elements
Theory and
Measurement

Design: Two-arm
RCT

N= 56

IV: Guided Imagery

Demographics:
Mostlymiddle aged
white women,
Setting: Nonprofit Mental
Health Agency

DV1: Compassion
Fatigue

Tools:
SRRS
BFI-10
ProQOL
PSQI Question 6
PSS
STAI - short
form

Statistical
Tests Used:

DV1:
No overall
increase or
decrease

Exclusion: Nonfull time,
substance abuse,
suicidal ideation,
serious mental
health issues, use
of guided imagery
prior to study

Definitions:

Attrition:
Lost 7 from
treatment
Lost 10 from
control
N= 6

Guided Imagery relaxation technique
that relies on
descriptive language

Purpose:
Determine if Guided
Imagery could be an
effective tool

Country: United
States
Funding: None
reported
Bias: None

Reyes Ortega et al.
(2019)
A preliminary test
of social
connectedness
burnout
intervention for
mexican mental

Functional
Analytic
Psychotherapy

Design:
Interventional Study
Purpose: To see if
HTHP was able to
decrease job
burnout

Demographics:
5 therapists, 1
psychiatrist
Age: 26-44
3 male, 3 female

DV2: Stress Levels
DV3: Sleep quality
DV4: Anxiety

Burnout - physical,
mental, and emotional
exhaustion

Unpaired ttests

DV2:
Decrease
DV3:
Increase

Validity/
Reliability: yes

DV4:
Decrease

Level of
Evidence;
Application to
practice;
Generalization
Level of Evidence:
2
Strengths: valid
tools
Weakness:
Small sample size.
Potential bias
among workers
Feasibility: Yes
Application: Can
be replicated on a
larger scale

STS - harmful
reaction to workrelated trauma

IV: Helping the
Helper Program
(HTHP)

Tools:
Maslach Burnout
Inventory

DV1: Emotional
Exhaustion

World Health
Organization
Quality of LifeBREF

Statistical
Tests Used:

DV1:
Decreased

Level of Evidence:
3

Robust
improvement
rate
difference
score

DV2:
Decreased

Strengths: valid
tools

DV3:
Increased

Weakness:

Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS
Citation

health
professionals.
Country: Mexico
Funding: None
reported
Bias: Setting is
under co-direction
of first author

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

36
Sample/Setting

Variables

Setting:
Borderline
Personality
Disorder Clinic

DV2:
Depersonalization

Exclusion: All
mental health
workers were
invited. No explicit
exclusion.

DV4: Psychological
Health

Attrition: 0%

DV3: Personal
Accomplishment

DV5: Social
Relationships
DV6: Union and
Support

Measurement/
Instrumentation

Multidimensional
Scale of
Organizational
Climate
Validity/
Reliability: Yes

Data
Analysis

Results/
Findings

DV4:
Increased
DV5:
Increased
DV6:
Increased

Level of
Evidence;
Application to
practice;
Generalization
Small sample size.
Potential bias
among authors
No control group
Feasibility: Yes
Application: Can
be replicated on a
larger scale

Definitions:
Burnout - syndrome
of emotional
exhaustion,
depersonalization, and
lack of personal
accomplishment
Functional Analytic
Psychotherapy (FAP)
- a contextualbehavioral therapy
approach in to
improve client
behavior related to
interpersonal
relationships
Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS

37

Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Level of
Evidence;
Application to
practice;
Generalization

Hofer et al. (2018).
Self-Help for stress
and burnout
without therapist
contact: An online
RCT

Acceptance
and
Commitment
therapy

Design: RCT

N= 119
61 - intervention
58 - control

IV: ACT self-help
book

Statistical
Tests Used:

DV1:
Improved

Level of Evidence:
2

SPSS

Demographics:
Average Age: 44
Mosty female

DV2: Burnout

Tools:
-Perceived Stress
Scale
-Maslach
Burnout
Inventory General Survey
-Beck Depression
Inventory
-Mental Health
Continuum-Short
Form
-Emotion
Regulation Scale
-Acceptance and
Action
Questionnaire II
-Cognitive
Fusion
Questionnaire
-Kentucky
Inventory of
Mindfulness
Skills

DV2:
Improved

Strengths: valid
tools

DV3:
Improved

Weakness:

Country:
Switzerland
Funding:
Schweizerischer
Nationalfonds zur
Förderung der
Wissenschaftlichen
Forschung
Bias: 2 of the
authors wrote the
self-help book
utilized in the study

