Our latest columns exploring ways to integrate simulation into mindfulness training have generated quite a lot of discussion. We have fielded many questions revolving around the theme "How do we integrate this important teaching with limited time, resources, and space?" In this column, we have selected three questions from the field we felt were most relevant to our readers. We hope our response is sensible, practical, and easy to employ. In case you were wondering, a group as diverse as the nursing professional development (NPD) community generates all sorts of questions, ranging from "how to educate the range of learners from those basic to the advanced" to "how to navigate systems-related barriers" to "how to make a return on investment (ROI) appeal to leadership" regarding mindfulness training. So, let's jump right in.

Sue from Michigan asks, "I'm a fairly new NPD practitioner. I love simulation for teaching clinical skills, but how do I teach nontechnical skills such as 'mindfulness'? Can you provide a framework with practical steps?"

CWP & MEH: This is a great question, Sue. Simulation works well for teaching both technical and nontechnical skills as it engages learners in a deeper way than material presented in just a didactic manner. The framework that we have been using for mindfulness education is the Six Mindfulness Strategies Model (Park & Holtschneider, 2018). The model includes the essential steps to developing a measured response to a negative stimulus, which are to pause, breathe, identify your emotion (not the other person's emotion), recognize the space between stimulus and response, choose how to respond, and finally respond. By simulating real-life situations with our learners and encouraging them to practice using these steps, we can help them develop skills to mitigate potentially destructive and relationship-damaging interactions. Teaching these steps can be taught as a standalone session, particularly if you have time allotted in an established educational offering, such as nursing orientation, new graduate transition to practice, and student nurse extern programs.

These mindfulness steps can also be incorporated into simulations that you already have in place. For example, if you already have a simulation that you regularly use to teach management of a clinical case, such as quick recognition and treatment of myocardial infarction, you could add a standardized patient into the scenario to play an irate or impatient clinician. You could then debrief the team on how these mindfulness strategies can help keep the potentially volatile situation from getting out of hand.

Whether teaching mindfulness strategies as a stand-alone topic or incorporating them into existing scenarios, our best advice is to jump in and try different approaches to see what works best for you at your facility.

Janet from New Jersey asks, "As much as I would love to focus my teaching on topics such as mindfulness and using your Six Mindfulness Strategies, I have so many other educational requirements that I have to meet with my learners. How can I do this in my busy workplace?"

CWP & MEH: Quite a few of our readers have asked this very question. Clearly this is a common issue. As we have discussed in our previous three columns, mindfulness practices can help enhance an individual's well-being and contribute to a positive work environment. Yet, a topic such as this is generally considered to be "nice to have" rather than essential in most workplaces.

One way to navigate through this dilemma is to consider introducing this important topic during established educational opportunities as previously mentioned, such as during orientation, new graduate transition to practice programs, and student nurse extern programs. These are a few examples where NPD practitioners exert a relatively high level of control over the learners' schedules. Securing a dedicated educational place in these areas, where you commit to presenting content on mindfulness and leading some relevant scenarios, can provide a great avenue to start piloting how such training will unfold and be received.

Here's our approach. We have incorporated simulation of mindfulness scenarios into our professional practice lecture time given during new nurse orientation. We introduce the Six Mindfulness Strategies and facilitate practice with several straightforward cases that include situational scenarios that involve a negative interaction, such as being yelled at in the workplace by another clinician. All levels of learners can relate to being in these challenging situations in their own lives and can also identify how they have suboptimally handled them in the past.

New graduate transition to practice programs and summer nurse extern programs provide a rich opportunity for starting mindfulness education as these learners generally attend educational days throughout their programs. This offers time to do follow-up on content and allows for discussion on how they have incorporated mindfulness principles into their daily practice. They also can serve as promoters of this training when they go back to their individual units and spread the word about its potential value.

As a word of caution, before jumping straight into lecturing learners about mindfulness, it may be helpful to ask the group what they think of when they hear the word "mindfulness." The answers are often wide-ranging and sometimes rather surprising. We have heard responses such as "being present in the moment," "breathing deeply," "meditating," "Zen," "yoga," and "being calm." We'd love to hear what your learners say in response to the question.

Let's entertain a third question. Joe from New Mexico asks, "Do you have any suggestions on how to present an ROI proposition to hospital leaders who remain skeptical about the value of this type of training?"

CWP & MEH: Joe, thank you for that question. As NPD practitioners, we share the important responsibility to remain proactive with the leadership and to affect positive change within our work environment. Across the United States, every organization is wrestling with the issues of workplace safety, hostility, and possibly burnout. The good news is that society, in general, is beginning to appreciate the importance of being mindful and the need for mindfulness training in our exceedingly fast-paced world. We are seeing many references to mindfulness in journals and the popular press. So naturally, we believe mindfulness training is relevant to the ROI conversation with the leadership.

The American Association of Critical-Care Nurses (2016) delineates six standards that are essential for workplaces to maximize patient outcomes, nurse satisfaction, and professional fulfillment. Despite the standards, many workplaces remain unhealthy and face high nurse turnover rates, high call out rates, and workplace dissatisfaction. The costs associated with paying overtime and last minute coverage fees for a colleague who calls out significantly impacts the staffing budget. Worse yet, when the workplace becomes exhausting, toxic, or unbearable, many nurses become "burned out" and either quit or leave that clinical space. Although the cost associated with nurse turnover remains variable across the United States, overall the hospital cost to replace one RN is between $37,700 and $58,400 (Nursing Solutions, Inc., 2016). If there is any truth in the proverb, "An ounce of prevention is worth a pound of cure," the hospital leadership would be wise to place greater emphasis on teaching and empowering nurses with mindfulness tools. We are convinced that this type of training enhances one's ability to handle stressful situations.

We want to thank all of those who have written to us with questions and comments. In our next column, we will continue to answer questions from readers and explore the various ways that simulation as a modality can be used to teach and rehearse mindfulness principles. Have you started to implement mindfulness teaching yet? If so, what successes and challenges have you encountered? What responses have you received from your learners and those in hospital administration? Please e-mail us at mailto:[email protected] and mailto:[email protected] to continue the dialogue.

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