Does Mindfulness Training Enhance the Professional Development of Residents? A Qualitative Study

Sustainable benefits of mindfulness training in health professions education

BACKGROUND

Healthcare work and even studies towards a healthcare profession is associated with a high prevalence of distress. According to recent meta-analyses, half of the medical students worldwide suffer from burn out prior to residency, and 34% of nursing students suffer from depression. The aim of this study was to investigate healthcare students' long-term experiences of mindfulness training, and whether, how and why students were continuing their mindfulness practice after graduation. Further, to assess if background characteristics were associated with continuing mindfulness practice.

METHODS

A mixed method survey study based on predetermined and open-ended questions. Qualitative and quantitative data were analysed concurrently to assess effects on, and a deepened understanding of stress management, use of mindfulness in relation to patients, oneself and others, and continued practice of mindfulness.

RESULTS

Two hundred one of the 380 (52,8%) students completing the mindfulness based stress management course (MBSM) answered the questionnaire. Of all, 175 (87,1%) students also answered free text questions. The qualitative analysis identified five themes: "Positive" Experiences, "Negative" Experiences, "Origin and development of interest in mindfulness" and "Continuing practice of mindfulness". A considerable proportion of the participants experienced increased acceptance, relaxation, ability to face difficulties, self-compassion and better interaction with patients, but some participants also experienced negative experiences such as aversiveness and ineffectiveness of the course. Those continuing to practice mindfulness after graduation were more likely (85.3%) to say that the gained competence helped in their relationship with patients, compared to those who did not continue to practice (57.1%); (chi2 = 18.13; df = 2; p < 0.001). Among those who had previous mindfulness or similar experience, 84% continue to practice mindfulness after the course, compared to 50% of those who had no previous experience (chi2 = 26; df = 1; p < 0.001).

CONCLUSION

The long-term follow-up of mindfulness training for healthcare students shows that participants maintain a sustained capability to handle stressful work situations in their professional practice and develop a more compassionate relationship with themselves. We argue that skills to care for one's inner environment, such as learning mindfulness as a student, can contribute to a sustainable future professional life. However, further research is needed to confirm the transferability of the results.

Mindfulness, Self-Compassion, and Perfectionism in Physician Assistant Students: Implications for Wellness Curricula

Objectives

There is growing consensus that wellness strategies should be incorporated into health professions education; however, there is more to be learned about developing targeted, effective curricular interventions. Study objectives were to identify aspects of mindfulness most prominent in physician assistant (PA) students and determine which aspects of mindfulness most strongly predict well-being. The study examined cognitive patterns, protective (self-compassion) and harmful (maladaptive perfectionism), that underlie impostor phenomenon which may impact professional identity development and risk for burnout.

Methods

Newly matriculated students (n = 351) at six PA programs nationally were invited to participate. Validated survey instruments assessed mindfulness, self-compassion, maladaptive perfectionism, impostor phenomenon, and well-being. Data were assessed using descriptive statistics and linear regressions.

Results

The survey response rate was 94.8% (351/370). At the onset of training, PA students were highest in Non-judgement, followed by Observation and Description. Their relatively lowest levels were Non-reactivity and Acting with Awareness. Of the five aspects of mindfulness, Non-judgement was the strongest predictor of well-being, followed by Description and Non-reactivity. Collectively, these three abilities explained 24.62% of variance in well-being. Higher levels of maladaptive perfectionism and lower levels of self-compassion accounted for 53% of the reported level of impostor phenomenon in PA students.

Conclusion

Study results provide direction for educators when developing wellness curricula. Three of the five aspects of mindfulness examined were significant predictors of well-being. Higher levels of maladaptive perfectionism and lower levels of self-compassion accounted for experiences of impostor phenomenon in PA students. Findings suggest potential benefit from a targeted approach to implementing mindfulness curricula.

A realist review of programs fostering the resilience of healthcare students: What works, for whom and why?

BACKGROUND

Various programs aimed at fostering the resilience of students have been implemented into healthcare undergraduate and postgraduate educational courses and degree programs. Which of these increase their participants' resilience under which circumstances, for whom and why remains uncertain.

METHODS

A realist review of articles reporting program outcomes as measures of resilience through the use of via validated psychometric surveys was conducted to investigate which contexts favour the development of resilience of healthcare and health sciences students and which mechanisms have to be activated to achieve this outcome.

RESULTS

Thirteen Context-Mechanism-Outcome Configurations were synthesised from data presented in 43 articles. These were combined with theories explaining the theoretical and psychological frameworks underpinning programs to develop a program theory of how and why resilience fostering programs work. Contexts which favour the development of resilience were the use of validated psychological frameworks as program foundation, e.g. Cognitive Behavioural Therapy, mindfulness-based training. Expert facilitation, longitudinal integration into curricula, flexible and multi-modal design and delivery, and opportunities for students to apply and practice resilience-building strategies also created favourable contexts. Meeting students' or practitioners' needs activated mechanisms of trust, engagement and recognition of a program's value and real-world benefits. An increase in resilience was achieved by students developing reflective skills, metacognitive awareness and positive habits of mind.

CONCLUSION

The program theory established via a realist review provides guidance on how the individual resilience of healthcare students can be fostered throughout their undergraduate, postgraduate degrees and early practice, potentially supporting them to flourish and remain long-term in their chosen professional roles.

Mindfulness in the Medical Learning Environment: An Opportunity for the Struggling Learner?

Mindfulness is defined as nonjudgmentally and purposefully paying attention in the present moment. Mindfulness may be a valuable tool in the remediation armamentarium, useful in bringing attention to an individual's struggles. However, such application has largely been unexplored. In this essay, we provide a conceptual framework for future empirical study of mindfulness interventions for struggling medical learners. We review literature on mindfulness interventions in medical education at-large, apply them to the struggling medical learner, discuss limitations to mindful practice, and provide recommendations that will help faculty assigned to struggling learners be mindful themselves to optimally function in these roles.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02115-8.