Purpose: To
determine if a selfhelp book could
decrease burnout

Setting: Online
Exclusion:
Concurrent
psychotherapy,
suicidal intent

DV1: Perceived Stress

DV3: Depressive
symptoms
DV4: Well-being
DV5: Impact of
difficult emotions
DV6: Psychological
Flexibility

Attrition: 17.6%
Definitions:
Burnout: one’s
response to chronic
stressors in the
workplace
ACT: a CBT with the
goal of enhancing
psychological
flexibility

Reliable
Change
Index

DV4:
Improved
DV5:
Improved
DV6:
Improved

Reliant on selfreported
information
Feasibility: Yes
Application: Can
be replicated on a
larger scale

Validity/
Reliability: Yes

Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

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38

Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Cascales-Perez et
al. (2021).
Effects of a
mindfulness-based
programme on
health- and workrelated quality of
life of healthcare
professionals

Maslach’s
Theory of
Burnout

Design: RCT

N= 58
30 = intervention

IV: Mindfulnessbased stress reduction
programme

Tools:
Five Facet
Mindfulness
Questionnaire

Statistical
Tests Used:

DV1:
Improved

Level of
Evidence;
Application to
practice;
Generalization
Level of Evidence:
2

KolmogorovSmirnoff test

DV2:
Decreased

Strengths: valid
tools

SF-36 Health
Questionnaire

Levene Test

Country: Spain
Funding: None
Bias: Potential
selection bias

Purpose: Evaluate
the effectiveness of
mindfulness-based
stress reduction to
improve quality of
life and analyze
persistence of
improvement after
follow-up

Demographics:
Mean Age: 49-52.
Majority were
nurses
Setting: Primary
Care centers in
Alicante Public
Health Service
Exclusion:
Psychiatric
diagnosis
Attrition: 0%

DV1: Quality of Life
DV2: Burnout

Profile of Mood
States
Maslach Burnout
Inventory
Professional
Quality of Life
Validity/
Reliability: Yes

Mixed 2x2
ANOVAS
Repeated
Measures
ANOVAS

No one dropped
the study
Weakness:
Small sample size
Not blinded
Feasibility: Yes
Application: Can
be replicated on a
larger scale

Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS

39

Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Watanabe et al.
(2019).
Brief mindfulnessbased stress
management
program for a
better mental state
in working
populations happy nurses
project: A
randomized
controlled trial

Maslach’s
Theory of
Burnout

Design: RCT

N= 80
Demographics:
Female
Nurses
21-55 yrs old
Setting: Inpatient
Wards at the
general hospitals
in the Tama
Region

IV: Mindfulnessbased stress
management program

Tools:
Hospital Anxiety
and Depression
Scale

Statistical
Tests Used:

No
significant
differences
found

Country: Japan
Funding:
Intramural
Research Grant for
Neurological and
Psychiatric
Disorders of
National Center of
Neurology and
Psychiatry, Japan
Bias: None

Purpose: Compare
the effectiveness of
a brief mindfulnessbased stress
management
program (IV) with a
psychoeducation
leaflet group
(Control)

Exclusion:
planning to take
leave within 26
weeks, engaged in
psychotherapy,
being treated for
mental health
disorder, history of
taking
supplements,
clinical depression,
consumption of
fish more than 4x a
week, taking
anticoagulants,
history of stroke
Attrition: 3
dropped from
intervention group

DV1: Depression
DV2: Anxiety

PHQ-9

DV3: Burnout

Generalized
Anxiety Disorder
Scale

DV4: Insomnia

Maslach Burnout
Inventory
Insomnia
Severity Index

Mixed model
repeated
measures
analysis

Level of
Evidence;
Application to
practice;
Generalization
Level of Evidence:
2
Strengths: valid
tools
low attrition rate
Weakness:
Small sample size
Feasibility: Yes
Application: Can
be replicated on a
larger scale

The World
Health
Organization and
Work
Performance
Questionnaire
EuroQol
Validity/
Reliability: Yes

Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS

40

Citation

Theoretical/
Conceptual
Framework

Design/ Method/
Purpose

Sample/Setting

Variables

Measurement/
Instrumentation

Data
Analysis

Results/
Findings

Wampole et al.
(2020).
Exploring social
work lead
mindfulness-based
intervention to
address burnout
among inpatient
psychiatric nurses:
A pilot study

Theoretical
Framework:
Maslach’s
Theory of
Burnout

Design: Exploratory
Study

N= 5
Demographics:
Nurses
Mean Age: 42
Experience: 13 yrs

IV: SW led
mindfulness
intervention

Tools:
Maslach Burnout
Inventory Human Services

Statistical
Tests Used:

DV1:
Minor
improveme
nt

Country: U.S.
Funding: None
Bias: None

Conceptual
Framework:
Dialectical
Behavioral
Therapy

Purpose: If SW led
mindfulness
intervention can
lead to reduction in
burnout

Setting: 1
inpatient
psychiatric unit
Exclusion:
Uncontrolled
mental health
disorder, nonnurses, nurses not
working in direct
care
Attrition:

DV1: Burnout

Descriptive
Statistics

Level of
Evidence;
Application to
practice;
Generalization
Level of Evidence:
3
Strengths: valid
tools

Definitions:

Weakness:

Burnout: adverse
behavioral, emotional,
and physical
symptoms developed
in relation to the
workplace

Small sample size

Mindfulness: the
practice of directing
one’s thoughts and
emotions to the here
and now

intervention not
held at a regular
interval
Feasibility: Yes
Application: Can
be replicated on a
larger scale

Key: ACT Acceptance and Commitment Therapy, CBT Cognitive Behavioral Therapy, CF Compassion Fatigue CPS Child Protective Services, DV Dependent Variable, IV
Independent Variable, RCT Randomized Control Trial, S.P Social Pedagogues, SUD Substance Use Disorder SW Social Worker

SECONDARY TRAUMATIC STRESS

41

Table A2
Synthesis Table
Study
(Author, year)
Design
LOE
Sample
n subjects
M-Age
AR
Nurses
SW
MD/NP
Other

Sampson et
al., 2020

Günüşen et al.,
2020

Strauss et al.,
2021

RCT
II

RCT
II

89

48
34-36
8.3%
48

17%
89

Xie et al.,
2020

Kiley et al.,
2018

Reyes Ortega
et al., 2019

Hofer et al.,
2018

RCT
II

RCT
II

RCT
II

IS
III

RCT
II

234
42-44
18%
59
45
10
120

168
27

56

6
26-44
0%

119
44
17.6%

30%
168

CascalesPerex et al.,
2021
RCT
II

Watanabe et
al., 2019

Wampole et
al., 2020

RCT
II

ES
III

58
49-52

80
30
3.75%
80

5
42
0%
5

X

X

X

X
X

30
5
1
44

12
16

Setting
Hospital
Clinic
Online
Interventions
MINDBODYSTRON
G
Guided Imagery
HTHP
Self-Help Book
MBI
CBT
Outcomes/ Themes
Stress Levels
QoL
Burnout
Anxiety
Depression

X

X

X
X

X

X

X
X

X
X
X
X
X
↓

↓
↓

↓
↑
-

X
X
↓
↑
↓
↓

X

X

↓

↓
↑
↓

↓

↓

↓
↓

↑
↓

-

↑

Key: AR Attrition Rate CBT Cognitive Behavioral Therapy ES Exploratory Study HTHP Helping the Helper Program IS Interventional Survey LOE Level of Evidence M-Age Mean Age MD Doctor
MBI Mindfulness-Based Intervention NP Nurse Practitioner QoL Quality of Life

SECONDARY TRAUMATIC STRESS

42
Appendix B

Models and Frameworks
Figure B1
Model of Burnout

Note. Demonstrates the factors influencing burnout noted by lack of resources and demands.
Shows the three components of burnout: exhaustion, cynicism/depersonalization, and diminished
accomplishment. Displays the consequences of burnout noted by costs (Maslach, 1998).

SECONDARY TRAUMATIC STRESS
Figure B2
The Clinical Scholar Model

Note. The Clinical Scholar Model encourages nurses to use EBP to implement clinical change
and develop a culture of innovative change (Strout et al., 2009).

43

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44
Appendix C

Methods Documents
Figure C1
Approval: Expedited Review

SECONDARY TRAUMATIC STRESS
Figure C2
Recruitment Flyer

45

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Figure C3
Consent Form

46

SECONDARY TRAUMATIC STRESS
Figure C4
Demographic Survey

47

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Figure C5
Maslach Burnout Inventory: Human Services Survey for Medical Personnel

This survey is completed before and after the mindfulness intervention.

48

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Figure C6
Educational Flyer

49

SECONDARY TRAUMATIC STRESS
Figure C7
Weekly Check in Email and Check in Questionnaire

50

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51
Appendix D
Logic Model

Goals: The purpose of this doctoral nursing project is to reduce feelings of burnout in mental health professionals through a mindfulness grounding technique.

