Meditation-based on mindfulness in Primary Health Care: care strategy in the nurse’s role^a

Abstract

Objective  to understand how the meditation based on mindfulness can be a care strategy in the context of nurses' work in Primary Health Care.

Method  qualitative, participatory research, carried out with 16 nurses from a municipality in southern Brazil. Data collection was carried out between September 2020, using open-ended in-depth interviews in virtual format. Thematic content analysis was used for interpretation.

Results  care approaches mindfulness-based meditation, especially in relation to the principles of acceptance, self-knowledge, compassion, patience and understanding of human beings. Through meditation, nurses develop a low-cost care strategy, which uses the capacity and training of the human mind to be present and connect with what is really involved.

Conclusion and implications for practice  the meditation is a care resource in the context of Primary Health Care nurses' work, however, it is known that it is not a widely used practice, which still constitutes a challenge for professionals, healthcare services health and training institutions.

Keywords:
Health; Mindfulness; Meditation; Nurses; Primary Health Care

Resumo

Objetivo  compreender como a meditação baseada em mindfulness pode ser uma estratégia de cuidado no contexto de atuação dos enfermeiros na Atenção Primária à Saúde.

Método  pesquisa qualitativa, participante, realizada com 16 enfermeiras de um município do Sul do Brasil. A coleta de dados realizou-se entre setembro e dezembro de 2020, com utilização da entrevista aberta em profundidade, em formato virtual. Para a interpretação, utilizou-se a análise de conteúdo do tipo temática.

Resultados  o cuidado se aproxima da meditação baseada em mindfulness no que tange aos princípios de acolhimento, autoconhecimento, compaixão, paciência e compreensão do ser humano. Por meio da meditação, os enfermeiros desenvolvem cuidado de baixo custo, que se utiliza da capacidade e treinamento da mente humana em estar presente e se conectar com o que está realmente acontecendo.

Conclusão e implicação para a prática  a meditação é um recurso de cuidado no contexto de atuação dos enfermeiros da Atenção Primária à Saúde, contudo, sabe-se que não é uma prática amplamente utilizada, o que ainda constitui um desafio para os profissionais, serviços de saúde e instituições formadoras.

Palavras-chave:
Atenção Plena; Atenção Primária à Saúde; Enfermeiros; Meditação; Saúde

Resumen

Objetivo  comprender cómo la meditación basada en mindfulness puede ser una estrategia de cuidado en el contexto del trabajo del enfermero en la Atención Primaria de Salud.

Método  investigación cualitativa, participativa, realizada con 16 enfermeras de una ciudad del Sur de Brasil. La recolección de datos se realizó entre septiembre y diciembre de 2020, mediante entrevistas abiertas en profundidad, en formato virtual. Para la interpretación, se utilizó el análisis de contenido temático.

Resultados  el cuidado se aproxima a la meditación basada en mindfulness en cuanto a los principios de aceptación, autoconocimiento, compasión, paciencia y comprensión del ser humano. A través de la meditación, los enfermeros desarrollan una atención de bajo costo, que utiliza la capacidad y el entrenamiento de la mente humana para estar presente y conectarse con lo que realmente está sucediendo.

Conclusión e implicación para la práctica  la meditación es un recurso de cuidado en el contexto del trabajo de los enfermeros de Atención Primaria de Salud, sin embargo, se sabe que no es una práctica ampliamente utilizada, lo que aún constituye un desafío para profesionales, servicios de salud e instituciones de formación.

Palabras-clave:
Atención Primaria de Salud; Mindfulness; Enfermeros; Meditación; Salud

INTRODUCTION

In Nursing assistance, care promotes the adoption of behaviors and the creation of scenarios to reconstruct intersubjectivity, as it is not limited to the technologies used. The meaning attributed to care refers to all the ways of caring and interacting between professionals, users and families. Therefore, care modalities differ from each other, ranging from therapy, procedures and techniques to strategies for preventing and maintaining physical, mental and social health. The act of touching, comforting and carrying out educational activities, being present, are care actions by nurses that are not prescribed in medical records and manuals.¹

In this context, meditation stands out as a care strategy in nursing practice, consolidating an emerging area of knowledge and study. There are currently many types of meditative practices available, with specific methods and purposes, including mindfulness-based meditation.² It is translated into Portuguese as mindfulness and is a meditation practice known as the heart of Buddhist meditation. However, it has a universal, non-religious essence³ and is part of the integrative and complementary health practices within Primary Health Care and the Unified Health System.