A systematic scoping review on group non-written reflections in medical education

BACKGROUND

Medical education is tasked with shaping how medical students and physicians think, feel and act as professionals, or their Professional Identity Formation (PIF). This process has traditionally rested upon imparting knowledge; integrating sociocultural, professional and organizational expectations and codes of conduct; inculcating program and practice beliefs, values and principles (belief systems); and imbuing shared identities - quintessential elements that, together, comprise the socialization process. Key to supporting this socialization process is reflective practice. However, regnant approaches to mobilizing reflective cycles are faced with resource, personnel and time constraints, hindering efforts to nurture PIF. Group non-written reflections (GNWR) - broadly defined as facilitator-led discussions of shared reflective experiences within groups of learners - may prove to be an effective compromise. To address diverse approaches and a lack of effective understanding, we propose a systematic scoping review (SSR) to map the current use of GNWR in medical training and its role in shaping PIF.

METHODS

Guided by the Systematic Evidence-Based Approach (SEBA)'s constructivist ontological and relativist epistemological position, this SSR in SEBA searched for articles on GNWR published in PubMed, Embase, Psychinfo, CINAHL, ERIC, ASSIA, SCOPUS, Google Scholar, Open Grey, GreyLit and ProQuest databases. The data found was concurrently analyzed using thematic and direct content analysis. Complementary themes and categories identified were combined, creating the domains that framed the discussion.

RESULTS

Of the 8560 abstracts and 336 full-text articles reviewed, 98 articles were included. The four domains identified were: (1) Indications of use and their value; (2) Structure and how they can be used; (3) Models of reflective practice in GNWR; and (4) Features of communities of practice and the socialisation process.

CONCLUSION

This SSR in SEBA concludes that GNWR does impact PIF when effectively structured and supported. The Krishna-Pisupati Model for PIF platforms a model that explains GNWR's effects of PIF and advances fourteen recommendations to maximize GNWR use.

The role of mindfulness in stress, productivity and wellbeing of foundation year doctors: a mixed-methods feasibility study of the mindful resilience and effectiveness training programme

BACKGROUND

Medical Foundation Year (FY) doctors demonstrate greater psychological distress compared with the general population and other student groups. This feasibility study investigated FY doctors' perceptions of mindfulness and the impact of a mindful resilience and effectiveness training (MRET) programme on stress, wellbeing, and performance.

METHODS

Mixed-methods study utilising a questionnaire (study 1, N = 144) and a pre-post analysis design of MRET programme (study 2, N = 13), along with focus groups (N = 7).

RESULTS

In study 1 28.5% of FY's reported using mindfulness. All five mindfulness facets were significantly, and positively, associated with mental wellbeing (p < 0.05). Acting with awareness (AA) and non-reactivity (NR) were significantly, positively associated with a challenge responses to stress (p < 0.05). Threat and loss appraisals were negatively associated with AA, NR, and non-judging (p < 0.01). Perceived productivity was positively associated with mindfulness facets: describing, AA, and NR (p < 0.001). In study 2, there were significant increases in wellbeing and mindfulness facets observing, describing, AA, and NR, and threat appraisals decreased (p < 0.05). The main themes identified across the focus group included Reframed Mindset, Values-Based Action, Embodied Leadership and Pedagogy.

CONCLUSIONS

There exists a relationship between mindfulness, psychological wellbeing, and performance in FYs. The MRET prorgamme improved psychological wellbeing and reduced threat appraisals. Future work could focus resources on enhancing the skills of AA and NR, as this may be sufficient to bring about meaningful improvements in wellbeing, percieved productivity and cognitive reappraisal of stressful life events.

Mindfulness-based supportive therapy on reducing suffering in patients with advanced cancer: randomised controlled trial

OBJECTIVES

Suffering is common among patients with advanced cancer. The practice of mindfulness during patient care can potentially reduce suffering. We aimed to examine the efficacy of mindfulness-based supportive therapy (MBST) on reducing suffering in patients with advanced cancer.

METHODS

We conducted a parallel-group, single-blinded, randomised controlled trial at the University of Malaya Medical Centre, Malaysia. Seventy-three patients with advanced cancer with an overall suffering score ≥4/10 based on the Suffering Pictogram were recruited and randomly assigned into either the MBST group (n=34) or the control group (n=39).

RESULTS

There was a statistically significant reduction in the overall suffering score in the MBST group compared with the control group (U=432.5, median1=-2.0, median2=-1.0, z=-2.645, p=0.008). There was also significant improvement in the total Hospital Anxiety and Depression Scale score (U=483.5, median1=-4.0, median2=-3.0, z=-1.994, p=0.046), and the total Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being score (U=252.0, median1=+14.5, median2=+5.0, z=-4.549, p=0.000) in the MBST group compared with the control group.

CONCLUSIONS

The results provided evidence that the practice of MBST during patient care could promote positive psychosocial outcomes.

Reflection on medical errors: A thematic analysis

BACKGROUND

As there is a need to prepare doctors to minimize errors, we wanted to determine how doctors go about reflecting upon their medical errors.

METHODS

We conducted a thematic analysis of the published reflection reports of 12 Dutch doctors about the errors they had made. Three questions guided our analysis: What triggers doctors to become aware of their errors? What topics do they reflect upon to explain what happened? What lessons do doctors learn after reflecting on their error?

RESULTS

We found that the triggers which made doctors aware of their errors were mostly death and/or a complication. This suggests that the trigger to recognize that something might be wrong came too late. The 12 doctors cited 20 topics' themes that explained the error and 16 lessons-learnt themes. The majority of the topics and lessons learnt were related more to the doctors' inner worlds (personal features) than to the outer world (environment).

