Effect of Mantram Repetition as Mindfulness Strategy on Psychological Wellbeing among Nurses in Psychiatric Wards

Background: Nurses treating patients having psychiatric disorders experience numerous stressful events affecting patients' care. Mindfulness mantram repetition, where a sacred word or phrase is silently repeated, can be used as a stress management technique to retrain an individual's attention. Aim: To evaluate the effect of mantram repetition as mindfulness strategy on psychological wellbeing among nurses in psychiatric wards. Design: Quasi-experimental (one group pre-post). Setting: The research carried out at "The Psychiatry, Neurology and Neurosurgery Center, affiliated to Tanta University Hospitals, Gharbya governorate, Egypt. Subject : A convenience sample of 50 nurses. Tools: two tools used in this research Tool I; The Perceived Stress Scale (PSS). Tool II; Ryff’s Psychological Well-Being Scales (PWB). Results: A high statistically significant differences between nurses' levels of stress before and after the mindfulness mantram repetition intervention ( P-value = 0.000). A high statistically significant differences between nurse's psychological wellbeing before and after the mindfulness mantram repetition intervention ( P-value = 0.000), and a statistically significant negative correlation between nurses’ level of stress, and their psychological wellbeing r = -.381, P-value = 0.06. Conclusion: The mindfulness mantram repetition intervention had a considerable positive impact on reducing the nurses' stress and improving their psychological wellbeing . Recommendations: Enhancing nurses' coping mechanisms by making time for mindfulness activities and encouraging them to use this activity.


Introduction
Nursing is a demanding profession with high levels of stress, particularly for nurses providing in-hospital care (Jokwiro et al.

2021).
Nurses working with psychiatric patients face higher stress than those in other departments due to the unique nature of their work, increasing their work risk.The psychological and social stress experienced by these nurses is greater than that of general nurses (Goldberg 2018).
Nurses working in the field of psychiatry often report facing various stressors due to the demanding and high-risk nature of their job (Badu et al., 2020).These stressors are related to working with coworkers, patients, and their families, as well as the

Subject and Method
Design: The study followed a quasi-experimental design one group pre-posttest.

Setting:
Data collection was performed at "The fairly often was scored (3) and very often was scored (4).

Scoring system:
The total PSS score range from 0-40.

Method:
An authorized letter was allotted from faculty of nursing, kafrelsheikh University to setting of the study application to obtain approval for data collection.
The researchers translated the study's tools into Arabic and had them tested for content validity by a jury of five experts in the field of psychiatric nursing to ensure that the items were appropriate for measuring what they were supposed to measure, and the tool was found to be valid.
 Written consent for voluntary participation was obtained from all nurses participating in the study.
 The subjects were informed about the purpose of the study and ensured that the information acquired would be kept Actual study: The actual study divided into the four phases.

Phase one: Assessment phase (pretest)
The study subjects were given the tools

Phase four: Evaluation phase
The evaluation phase of the mindfulness mantram intervention involved reapplying the study tools to all participants both immediately after the intervention and one month later.The purpose was to assess the effectiveness of the intervention.

Statistical Analysis:
The data was processed using SPSS (version 19) software for organizing, tabulating, and statistical analysis.
Quantitative data was evaluated using range, mean, and standard deviation calculations.
For qualitative data, the frequency, percentage, and comparison between categories were assessed using Chi square test.T-test was used for comparison between independent groups' means and paired t-test for related groups.ANOVA test was used for comparing means of more than two groups.
Results were considered significant at P<0.05 and highly significant at P≤0.001.

Results
Table     The study found statistically significant relationships between nurses' level of stress and their residence, income, and years of experience.This may be due to the cultural and social differences between urban and rural areas, the impact of income on stress levels and ease of life, and the influence of work experience on coping with work conditions.
Additionally, the study also revealed statistically significant relationships between nurses' level of psychological well-being and their marital status, education level, income, and years of experience.This may be due to the social and psychological support provided by partners and families, the positive impact of higher education levels on career and social domains, the benefits of higher income on

Conclusion
Based on the results of the present study, it can be concluded that the mindfulness mantram repetition intervention had a considerable positive impact on reducing the nurses' stress and improving the nurses' psychological wellbeing.