It is a method that proposes living the present moment in full, allowing transformation in human beings. It is a practice, a way of life, a habit, which has a positive influence on health, well-being, quality of life and mental balance. The development of meditation is a continuous process that evolves over years of daily practice.³

It can be taught and honed in training courses, but the practice of mindfulness-based meditation is challenging, especially when it comes to maintaining it in the face of life's stressful situations. The constant exercise of this type of meditation allows the feeling of compassion to increase, because the practitioner gets used to accepting the moment as it is, without judgment, helping to improve decision-making and interpersonal communication.⁴

The practice of meditation based on mindfulness causes changes in brain areas as it exercises attention in the present moment, because in this type of practice the mind not only thinks, but is aware that it is thinking.⁵ In nursing care, the practice of meditation based on mindfulness can show changes in brain areas in practitioners, which improves their knowledge of themselves and others. Thus, this meditative practice is an important intervention tool for health care, which works on reducing people's physical and mental distress and can integrate the care provided by nurses in health institutions. This practice allows patients to become aware of self-knowledge, mainly how the body reacts in stressful situations, how to deal with emotions and the physiological impact of their disease, trauma or hospitalization. Nurses can also benefit from this practice, as it promotes health, prevents illness and acts to treat stress-related problems, tackling unbalanced situations with assertiveness in the work process.⁴

Authors who sought to evaluate the effects of using mindfulness-based meditation and acupuncture in healthy individuals identified a significant improvement in levels of anxiety, depression and quality of life after one month of treatment. Thus, mindfulness and acupuncture protocols appear to be feasible and potentially effective in improving the quality of life of healthy people with common mental suffering. However, only the effects of mindfulness were maintained throughout follow-up among the participants.⁶

In addition, breathing exercises and meditation are recognized in England as mind-body practices that lead to stress reduction and physical and mental well-being, becoming important allies in relieving pressure on the National Health Service and reducing the need for medical and psychological treatments.⁷

The research question thus arose: How can mindfulness-based meditation be a care strategy in the context of nurses' work in Primary Health Care? To this end, it was based on the theoretical framework of Jon Kabat-Zinn. In 1979, this author started a Stress Reduction Clinic at the University of Massachusetts Medical Center, using mindfulness as an eight-week intervention program and systematizing meditation as a method of health care in the Western world.³

This study proved to be relevant and to have the potential to produce knowledge in an area that is still little explored by nurses. The biomedical model prevails in health care, predominantly acting on diseases to the detriment of care. Therefore, it is increasingly necessary to invest in broad and comprehensive approaches to understanding the needs of each human being, which justified the development of this investigation, which aimed to understand how meditation based on mindfulness can be a care strategy in the context of nurses' work in Primary Health Care.

METHOD

This is a qualitative, participatory study that seeks to understand social reality by bringing together and allowing intimacy between the educator (researcher) and the students (those being researched), based on empathy and motivation.⁸

The study was developed in the Primary Health Care network from a capital city in the Brazilian South region. The participants were 16 nurses, representing at least one nurse per Health District. The research participants were selected for convenience, intentionally, based on their involvement with the research problem and the criterion of data saturation was not used, precisely because we sought to unveil the object of study with robustness and representativeness.

The inclusion criteria were: to be a nurse; to be linked to Primary Health Care, whether a civil servant or not; to know some kind of integrative and complementary health practices; to be at least 18 years old; of both genders; and to commit to taking part in all stages of the research. The exclusion criteria were as follows: other health professionals (physicians, dental surgeons, nursing technician/assistants) and being on holiday, away from work or on leave during the data collection period.