CONCLUSION

To minimize errors, doctors should be trained to become earlier and in time aware of distracting and misleading features that might interfere with their clinical reasoning. This training should focus on reflection in action and on discovering more about doctors' personal inner world to identify vulnerabilities.

Reflecting on insight and insights into reflection: a systematic review of insight and reflection in post graduate medical education

BACKGROUND

Clinicians recognize insight as important for safe independent medical practice. Clinical education literature focuses on self-reflection. The aim of this review is to describe how clinical educators conceptualize reflection and ask is it analogous to how clinicians conceptualize insight?

METHODS

Using PRISMA guidelines, a systematic review of the literature around insight and reflection in postgraduate medical education was undertaken. A thematic analysis of the concepts of insight and reflection was performed.

RESULTS

A total of 75 reports were included in the analysis. The literature focussed predominantly on reflection with little discussion of insight. Three main themes were generated: episodic reflection; cyclic reflection; reflection as a state. Reflection as a state seemed to be the professional quality most often aspired to but was less well defined in terms of educational interventions. When more than one model was described, it was often with a reflective state being the ideal that episodic or cyclic reflection may approximate. It is not clear that it is possible to progress up the hierarchy.

CONCLUSION

We present a novel description of a hierarchy from discrete episodes of reflection, to cyclic processes that involve reflection, through to a state in which the practitioner is reflective. There is no unified understanding of how an individual ascends this hierarchy, or a cohesive description of what insight is for an independent medical practitioner. This review highlights the need for research into how practicing clinicians conceptualize and characterize insight in their training and practice.

The influence of mindfulness-based stress reduction on the work life of healthcare professionals - A qualitative study

BACKGROUND

and purpose: Quantitative studies show that mindfulness-based interventions can reduce stress and burnout in healthcare professionals. Few qualitative studies have explored healthcare professionals' experiences with mindfulness training. The aim of the study was to explore healthcare professionals' experiences of how attending a course in Mindfulness-Based Stress Reduction influenced their work life, including their relationship with patients and colleagues.

METHODS

Fifty-six healthcare professionals attended a Mindfulness-Based Stress Reduction course between January and June 2022. Participant observation followed by six semi-structured focus group interviews and 15 individual interviews were conducted. Data were collected in a cardiology department and in an obstetrics and gynaecology department. Thematic data analysis was performed. Reporting followed COREQ guidelines.

RESULTS

Six themes were identified: 1) Allowing a pause and focusing on one thing at a time, 2) Awareness of the freedom to choose, 3) The need for self-compassion, as a prerequisite for taking care of others, 4) The value of presence and calmness in patient encounters, 5) Awareness of how stressful behavior affects oneself and others, 6) The value of practicing mindfulness with colleagues.

CONCLUSION

This study suggests that offering Mindfulness-Based Stress Reduction to healthcare professionals can start a positive process of change from a tendency to neglect personal needs to becoming more compassionate towards oneself and others. Mindfulness training may thus prevent burnout and lead to a more compassionate workplace culture that also manifests in better patient care. However, a collective understanding and knowledge of mindfulness in the work setting may be necessary to sustain these changes.

Resident Physician Perspectives on Mindfulness Education in Residency: A Multispecialty Qualitative Assessment of Clinical Care Impact

Background

Mindfulness training positively influences residents personally and professionally. Routine integration into residency may be impacted by limited understanding of the ways in which mindfulness training enhances clinical care.

Objective

We explored residents' direct experience and personal application of mindfulness in their clinical work following 10 hours of mindfulness training.

Methods

Mindfulness training sessions were facilitated between 2017 and 2019 for 5 groups of residents: pediatrics, ophthalmology, postgraduate year (PGY)-1 anesthesiology, and 2 different years of PGY-1 family medicine residents. Training was integrated into resident protected didactic time and attendance was expected, although not mandated, with the exception of pediatrics, in which the department mandated the training. Qualitative evaluation was conducted using a voluntary, semi-structured, de-identified phone interview within 2 months post-training. Reviewers independently coded the transcripts and then dialogued to reach consensus around emergent themes.

Results

Thirty-six of 72 residents (50%) who participated in the training completed interviews. Themes were similar across specialties. All residents acknowledged the potential usefulness of mindfulness training during residency. Six residents (17%) reported they had not applied the mindfulness training to their daily work by the end of the course. There were 4 emergent themes related to clinical application of mindfulness training: integrating brief moments of mindfulness practice, self-awareness, relational presence with patients, and maintaining perspective during clinical encounters and residency training as a whole.

Conclusions

After completing a 10-hour mindfulness training program, residents reported enhanced perspective-taking and relationship-building with themselves and their patients in clinical settings across medical and procedural specialties.

Understanding students' motivations for participating in a mindfulness course: a qualitative analysis of medical students' views

OBJECTIVES

Improving medical students' wellbeing and empowerment through curricular activities is a topic of interest worldwide. Mindfulness-based interventions (MBIs) are increasingly implemented in medical education often as part of elective courses. To better understand training outcomes and adjust curriculum to students' needs, we will explore why will medical students participate in meditation-based education?

METHODS

We analyzed 29 transcripts from the first session of an 8-week MBSR program offered to medical students in French. Transcripts were coded and analyzed using a qualitative content thematic analysis and the constant comparison method.

RESULTS

Analyses resulted in three themes describing students' motivation: (1) Medical education and the physician's role, i.e. improving interpersonal skills, acquiring skills oriented toward a more integrative medicine, being more productive in a highly competitive context. (2) Caring for my health i.e. aiming at stress reduction, emotion regulation, and improving self-compassion. (3) A quest for meaning, i.e. optimizing meaning of care, and meaning of life.