Recommendation
The findings of this study inspired a number of suggestions: • The mindfulness mantram repetition intervention program should be used with general population • Further researches with larger and higherquality trials are needed to draw more conclusive and generalizable results.
• The mindfulness mantram repetition intervention should be used as a complementary treatment for nurses and patients.
• Postgraduate education curricula should cover this topics

(
psychiatric nurses have garnered significant attention due to its negative effects on the nurse, their work, and the patients they care for (Hasan & Tumah, 2019).Mindfulness is defined as a self-directed practice aimed at relaxing the body and calming the mind through focus on the present moment (Mansor et al 2022).It involves paying attention to one's thoughts, bodily sensations, and external stimuli without judgment or assigning meaning to them (Zhang et al 2021).Mindfulness therapy employs various techniques, such as meditation, physical awareness, yoga, and mantras, to increase inner focus and improve self-regulation, ultimately reducing stress, alleviating pain, and enhancing overall wellbeing (Álvarez-Pérez et al., 2022).Mantram (also known as mantra) is an ancient practice that can be found in many spiritual traditions.It involves repetitively repeating a single word, phrase, or prayer and is sometimes referred to as a mantram in Eastern traditions or a holy name in Western traditions (Oman & Bormann.2020).This mindfulness practice has been used for centuries in various religious traditions and can be done anywhere without the need for a specific time or place, unlike many meditation techniques (Badu, 2022).A mantram is a personal, sacred word or phrase that a person repeats to themselves intermittently throughout the day to improve their focus and redirect their thoughts.The practice of repeating the mantram involves slowing down and becoming more mindful, focusing on the present moment without distractions, and avoiding multitasking (Lynch et al., 2018 & Leary et al., 2018).The mantram repetition program has been shown to alleviate stress and psychological distress and enhance quality of life in various populations.The program instructs individuals to slow down their thoughts and focus their attention by repeatedly saying a personal word or phrase with spiritual significance (Indradevi 2020 & Bormann et al 2014).The practice is simple and can be done discreetly, and is recommended to start during relaxed moments and before bed to facilitate relaxation, increase mindfulness, and improve sleep (Beck et al 2017).As the individual progresses, the technique can be used during stressful events or intrusive thoughts to regulate emotions and calm behavior (Indradevi, 2020).The psychological well-being of nurses is a major concern in the nursing profession (Lee et al 2019).Nurses with higher levels of mindfulness are better equipped to maintain their well-being by having greater emotional awareness, understanding, acceptance, and the ability to improve negative moods (Foster et al. 2018).This study explored the impact of using mantram mindfulness therapy as a stress intervention for nurses working in psychiatry on their psychological well-being et al 2020).This has led to negative impacts on the psychological wellbeing of nurses, which in turn affects their health and the quality of patient care (Hasan & Tumah 2019).The stress is due to conflicting roles, aggressive behaviors from patients, and role conflict.To address these issues, mindfulness mantram repetition has been introduced as a stress intervention for nurses working with psychiatric patients, as spirituality has been recognized as a crucial factor for health and well-being (Lynch et al. relations, purpose in life, and self-acceptance).Each item was scored on a 5-point Likert scale ranging from 1 "strongly disagree" to 5 "strongly agree".The total score was (42 to 210).Scoring system of PWBscale was as follow: > 50% = low Psychological well-being 50 % -75% = average Psychological wellbeing > 75% = high psychological well-being Tools of the study were supported by nurses' sociodemographic and professional information such as age, gender, residence, income, level of education, and years of experience.
confidential and utilized only for the purpose of the study. Respecting the right of the study subjects to refuse to participate or to withdraw from the study at any phase was emphasized. The nature of the study does not produce harm for subjects A pilot study was carried out before embarking in the field of work on 10% from total subjects to ascertain the clarity and applicability of the study tool.Also, it served to estimate the approximate time required for filling study tool as well as to identify obstacles that might be faced during data collection.After pilot study, it was found that each nurse took 15-20 minutes to fulfill tool of the study and no modification was done on study tool.The pilot subjects were excluded later from actual study sample.Internal consistency of the study tools (tool I and tool II) was done using Cronbach's Alpha coefficient, which yielded values of r = (0.924, 0.782) respectively.The data was collection over a period 3 months started from May 2022 to August 2022.