The information was collected using the open in-depth interview technique, in virtual format, with each interview lasting a mean of 20 to 30 minutes. In this type of interview, the interviewee is invited to speak freely about a subject and the researcher's questions aim to deepen their reflections. In addition, the subject matters do not follow a static sequence, as it is determined by the concerns and relevance that each interviewee attributes to the topic. The amount of material produced in these interviews tends to be greater, denser, with a degree of depth that is incomparable to, for example, a closed interview or a questionnaire, because qualitative proximity makes it possible to reach dimensions that are inaccessible to a simple question and answer.⁹

In this research, the open in-depth interviews were conducted through the following indications: I. Tell me about meditation, care and autonomy; II. Tell me about mindfulness-based meditation in your life, work and society; III. How can meditation be a strategy for care and professional autonomy for Primary Health Care nurses? The interviews were conducted individually with each participant on days and times previously scheduled. They were carried out from September to December 2020 and developed by a PhD student nurse with experience in this type of approach, through the Google Meet platform, recorded and later transcribed.

Thematic Content Analysis was used to interpret the data. Thematic analysis was developed in three stages: pre-analysis, material exploration and treatment of the results obtained and interpretation.⁸ Initially, the recorded interviews were completely transcribed and the files organized into folders, with the participants identified. An exhaustive reading of the material was also performed in this stage. At a second moment, the data were aggregated into two categories, based on the identification of the main nuclei of meanings found in the interviews. In the last stage, the data were processed, interpreted and discussed against the national and international literature.

The research followed the principles of Resolution 466/2012 of the National Health Council, which governs studies with human beings.¹⁰ The study was approved by the Research Ethics Committee of a Public University in Southern Brazil, under opinion number 4.193.694, dated August 2020, and by the Municipal Health Department of a municipality in Southern Brazil, under opinion number 4.285.417, dated September 2020. In order to safeguard and preserve the participants' identity, anonymity was maintained by using names of crystals, chosen by the nurses themselves. In addition, the checklist of consolidated criteria for qualitative research (COREQ) was used in order to qualify the research carried out.¹¹

RESULTS

The 16 participants in the study were female, represented nine (90%) of the Municipal Health Department's Health Districts, were aged between 35 and 69, and had between eight- and 22-years’ experience working in Primary Health Care.

In relation to their training levels, 13 (81.25%) had some lato sensu post-graduate degree, one (6.25%) also had a stricto sensu post-graduate degree (at the MSc level) and three (18.75%) had no post-graduate degrees. In relation to religion: non-practicing Catholics (six), practicing Catholics (five), no religion (three), Evangelical (two), Spiritist (two), wishes to learn about Buddhism and Spiritism (one), and Buddhist (one). It is worth noting that some participants included two or more religions as beliefs professed.

In relation to courses/experiences with integrative and complementary health practices, the participants had varied training and experience: meditation/mindfulness, acupuncture, auriculotherapy, reiki, aromatherapy, massage, Bach florals, suction cups, Access bars, herbal medicine and family constellation. A total of nine (56.25%) participants knew some type of meditation and practiced or had already practiced it at some point in their lives; four (25%) had a post-graduate degrees in Acupuncture; and six (37.5%) had training in Auriculotherapy.

From the information analysis, carried out manually by the researchers using Microsoft Excel spreadsheets and functions and following the recommended stages (pre-analysis, material exploration and treatment of the results obtained and interpretation), six thematic categories were reached, two of which are presented in the following results: I. Mindfulness-based meditation: Unveiling its concept and applicability in nurses' routine; and II. Nurse care through mindfulness-based meditation in Primary Health Care. These categories were derived from the data and the participants did not validate the findings, as this stage was not foreseen in the research.

I. Meditation-based on mindfulness: Unveiling its concept and applicability in nurses' routine.

The interviewees attributed different meanings to meditation, based on their experiences in the field of integrative and complementary health practices. Some reports indicated that meditation is a self-knowledge strategy, seeking inner quietness/peace and emptying the mind. In addition, it emerges as a strategy to calm thoughts and feelings down and practice silence.