CONCLUSION

The results highlight the congruence between the perceived motivations and the evidence on the effect of mindfulness on self-care, the development of humanistic medical skills, and the meaning of care. Some findings raise the issue of the limits of using mindfulness to enhance one's productivity. Notably, participants articulated the need for self-care as in mindfulness training, with the ability to care for others.

Mindfulness and compassion training for health professionals: A qualitative study

Background

Compassion is a key component of quality care. Encouraging Health Care Professionals (HCPs) to develop a patient-centered care relationship through mindfulness and compassion training may be beneficial for both patients and HCPs.

Method

We assessed the impact of a compassion-centered mindfulness program [i.e., the Mindfulness Based (MB) CARE program] on healthcare practice conducting 10 phone interviews with HCPs who experienced the program.

Results

The training had an overall positive impact on the HCPs ability to feel compassion toward their patients and themselves, helped them develop kindness toward themselves and their patients, and enhanced their attention to their patient's needs and theirs. Participants were better able to accept the difficult work experiences or those their patients experienced, with more perceived equanimity and less reactivity.

Conclusion

Professional mindfulness and compassion training programs could be operational levers for institutions aiming at fostering more compassionate HCPs-patients relationships.

Reduced Anxiety Associated to Adaptive and Mindful Coping Strategies in General Practitioners Compared With Hospital Nurses in Response to COVID-19 Pandemic Primary Care Reorganization

COVID-19 pandemic imposed psychosocial stress increasing in frontline healthcare workers, who managed by responding with different coping strategies. General practitioners were targeted by an extraordinary increase in the demand for reception, diagnosis and treatment from all patients even if working in solo. In Italy, the emergency changed risk assumption and roles in between primary care, unraveling the emotional distress of general practitioners, who suffered not only for isolation, but also emotional threatens. In this correlational study we wanted to evaluate trait anxiety and stress as perceived by general practitioners working in individual ambulatory practice room, and by hospital ward nurses working in group, during a chronic phase (February-May 2021) of COVID-19 pandemic. Our hypothesis is that a different work social organization in clinic contest as for general practitioners compared with nurses could induce adaptive or non-adaptive coping to stress under emergency and mindful attitude could be crucial. A number of 37 general practitioners, and 36 nurses were taken from the sanitary district of ASL1 Avezzano-Sulmona-L'Aquila in Italy. For our analyses we used the Health Professions Stress and Coping Scale to assess the risk of burn-out, and detect the coping strategies. We also used the Cognitive and Affective Mindfulness Scale-Revised, investigating whether clinicians used an eventual mindful attitude to prevent anxiety and responding with adaptive coping strategies. General practitioners reported high levels of anxiety, associated to an increased use of emotional distress. Mindful attitude was protective for anxiety in both general practitioners and nurses. As anxiety increased, it was coped by increasing the demand for social support. This coping strategy correlated with emotional distress and when enhanced, it corresponded to avoidance of the problem. Mindful attitude addressed general practitioners to adaptive coping strategies as the solution of the problem. On the other side, nurses accepted the problem but addressed it to others, by avoiding solving it themselves as beyond their role and organizational responsibility. In conclusion, mindful attitude can prevent dysfunctional reactive behaviors among clinicians at the forefront of emergency and reduce emotional distress for isolation as suffered by general practitioners.

Wellness in Physician Assistant Education: Exploring Mindfulness, Well-Being, and Stress

PURPOSE

The current study examined stress reduction activities most commonly used by matriculating physician assistant (PA) students to better understand how students are approaching self-care and management of stress. In particular, the study examined levels of mindfulness and well-being to understand how these relate to various stress reduction approaches at the time of matriculation.

METHODS

Newly matriculated students at 9 PA programs located across the nation were surveyed (n = 294). Validated survey instruments assessed levels of mindfulness and general well-being. Stress reduction activities were also assessed. Univariate and multivariate analyses were used to examine levels of mindfulness and levels of well-being to see how these relate to various stress reduction approaches.

RESULTS

The survey response rate was 72%. Nearly one-third of respondents (32%) identified meditation as one of their stress reduction activities, and more than half (53%) reported having participated in mindfulness practice at least once in the past year. Sixty-four percent of students reported awareness of mindfulness practices, while only 16% reported frequent practice within the year prior to matriculation. When looking at variables of interest, decentering and psychological flexibility were significant in accounting for student-reported perceived stress and life satisfaction.

CONCLUSION

PA students are likely receptive to mindfulness-based interventions that have the potential to improve well-being and reduce stress. There is opportunity for programs to incorporate reliable and structured training within curricula that effectively increases levels of mindfulness and, in doing so, can lead to improvement in perceived stress and life satisfaction. Further research may assist educators in the development of strategies to promote student and clinician wellness.

Comparing the Effectiveness of Virtual and In-Person Delivery of Mindfulness-Based Skills Within Healthcare Curriculums

Purpose

To promote well-being, healthcare education programs have incorporated mindfulness-based skills and principles into existing curriculums. Pandemic-related restrictions have compelled programs to deliver content virtually. Study objectives were to determine (1) whether teaching mindfulness-based skills within physician assistant (PA) programs can promote well-being and (2) whether delivery type (virtual vs. in-person) can impact the effectiveness.

Methods

During this 2-year study, a brief mindfulness-based curriculum was delivered to incoming first-year students at six PA programs, while students at two programs served as controls. The curriculum was delivered in-person in year one and virtually in year two. Validated pre- and post-test survey items assessed mindfulness (decentering ability, present moment attention and awareness, and psychological flexibility) and well-being (perceived stress and life satisfaction).