OUTPUTS

INPUTS
Psychiatric Mental Health
Nurse Practitioners
Psychiatrists
Employees with direct
mental health patient care
Participant Demographic
Questionnaire
Maslach Burnout
Inventory Human Services
Survey for Medical
Personnel (Lin et al.,
2022).
Educational brochure
about grounding technique
(created by project leader)
Educational video about
grounding technique
(created by project leader)

Activities

A

Target

Collect initial data
using surveys (Lin et
al., 2022; Bride et al.,
2022)
Educate participants on
grounding technique
using brochure and
video (what it is, how
to do it, benefits)
Encourage participants
to complete grounding
technique during work
(at least once a day)

Providing education
materials on mindfulness
and teaching a grounding
technique aligns with
Maslach
multidimensional theory
of burnout (Maslach,
1998).

Short
Sh

Increased knowledge
on grounding
techniques,
mindfulness and its
effects on burnout
and secondary
traumatic stress

Psychiatric
Mental Health
Nurse
Practitioners
Psychiatrists

Comfortability
utilizing grounding
technique at work, at
least once.

Employees with
direct mental
health patient
care
Providing an intervention
to address the lack of
resources can impact the
organizational cost of
turnover and absenteeism
per Maslach
multidimensional theory
of burnout (Maslach,
1998).

OUTCOMES
Medium
M di

Continued
understanding of
mindfulness and the
grounding technique.

Consistent use of
grounding technique
during the workday
(1-2 times a day)

Decrease in Burnout
symptoms (Maslach
Burnout Inventory,
Human Services
Survey for Medical
Personnel)
Decrease in
Secondary Traumatic
Stress Symptoms
(Secondary
Traumatic Stress
Scale

IMPACT
L

Continued
understanding of
mindfulness and the
grounding technique.

Consistent use of
grounding technique
during the workday
(at least 1x/day but
up to as many times
needed)
Decrease in Burnout
symptoms (Maslach
Burnout Inventory,
Human Services
Survey for Medical
Personnel)
Decrease in
Secondary Traumatic
Stress Symptoms
(Secondary
Traumatic Stress
Scale
Lower scores
compared to first day.

Educational
materials on
mindfulness and
techniques for
employees (new
and old)
Ongoing use of
education
materials.
Employees
continue to use
mindfulness
throughout their
work days
Improved
knowledge on
mindfulness.
Reduction in
burnout
Prevent increase
in organization
turnover.
Maintain current
retention rate

Assumptions: The participants will have some symptoms of burnout and secondary traumatic stress (Brown et al., 2022; Yazici and Ozdemir, 2022). The
participants will not have their own mindfulness techniques. The participants will learn from the educational materials provided. The participants will
complete the grounding technique regularly.

SECONDARY TRAUMATIC STRESS

52
Appendix E
Project Budget

Direct Cost

Indirect Cost

Activities
Permission to utilize
picture of burnout
inventory in paper and
for IRB review
License permission to
distribute and collect
burnout inventory in
project

Cost

Total
$50

$2.50 per test
(min 50)

$250

$50

Internet bill
Canva Pro subscription
(create flyers, brochures,
etc)

$200/month
$12.99/month

Funding

American Rescue Plan –
improving mental health
worker retention and
mental health (Assistant
Secretary for Public
Affairs, 2022).

$103 million
nationwide

Potential
Revenue/Cost
Savings

Avoid turnover/low
retention costs

$3045,000/recruit

$320
$1200
$77.94
$1200.94

Inaccessible
+$390,000 $585,000

SECONDARY TRAUMATIC STRESS

53
Appendix F
Results

Table F1
Demographics Table
Variable
Gender

Male
Female
Highest Education
Masters
Role/Job Title
NP
Time in Mental Healthcare
2 – 5 years
< 1 year

%

n
1
2

33.33
66.67

3

100

3

100

2
1

66.67
33.33

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54

Table F2
Summary Statistics of Ages
Variable
Age

M
39.33

SD
2.08

n
3

SEM
1.20

Min
37.00

Max
41.00

SECONDARY TRAUMATIC STRESS

55

Table F3
Summary Results from the MBI pre and post Intervention
M
SD
Note. N=3.

EE Pre
26.00
14.00

EE Post
27.67
7.51

DP Pre
9.00
7.55

DP Post
9.67
6.11

PA Pre
31.33
2.52

PA Post
27.67
5.03

SECONDARY TRAUMATIC STRESS

56

Table F4
Statistical Significance Results from the MBI pre and post Intervention
t
p
d

EE
-0.34
0.764
0.20

DP
-0.046
0.691
0.26

PA
0.95
0.441
0.55

Note. N=3. Degrees of Freedom for the t-statistic = 2. d represents Cohen’s d.