I learned about a mindfulness course, and it was very special to be able to get in touch with myself a little bit and get to know myself in a way that I could calm down and accept. Meditation is quietness. I think it's contact with myself, it's stopping the world outside, freezing everything and taking that time for yourself. (Angelite)

For me, meditation is an introspective moment when you empty the mind, a moment of silence, because the world is too noisy. (Honey Calcite)

[...] meditation brings peace. The breathing process brings peace, comfort [...] I think that meditation is a connection process of your physical body with your mental, spiritual and psychological part. I believe that it's a connection with our several beings, to try to connect with a common objective. (Citrine)

To meditate is to look at the inside, it's looking at internal issues. (Quartz)

It was evidenced that the participants recognize the effects of meditation, especially to promote their mental health and quality of life.

Meditation improves brain oxygenation, serotonin, heart beats, even immunity, it has all these beneficial effects. (Honey Calcite)

Self-knowledge, feelings of joy and pleasure, improved mood, stress reduction, improved sleep quality. (Black Turmaline)

We have many problems, manifestations of mental diseases due to patients' imbalances. I think that the ideal would be to have a meditation group so that, in the group, the patients can find themselves, reorganize themselves with the life processes. (Orange Calcite)

Meditation can be used in mental health situations; I believe in that. Stress, anxiety, depression, it works on those issues, focusing on mental health. Because if you're mentally well, it'll reflect in your body. If you enjoy good mental health, you're going to have good physical health too. Everything is connected. (Green Quartz)

It was also unveiled that meditation is driven/anchored by conscious breathing, which is the first step to reach the meditation state. This ratifies the therapeutic aspect of breathing for balance and health promotion.

Mainly breathing, so I can calm down [...]. Generally, it's when I'm too accelerated, too agitated, with too many things to do, that my head won't stop. Then I breathe, I calm down and manage to lead things. Three breaths usually calm me down. What strikes me is the ability to pay so much attention to your breathing that you feel the cold air coming in through your nostrils. (Angelite)

Breathing helps. In fact, it is the anchor of meditation. (Tiger Eye)

In addition to the formal meditation practice, informal mindfulness practice in the participants' everyday lives was highlighted as a strategy to live with more awareness, connection with the present moment and assertiveness, especially in times of stress.

I use meditation at home at all times. I've used it to be fine with myself. When a stressful situation arises and I need to make a decision, I first take a deep breath. (Tiger Eye)

I practice at home. I started doing it due to the anxiety thing itself, I've practiced meditation for more than six years. I started alone, I sought meditation practices on YouTube. What I perceived in myself was a big sensation of managing to control anxiety [...] (Amazonite)

The results showed that meditation is an integrative and complementary health practice known by the participants and is used as an individual strategy for daily care and self-care. Through the participants' reflections, there was an awakening to sowing meditation in nurses' performance, as a care and autonomy strategy in Primary Health Care.

II. Nurse care through mindfulness-based meditation in Primary Health Care.

The participants highlighted care as a Nursing legacy and as the possibility to meet the human beings assisted, seeking to understand them without any need for technological devices. On the contrary, care shows itself in the relationship marked by equality and horizontality between the professional and the person that needs to be cared for, going beyond the disease.

Care is when you don't just focus on the clinical aspect, the illness, the pain, but to go beyond that. It's trying to identify with the patient the origins of the pain. For example, sometimes it's not just physical pain, but pain in the soul. (Blue Quartz)

Care is when you look at a person and manage to perceive what they need to be OK. Care is being able to look and do your best. (Quartz)

Care is being able to take people in when they need it, being able to support them. Often, people come in crying, and we go and talk to them. Caring isn't just about the illness; it's about caring for the whole person. (Blue Calcite)

Care was unveiled as a nurses' concept and practice in Primary Health Care, with a multidimensional and social aspect.