Results

As expected, coping abilities and well-being were adversely impacted by educational demands. The mindfulness-based curriculum intervention was effective in increasing mindfulness and life satisfaction, while decreasing perceived stress when delivered in-person. Virtual curricular delivery was effective in decreasing perceived stress but not improving life satisfaction. Over half of the participants receiving the curriculum reported positive changes on mindfulness measures with approximately 14-38% reporting a change of greater than one standard deviation. Changes on mindfulness measures explained 30-38% of the reported changes in perceived stress and 22-26% of the changes in life satisfaction. Therefore, the mindfulness curriculum demonstrated statistically significant improvements in measures of mindfulness and mitigated declines in life satisfaction and perceived stress.

Conclusion

Mindfulness-based skills effectively taught in-person or virtually within PA programs successfully promote well-being.

Experiences of Clinical Clerkship Students With Mindfulness-Based Stress Reduction: A Qualitative Study on Long-Term Effects

Purpose

To explore the mindfulness practice, its long-term effects, facilitators and barriers, in clinical clerkship students 2 years after participation in an 8-week mindfulness-based stress reduction (MBSR) training.

Method

A qualitative study was performed by semi-structured in-depth interviews with 16 clinical clerkship students selected by purposive sampling. Students had participated in a MBSR training 2 years before and were asked about their current mindfulness practice, and the long-term effects of the MBSR training. Thematic analysis was conducted using the constant comparison method. Data saturation was reached after 16 interviews.

Results

Most interviewees were still engaged in regular, predominantly informal, mindfulness practice, although some discontinued mindfulness practice and reported an “unchanged lifestyle.” Three main themes came forward; (1) “focused attention and open awareness” during daily activities as core elements of long-term mindfulness practice; (2) “changes in behavior and coping” that resulted from taking a pause, reflecting, recognizing automatic behavioral patterns and making space for a conscious response; (3) “integration in personal and professional life” by enhanced enjoyment of daily activities, improved work-life-balance and making different career choices. Barriers and facilitators in starting and maintaining mindfulness practice were (1) understanding and intention as “pre-conditions”; (2) practical, personal, and professional factors of students in maintaining practice.

Conclusion

Two years after participation in a MBSR training, many interviewees were still engaged in (mostly informal) mindfulness practice contributing to both personal and professional changes. In light of the high clerkship demands, MBSR training could be a valuable addition to medical curricula, supporting medical students in developing necessary competencies to become well-balanced professionals.

Mindfulness-based stress reduction intervention for elementary school teachers: a mixed method study

BACKGROUND

In the Netherlands, more than half of the teachers working in primary education experience high levels of work stress. Compared to other professions, teachers are more likely to drop out from work and develop mental illnesses. Almost one in five even choose a new profession within 5 years after starting as a teacher. This indicates an urgent need for interventions to reduce stress levels in teachers. However, few evidence-based effective interventions targeting stress and work-related problems in the primary educational system are available.

AIM

In the current paper, we describe the protocol for a randomized controlled study (RCT) comparing an 8-week mindfulness-based stress reduction (MBSR) intervention with a wait list control condition in primary school teachers. We hypothesize that teachers who participate in the MBSR programme will report less stress (primary outcome) than those in the control group at post-test and at 3-month follow-up. We also expect a decrease in teachers' absenteeism and improvements of mental health, teacher skills, classroom climate quality and the pupil-teacher relationship (secondary outcomes). Finally, we hypothesize that self-compassion, mindfulness skills and emotion regulation skills could mediate effects.

METHODS/DESIGN

A mixed-method study will be conducted among N=155 Dutch primary school teachers (grade 1 to 6). The quantitative study will be an RCT, in which teachers will be randomly allocated to the MBSR or waiting list control condition. Trial participants will not be made actively aware of their condition. The data analysts will be blinded. Online questionnaires will be sent to teachers before and after the MBSR programme, and at 3-month follow-up. Information about absenteeism will be collected. In the qualitative part of the study, we will interview teachers to examine their perceived effects of MBSR on their teaching skills, the classroom climate quality and the pupil-teacher relationship.

DISCUSSION

This protocol paper describes a mixed-method study design with an RCT and a qualitative evaluation to evaluate an MBSR programme on perceived stress among primary school teachers. If the MBSR programme proves to be effective, it could be implemented as a programme to reduce stress and improve mental health and teaching outcomes in primary school teachers.

TRIAL REGISTRATION

Nederland Trial Register NL. Registered on 19 November 2019-retrospectively registered, https://www.trialregister.nl/trial/8171.

What Is the State of Compassion Education? A Systematic Review of Compassion Training in Health Care

PURPOSE

To investigate the current state and quality of compassion education interventions offered to health care providers during training or practice, determine how the components of each education intervention map onto the domains of an empirically based clinical model of compassion, and identify the most common approaches to compassion education.

METHOD

The MEDLINE, Embase, CINAHL Plus with Full Text, Sociological Abstracts, Web of Science, ERIC, and Education Research Complete databases were searched from inception to March 2020 in this systematic review. Studies that evaluated a compassion education intervention for health care providers or those in training to enhance compassion toward patients and/or families were included. A narrative synthesis of the included studies was performed. The components of each intervention were mapped onto the domains of compassion described in the Patient Compassion Model.

RESULTS

One hundred eight peer-reviewed publications describing 103 interventions were included. Modalities ranged from establishing curricula and interventions in clinical settings to programs that used humanities-based reflective practices, clinical simulation, role modeling, and contemplative practices, with many education interventions adopting a multimodal approach. Most interventions mapped to the virtuous response domain of the Patient Compassion Model; very few mapped to the other domains of this model.

CONCLUSIONS

Most interventions were limited as they focused on a single domain of compassion; did not adequately define compassion; were assessed exclusively by self-report; were devoid of a comparator/control group; and did not evaluate retention, sustainability, and translation to clinical practice over time. The authors suggest that compassion education interventions be grounded in an empirically based definition of compassion; use a competency-based approach; employ multimodal teaching methods that address the requisite attitudes, skills, behaviors, and knowledge within the multiple domains of compassion; evaluate learning over time; and incorporate patient, preceptor, and peer evaluations.