individually and asked to fill out the scales in the presence of researchers for any clarification.The filling time for the scales was approximately 15 to 20 minutes.This phase aimed to assess the subjects' needs as a baseline for the intervention.Phase two: Development of the mindfulness mantram repetition intervention program The intervention was designed based on the results of phase one and a comprehensive review of relevant literature.(Álvarez-Pérez et al 2022, Duffy et al 2022, Harris et al 2021, Hallett 2021, Matko et al 2021, Indradevi 2020 & Bormann et al 2014). The mindfulness mantram intervention program was designed to reduce stress and improve psychological wellbeing of the participants.The program consisted of three core practices: mantram repetition, slowing down and one-pointed attention. Participants were divided into small groups of 3-5 individuals and conducted the program in 5 sessions per group over two days of the week (Saturday and Wednesday). Each session lasted for approximately 60-The implementation phase was divided into five sessions.The first session was an orientation aimed at building trust and introducing the objective of the program, while also discussing the major stressors faced by nurses in caring for patients with psychiatric disorders.At the session termination, the researchers revised the next sessions' schedule with the participants.In the second Session: This session covered the concepts of stress management techniques, types and importance of is being focused without diversion on a self-selected task; one-pointed attention is the opposed to multitasking.The third session involved clarifying the application of the intervention and demonstration/re-demonstration by the researchers and nurses.Every nurse selfselected a word or phrase with a spiritual meaning as (In the name of Allah' the most Merciful, the most Compassionate, There is no might or power except with Allah, There is no God but Allah, Muhammad is the messenger of Allah, Oh God bless and bless our prophet Mohammed, ……etc).Every meaningful word or phrase is repeated silently throughout the session 3 times; each time continued 5 minutes.The fourth session focused on enhancing the application of the mindfulness mantram intervention by every nurse for 10 minutes.Ensuring that mantram is portable and can be practiced anywhere; no special equipment, device applications, or specific practice locations are required.Feedback from the study subject was obtained.The researchers discussed with nurses their emotions regarding the mindfulness mantram intervention.The fifth session aimed to emphasize the importance of repeating the intervention throughout the day.The researchers evaluate the mindfulness mantram intervention.Throughout the program, the researchers served as facilitators and instructors, fostering critical thinking and encouraging participation and feedback from the participants.By the end of each session, the participants were asked to note any constructive changes they experienced.
Mantram mindfulness techniques allow persons to be more self-aware and present in the moment and manage their wellbeing (Oman & Bormann, 2020).The aim of this study was to evaluate effect of mantram repetition as mindfulness strategy on psychological wellbeing among nurses in psychiatric wards.The research findings provide support for the study's research hypotheses.The study found statistically significant differences in nurses' level of stress before and after the mindfulness mantram repetition intervention.The researchers attribute the significant reduction in perceived stress after the intervention to the ability of the nurses to better handle personal problems, cope with daily duties, control daily irritations, and manage anger outbursts.This suggests that the intervention program helped in improving the nurses' stress management skills.The results of the current study are in line with the research which highlighted that mantram repetition has beneficial effects on reducing stress Malaktaris et al., (2022) who also found that mantram repetition practice decreases stress symptoms.Hulett et al., (2022a) found in their study "Acceptability of the Mantram Repetition Program to Reduce Stress" that the study participants reported low to moderate levels of stress and anxiety after the intervention, compared to high stress levels before the intervention.Leary et al., (2018) in their study "The effect of mantram repetition on burnout and stress among VA staff" found that mantram repetition was effective in decreasing stress levels.Additionally, Bormann et al., and increased selfacceptance.These findings suggested that the intervention program had a positive impact on the psychological wellbeing of the nurses.These study findings aligned with the research on the benefits of mantram repetition on psychological wellbeing which conducted by Hulett et al., (2022b) and Oman was supported by the findings of Duffy et al., (2022), Harris et al., (2021) & Hallett, (2021) that suggested the use of mindfulness mantram repetition as a feasible and effective stress management strategy, as they are capable of improving psychological and social wellbeing in the workplace.

Table 5 :
Reveals that a significant

Table 7 :
The result demonstrated that,

Table 2 : Comparison between mean scores of the studied nurses' perceived stress pre and post intervention Pre Post Mean Difference Paired t-test
*Pre = preintervention *Post = post intervention