Caring is precisely looking at the other person as a whole [...] it's looking at the other person from their perspective. Family health provides a lot of this for us, when you know, you know the environment where the person lives, when you know the house they live in, when you know their family relationships, their work relationships, when you know them a little more deeply, you end up judging less and you literally exercise care. (Blue Quartz)

Care is so broad, it's everything, taking care of everything. It's taking care of all aspects of human beings, taking care of the social issues, the emotional issues, the physical body. (Angelite)

Care is a very broad word. Care is a word that has many meanings. It's a patient, an appointment, a form of assistance, it's what I can most do for the patient. (Orange Calcite)

In nurses' daily perspective, care involves autonomy, as it produces transforming relationships in the lives of people and families, making them responsible for their choices within the scope of the therapeutic path.

Care is that you have autonomy and provide autonomy to the person you're taking care of. (Citrine)

Care extrapolates what we learn as a rule in the basic techniques. It awakens self-care in the other, that accountability. I believe that care is also making the patients have the ability to be with themselves. It's to actually give tools for these people to go on in the best possible way, so that they're not dependent on the professionals. (Obsidian)

Care? I believe that it's when you stop to listen to the other, in the Primary Health Care context, seeking to assist in self-care. (Pink Quartz)

In addition to that, it was suggested that health professionals should resort to mindfulness with a view to assisting in the quality of the care provided, as well as to qualify the very coexistence among team members.

I believe that all health professionals should experience mindfulness, because it assists in care quality and coexistence among the professionals themselves. (Angelite)

It can be seen that meditation based on mindfulness is approaching care as a therapeutic resource for Primary Health Care nurses. In this scenario, by inserting meditation into the context of integrative and complementary health practices, spaces for democratizing meditation are promoted and access and the dimension of care and autonomy for nurses are expanded.

DISCUSSION

As a result of globalization and the epidemiological scenario, new and complex challenges have entered the context of Primary Health Care. From this perspective, the demands brought by users require increasingly sensitive and longitudinal care, and integrative and complementary health practices are essential resources for the development of comprehensive physical and mental health care, establishing themselves as a paradigm of health care. This paradigm rescues human beings' essence, promotes more conscious thinking about life and the experiences of illness, care and cure, and expands the professionals' perspective towards integrality and human multidimensionality.¹²

An integrative review study, which sought to characterize the benefits of integrative and complementary health practices, including meditation in nursing care, revealed the following main impacts: relaxation and well-being, reduction of pain and anxiety, reduction of signs and symptoms of diseases, in addition to strengthening professional-patient contact, reducing the use of medication and adverse reactions, improving the immune system and promoting quality of life. In this scenario, the role of Nursing is fundamental in the search for knowledge and qualified care practices, reducing the financial impact on secondary- and tertiary-level care.¹³

However, Nursing timidly contributes to scientific productions on meditation, still having a vast path to explore. The fact is that nurses can be trained to work with meditation within the care provided to the population, as they are professionals who, since graduation, have developed comprehensive, autonomous and expanded health practices.¹⁴ Meditation based on mindfulness isn't complicated and doesn't establish a feeling of success or failure, because even at times when it's difficult to meditate, it's possible to learn about the workings of the mind and benefit psychologically. It also promotes the cultivation of deep and compassionate awareness, stimulating rethinking/reflection on life and true values.³

Meditation practices are guided by two basic principles: The body influences the mental processes and the mental processes influence the body; and meditation begins with attention/awareness of the breath. There are different ways to cultivate mindfulness, such as formal or informal meditation practices. Formal meditation is characterized as a specific moment devoted to meditating, which can be performed sitting, standing, lying down or moving. In turn, informal meditation practice is the actual meditation of everyday life, which consists in making life have the same extension as the meditative practice, recognizing what is within us, what we want, what we do not want, and what we do not truly perceive with the meditation program.³

It is worth remembering that for professionals, frequent meditative practices also exert positive impacts on their health and work. Self-compassion is significantly and independently associated with happiness and well-being in health professionals who practice mindfulness.¹⁵ One study showed that the eight-week mindfulness-based stress reduction program helped to reduce work-related stress, anxiety, depression and other negative emotions among the nurses who took part in the study.¹⁶