Mindfulness Is Related to the Situational Awareness of Medical Students Confronted with Life-Threatening Emergency Situations

BACKGROUND

Emergency medicine can impose a heavy psychological burden on healthcare workers. Stress experienced during life-threatening situations may disrupt situational awareness (SA), i.e., the perception of environmental elements with respect to time and space, the comprehension of their meaning, and the projection of their state into the near future. We aimed to investigate whether mindfulness (a special way of paying attention: conscious, non-judgmental, and oriented to the present moment) can be related to the SA levels among final-year medical students confronted with life-threatening situations during medical simulations.

METHODS

The simulations were constructed as high-fidelity scenarios in children and adults (ClinicalTrials.gov ID: NCT03761355). The components of mindfulness were assessed using the Five Facet Mindfulness Questionnaire. SA among students was assessed using The Situation Awareness Global Assessment Technique at three levels: (1) data, (2) comprehension, and (3) projection.

RESULTS

In total, 117 students were included. Level 1 SA positively correlated with the overall mindfulness score and its components, i.e., nonreactivity, conscious presence, and nonjudgment. Moreover, level 3 SA significantly correlated with the description, but not with the overall mindfulness score. A regression model showed that nonreactivity explained 34% of Level 1 of SA variability. The addition of conscious presence and nonjudgment into this model did not change its predictive value.

CONCLUSIONS

nonreactivity a component of mindfulness of final-year medical students is related to the meticulous data collection of patients in life-threatening situations.

Relationship between mindfulness, stress, and performance in medical students in pediatric emergency simulations

Objectives: Pediatric teams of emergency departments work under extreme stress, which affects high-level cognitive functions, specifically attention and memory. Therefore, the methods of stress management are being sought. Mindfulness as a process of intentionally paying attention to each moment with acceptance of each experience without judgment can potentially contribute to improving the performance of medical teams. Medical simulation is a technique that creates a situation to allow persons to experience a representation of a real event for the purpose of education. It has been shown that emergency medicine simulation may create a high physiological fidelity environment similarly to what is observed in a real emergency room. The aim of our study was to determine whether the technical and non-technical skills of medical students in the course of pediatric high fidelity simulations are related to their mindfulness and stress. Participants and methods: A total of 166 standardized simulations were conducted among students of medicine in three simulation centers of medical universities, assessing: stress sensation (subjectively and heart rate/blood pressure), technical (checklists) and non-technical skills (Ottawa scale) and mindfulness (five facet mindfulness questionnaire): ClinicalTrials.gov ID: NCT03761355. Results: The perception of stress among students was lower and more motivating if they were more mindful. Mindfulness of students correlated positively with avoiding fixation error. In the consecutive simulations the leaders' non-technical skills improved, although no change was noted in their technical skills. Conclusion: The results of our research indicate that mindfulness influence the non-technical skills and the perception of stress of medical students during pediatric emergency simulations. Further research is needed to show whether mindfulness training leads to improvement in this field.

How can a 6-week training course shape mental healthcare professionals' understanding of mindfulness? Experiences at Weskoppies Psychiatric Hospital

BACKGROUND

Mindfulness-based practice has gained increasing attention in the mental health community over the last four decades, and many studies have explored the evidence of its various benefits among healthcare users and providers alike. However, there remains limited research regarding the understanding of mindfulness among mental healthcare professionals. This poses the question: how much do mental healthcare professionals really know about mindfulness, and can self-practice increase the understanding of these providers?

AIM

This descriptive or exploratory case study aimed to explore the understanding of mindfulness amongst 15 mental healthcare professionals.

SETTING

The study took place at Weskoppies Psychiatric Hospital.

METHOD

The study was conducted following a 6-week training course in which the participants were taught, and carried out mindfulness-based practices and techniques. The study also explored the following: (1) the healthcare workers' experiences, benefits and challenges regarding the consistent practice of mindfulness and (2) their confidence when explaining the concept of mindfulness, and the practices learned, to other colleagues and patients. Data were collected in the form of semi-structured interviews with the participants, 4-6 weeks after completion of the training course.

RESULTS

Three main themes were identified: (1) understanding of mindfulness expanded with practice; (2) unexpected experiences during the mindfulness course; and (3) experience caused partial gains in confidence and skills. Overall, 15 subthemes were derived from the data collected.

CONCLUSION

Self-practice of mindfulness can increase one's understanding of the concept and the confidence to teach informal techniques. More research is needed to determine how the design and duration of such training could impact this understanding and confidence.

Associations between job demands, job resources and patient-related burnout among physicians: results from a multicentre observational study

OBJECTIVES

To investigate associations of job demands and resources with patient-related burnout among physicians.

DESIGN

Multicentre observational study.

SETTING

Fifty medical departments at 14 (academic and non-academic) hospitals in the Netherlands.

PARTICIPANTS

Four hundred sixty-five physicians (71.6% response rate), comprising 385 (82.8%) medical specialists and 80 (17.2%) residents.

MAIN OUTCOME MEASURES

Job demands (workload and bureaucratic demands), job resources (participation in decision making, development opportunities, leader's inspiration, relationships with colleagues and patients)-measured with the validated Questionnaire of Experience and Evaluation of Work and Physician Worklife Survey-and patient-related burnout, measured using the validated Copenhagen Burnout Inventory.

RESULTS

Patient-related burnout was positively associated with workload (b=0.36; 95% CI, 0.25 to 0.48; p<0.001) and negatively associated with development opportunities (b=-0.18; 95% CI, -0.27 to -0.08; p<0.001) and relationships with patients (b=-0.12; 95% CI, -0.22 to -0.03; p=0.01). Relationships with patients moderated the association between bureaucratic demands and patient-related burnout (b=-0.15; 95% CI, -0.27 to -0.04; p=0.01).

CONCLUSIONS

Physicians with high workloads and few development opportunities reported higher levels of patient-related burnout. Those with positive patient relationships were less likely to experience patient-related burnout, even in the presence of excessive bureaucracy. Therefore, positive physician-patient relationships may be supported to reduce the likelihood of physicians' patient-related burnout. However, the specific support needed to effectively reduce patient-related burnout may vary per healthcare context and thus requires intensified research across healthcare systems and settings.

Healthcare professionals' experiences of using mindfulness training in a cardiology department - a qualitative study

OBJECTIVE AND AIM

Person-centred communication and healthcare professionals' ability to be attentively present in their encounter with patients are essential aspects of patients' experiences of well-being, ability to cope with illness-related challenges and feelings of being recognised. However, the ability to be attentive in relational encounters can be challenging for healthcare staff for many reasons, such as time constraints and a high work pace. Research suggests that mindfulness training could increase staff attentiveness and compassion, but only few qualitative studies have explored the subject. The aim of the current study was to explore doctors' and nurses' individual experiences of how attending an 8-week Mindfulness-Based Stress Reduction course (MBSR) influenced their clinical practice and encounters with colleagues and patients in a cardiology department.

METHOD

Qualitative interviews were held with six doctors and nurses who had completed the 8-week MBSR course. Interpretative phenomenological analysis was applied to explore and understand the meaning of the participants' accounts.

FINDINGS

The MBSR course appeared to have changed the healthcare professionals' thoughts and actions, especially regarding their ability to stay focused on the task at hand, to prioritise and to stay calm in an unpredictable and busy work environment. This was facilitated by using concrete techniques learned during the course, such as breathing and taking small breaks to clear their heads and help them be attentive in relation to themselves, colleagues and patients. Furthermore, they described an increased acceptance of their own limitations, better understanding of their colleagues and greater awareness of the unique patient.

CONCLUSION

These findings suggest that changing healthcare professionals' actions, mindset, awareness and understanding of others may result in a more compassionate work environment and more person-centred care.

Implementation of a Weekly Administrative Hour and the Impact on Case Logging and Duty Hour Reporting in Surgical Residents

OBJECTIVE

To investigate the impact of a dedicated weekly administrative hour on case logging, duty hour reporting, and duty hour violations.

DESIGN

Retrospective analyses of 2 timeframes pre-implementation and post-implementation of a dedicated weekly administrative hour in a surgical residency were assessed for changes in duty hour reporting, case logging, and duty hour violations. The preimplementation period spanned from July 2011 to June 2014 and the postimplementation period from July 2014 to June 2017.

SETTING

Community-based, university-affiliated hospital.

PARTICIPANTS

A total of 79 surgical residents were included over a 6-year period. The subjects worked before and after the implementation of a weekly dedicated administrative time.

RESULTS

Seven and 30-day procedure logging rates improved from 28.7% to 37.2% and 52.7% to 69.9%, respectively (p < 0.001). PGY 1 residents showed a significant increase in procedures logged within 7 days during the postimplementation period. PGY 1, PGY 2 and PGY 3 all showed a significant increase in procedures logged within 30 days during the postimplementation period. Seven and 30-day duty hour completion rates increased postimplementation from 7.8% to 9.2% (p < 0.001) and 64.7% to 67.3% (p < 0.001), respectively. Duty hour violations decreased in the postimplementation time frame (40.6% vs 29.2%, p < 0.001). Duty hour violations were more common in earlier years of training. PGY 1 were 15.6 times more likely to have an 80 hours. per week violation than a PGY5 (OR: 15.1; 95% CI: 2.1-118.0).

CONCLUSIONS

Procedural logging and duty hour compliance improved after implementation of a dedicated weekly time for administrative duties. The year of a resident in training is related to compliance with logging and may impact the incidence of duty hour violations. Residents reported significantly fewer duty hour violations, however this may be multifactorial.

A Cross-Sectional Study of Empathy and Emotion Management: Key to a Work Environment for Humanized Care in Nursing

Introduction

At the present time, technological advances have increased the technification of healthcare services, in which high priority is given to efficiency and results achieved, leading healthcare personnel to prioritize administrative and procedural aspects to the detriment of humanization of care and the work environment.

Objective

This study was intended to continue progress in research on the work environment based on the humanization construct by analyzing the explanatory value of emotional intelligence and empathy in nursing personnel.

Materials and Methods

The study was quantitative, observational, and cross-sectional. The sample was made up of 338 Spanish nurses with a mean age of 32.20 (SD = 7.54; range 22–56). The instruments employed for analysis were the Healthcare Professional Humanization Scale (HUMAS), Brief Emotional Intelligence Inventory for Adults, and Basic Empathy Scale (BES).

Results

Mood and stress management—both emotional intelligence components—and cognitive empathy explained over half (51%) of the variability found in humanization of care in a sample of nurses. Furthermore, the mediation models proposed emphasized the mediating role of cognitive empathy in stress management and improvement in mood and its relationship to humanization.

Conclusion

It is recommended that healthcare professionals reinforce their personal competencies in order to tend to the needs of their patients empathetically and improve emotional competencies for coping successfully with potentially stressful situations.