The practice of mindfulness has a positive influence on reducing stress, anxiety, depression and exhaustion, causing a sense of well-being and empathy in nurses and nursing students. It is therefore an effective strategy for preventing and managing stress and suffering in the workplace,¹⁷ corroborating the findings of this study. To this end, it is essential that professionals develop the habit of meditating in their daily lives and work, because only training will lead to a better perception of mood, less perception of stress and a more assertive response to stimuli.¹⁸

It is noted that, in Nursing, there is certain direction aimed at human beings and at care since training, with the purpose of maintaining people's health in all dimensions, stimulating integrality. As a profession, it stands out for care practice, which is nourished by scientific and ethical knowledge, allowing nurses to plan, guide, make decisions and reflect. In this sense, care is constituted in an inter-relational way and should be an objective, a goal in the nurses' work process.¹⁹

By considering care as the essence of nursing, the aim is to empower nurses and, consequently, people and their families, interweaving informal and popular knowledge with professional knowledge, in a constant dialog and movement of action-reflection-action, which has an impact on liberation and the adoption of practices that are more coherent with the life experiences of each individual and their family and social context, in order to manage their health-disease conditions.²⁰ Thus, meditation, as an integrative and complementary health practice, can be a care strategy that boosts autonomy and influences physical and mental health, enabling positive results in relation to stress, anxiety, depression, psychosomatic disorders, among others, and intensifies the human being's understanding of themselves, their feelings, signs and symptoms.

Integrative and complementary health practices promote new paths for care, solidifying multi-professional actions within the Unified Health System and in partnership with the local community, stimulating self-care and autonomy for individuals to take greater responsibility for their health and lives.²¹ To this end, the act of meditation is related to the work of nurses, because it promotes attentive observation, looking beyond the physical dimension and welcoming people centered on the present moment, making professionals more likely to understand users' anxieties and fears, calming them down and teaching them to breathe and relax. Encouraging the person being cared for to listen carefully to music, visualize images of nature and contemplate can help reduce anxiety and increase physical and psychological comfort, as meditation is a practice that works the body and mind, with low cost and high potential health benefits.²²

CONCLUSION

Meditation based on mindfulness is a care strategy in the context of nurses' work in Primary Health Care, as it enables them to accompany individuals and families, training them to use their minds for physical and mental health. Meditation can be guided by trained nurses as nursing care for different situations in the health-disease process.

This study has contributed to the production of knowledge for nurses who work and/or plan to work in the field of integrative and complementary health practices, as they are care techniques that can and should be used in Primary Health Care and have a positive impact on the lives of people and their families, as well as having important implications for nursing practice. However, it is known that integrative and complementary health practices, such as meditation/mindfulness, are not hegemonic care practices, thus marking a challenge for professionals, health services and training institutions. It is hoped to motivate nurses and universities to train in integrative and complementary health practices, especially meditation, in order to equip professionals for this type of care, seeking autonomy and integrality in health.

The study's limitations include the number and profile of the professionals who took part in the research, which may influence the results, given that it is a group of nurses with knowledge, training and experience in the world of integrative and complementary health practices and meditation.

• a
  Article extracted from the Doctoral Thesis in Nursing – Mindfulness in Primary Health Care: Building Nurse Care and Autonomy from the Perspective of Health Promotion. Author: Indiara Sartori Dalmolin. Advisor: Ivonete Teresinha Schülter Buss Heidemann. Programa de Pós-Graduação em Enfermagem. Universidade Federal de Santa Catarina. 2022.

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Edited by

• ASSOCIATED EDITOR
  Rodrigo Nogueira da Silva https://orcid.org/0000-0002-3870-5239

• SCIENTIFIC EDITOR
  Ivone Evangelista Cabral https://orcid.org/0000-0002-1522-9516

Publication Dates

• Publication in this collection
  09 Dec 2024
• Date of issue
  2024

History

• Received
  04 June 2024
• Accepted
  19 Oct 2024