Relationship between Executive Functions, Mindfulness, Stress, and Performance in Pediatric Emergency Simulations

Over the past decade, high-fidelity medical simulation has become an accepted and widely used teaching method in pediatrics. Both simulation and work in the real conditions of emergency departments are accompanied by stress that affects the executive functions of participants. One of the methods for reducing stress among medical students and healthcare professionals is the practice of mindfulness. The aim of this study was to examine whether executive functions, mindfulness, and stress are related to the technical and non-technical skills of medical students participating in medical simulations in pediatrics. The study included 153 final-year medical students. A total of 306 high-fidelity simulations of life-threatening situations involving children were conducted. Results: Stress and the coping mechanism of the participants were correlated to their skills during pediatric simulations. Some components of mindfulness, such as non-judgment and conscious action, were positively related to the skills of medical team leaders. Executive functions correlated with the non-technical skills and mindfulness of the medical students. Conclusions: Stress, mindfulness, and executive functions modeled the behavior and skills of medical students during pediatric simulations of life-threatening events. Further research in this area may prove whether mindfulness training will improve learning outcomes in pediatric emergency medicine.

Presence, resilience, and compassion training in clinical education (PRACTICE): Evaluation of a mindfulness-based intervention for residents

BACKGROUND

Residents’ well-being tends to decline in the course of training, yet research on preventive and restorative interventions for residents is limited. Mindfulness-based interventions have been successfully employed to support well-being in practicing physicians, but their impacts on residents are not well established.

OBJECTIVE

This paper describes the structure, content, and evaluation of a pilot mindfulness-based intervention program designated PRACTICE (presence, resilience and compassion training in clinical education) that was designed specifically to support resident well-being.

METHODS

A combined sample of 14 postgraduate year one residents from two residency training programs participated in a four-session (8 h) mindfulness-based intervention in the Fall/Winter of 2018. Participants were surveyed before, after, and at 3 months postintervention, on measures of wellness (Professional Fulfillment Index) and mental health (Patient Health Questionnaire-4), along with measures of program engagement.

RESULTS

Participants demonstrated a significant reduction in burnout at the conclusion of the program. Depression and anxiety screening scores also trended toward improvement. However, participants were not able to sustain these gains. Three months after the conclusion of the program wellness measures had returned to preintervention levels.

CONCLUSIONS

The results of this study support the use of mindfulness-based interventions in resident wellness programs. The lack of an enduring effect indicates the need for a maintenance phase intervention.

The impact of mindfulness-based interventions on doctors' well-being and performance: A systematic review

OBJECTIVES

The well-being of doctors is at risk, as evidenced by high burnout rates amongst doctors around the world. Alarmingly, burned-out doctors are more likely to exhibit low levels of professionalism and provide suboptimal patient care. Research suggests that burnout and the well-being of doctors can be improved by mindfulness-based interventions (MBIs). Furthermore, MBIs may improve doctors' performance (eg in empathy). However, there are no published systematic reviews that clarify the effects of MBIs on doctor well-being or performance to inform future research and professional development programmes. We therefore systematically reviewed and narratively synthesised findings on the impacts of MBIs on doctors' well-being and performance.

METHODS

We searched PubMed and PsycINFO from inception to 9 May 2018 and independently reviewed studies investigating the effects of MBIs on doctor well-being or performance. We systematically extracted data and assessed study quality according to the Medical Education Research Study Quality Instrument (MERSQI), and narratively reported study findings.

RESULTS

We retrieved a total of 934 articles, of which 24 studies met our criteria; these included randomised, (un)controlled or qualitative studies of average quality. Effects varied across MBIs with different training contents or formats: MBIs including essential mindfulness training elements, or employing group-based training, mostly showed positive effects on the well-being or performance of doctors across different educational and hospital settings. Doctors perceived both benefits (enhanced self- and other-understanding) and challenges (time limitations and feasibility) associated with MBIs. Findings were subject to the methodological limitations of studies (eg the use of self-selected participants, lack of placebo interventions, use of self-reported outcomes).

CONCLUSIONS

This review indicates that doctors can perceive positive impacts of MBIs on their well-being and performance. However, the evidence was subject to methodological limitations and does not yet support the standardisation of MBIs in professional development programmes. Rather, health care organisations could consider including group-based MBIs as voluntary modules for doctors with specific well-being needs or ambitions regarding professional development.

How medical specialists experience the effects of a mindful leadership course on their leadership capabilities: a qualitative interview study in the Netherlands

OBJECTIVES

Medical leaders are facing leadership challenges that ask for a leadership style that takes care of both themselves and their coworkers. Mindfulness may support this leadership style. We explored how a 'Mindful leadership for medical specialists' course affected medical specialists' leadership.

DESIGN

We conducted a qualitative study based on in-depth interviews. The grounded theory method was used to analyse the data.

SETTING

A university medical centre in the Netherlands.

PARTICIPANTS

Seventeen medical specialists (six male) with an average age of 51 years (ranging from 40 to 66 years).

INTERVENTIONS

The mindful leadership course consisted of 10-weekly 5-hour sessions that focused on cultivating mindfulness and compassion. In addition, sessions included didactic and interactional teaching about leadership theories.

RESULTS

Four categories emerged from the data: (A) Self - Attitude: psychological attitude towards self, (B) Self - Behaviour: behaviour towards self, (C) Other - Attitude: psychological attitude towards others, and (D) Other - Behaviour: behaviour towards others. Themes were defined within these categories: awareness of self, open mind, insight and appreciation of self (A), emotional and cognitive self-regulation, letting go of unhelpful behaviour and developing helpful behaviour (B), differences in attitude to others such as awareness of (impact on) others, keeping an open mind about others, allowing difficult emotions associated with others, appreciating of others (C), and communicating more effectively, providing direction, empowering and caring for others (D).

CONCLUSIONS

The results help us understand the core elements of mindful leadership, both with respect to one's psychological attitude and behaviour towards oneself and others. More research on mindful leadership and the effects on self and others is needed. Mindful leadership courses could be a valuable part of clinical training and might contribute to more sustainable healthcare organisations.