By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
SUMMARY POINTS
- This article reviewed investigations involving brief (< 4 hours) mindfulness interventions in healthcare providers working in hospital settings.
- Fourteen studies met inclusion criteria; seven of these were randomized, controlled studies.
- Outcomes among the studies varied and included measures of provider well-being and behavioral changes.
- Most of the studies demonstrated a decrease in stress level and anxiety, while only one showed decreased symptoms of burnout.
- None of the reviewed interventions were associated with a measurable effect on provider behavior, such as reduced clinical errors or increased attention to tasks, but data on these outcomes were limited.
SYNOPSIS: A review of studies regarding brief mindfulness interventions for healthcare providers found an association with improved measures of provider well-being and no evidence of behavioral changes.
SOURCE: Gilmartin H, Goyal A, Hamati MC, et al. Brief mindfulness practices for healthcare providers — A systematic literature review. Am J Med 2017; July 4. pii: S0002-9343(17)30633-2. doi: 10.1016/j.amjmed.2017.05.041. [Epub ahead of print].
The popularity of mindfulness can be a double-edged sword. Some may be wrongfully tempted to dismiss the term as part of a new trend with “Mindful Eating,” “The Mindful Teen,” and “Mindful Work” publications offering seemingly unlimited possibilities of finding solutions to life problems through this technique. Yet, the concept of mindfulness dates back to the late 1800s, when the term emerged as an adaptation of a Buddhist concept, Sati, one of the factors considered to be on the pathway to enlightenment.1 This Buddhist construct appears unrelated to the Hindi use of Sati.2
About 100 years later, the Buddhist concept was secularized by molecular biologist and meditator Jon Kabat-Zinn, who defined mindfulness as “the awareness that arises through paying attention on purpose in the present moment, and nonjudgmentally.”3
Medical evidence for use of mindfulness techniques, such as meditation, guided imagery, yoga, and desensitization-relaxation exercises, coexist with a more casual use in lay literature. Quality studies looking at use of these interventions to decrease stress and improve decision-making are growing.4 Given the high-tension and high-stakes outcomes inherent in medical practices, it is no surprise that attention has been paid to the use of mindfulness techniques among medical providers.
Preliminary studies show some promise for use of mindfulness interventions in healthcare practitioners, but the time required for training medical providers in these techniques is identified as a limitation to implementation.5 Brief interventions were developed as an attempt to surmount this obstacle. Gilmartin et al conducted a review of 14 relevant studies to determine if these brief mindfulness interventions showed significant association with improvement in provider well-being and/or behavior. For the study purposes, brief interventions were defined as those with training periods lasting less than four hours. Within this time frame, any technique that fit a general definition of mindfulness was included. Delivery systems ranged from in-person to recordings to virtual.
Measurements of well-being included self-reports of stress and anxiety levels, depression, symptoms of burnout, and quality of life. Behavior changes were more objective and included changes in academic performance, tests of attention, or incidence of diagnostic errors.
Fourteen studies met inclusion criteria, with just more than half of the studies published since 2015. More than 800 healthcare providers participated within hospital or inpatient settings. Studies were drawn from four countries — United States (nine studies), Canada (two studies), Thailand (two studies), and Australia (one study). Almost 80% of the participants were female. Half of the studies were conducted with nurses or nursing students, while the other half used physicians, medical students, or residents.
All fourteen studies used multiple measures of provider well-being. Although several of the studies identified significant change in only a subgroup of measures of well-being, only two studies found no significant improvement in any measure of provider well-being. On the contrary, only two studies included an assessment of changes in provider behavior following intervention, and neither found a significant association between a brief mindfulness intervention and change in provider behavior. (See Table 1.)
Table 1: Selected Outcomes of Measures of Provider Well-being |
||
Measure |
Consolidated Results |
Type(s) of Intervention |
|
Stress: measured with Perceived Stress Scale or Nursing Stress Scale |
5/6 studies reported reduced stress levels with P values < 0.056,7,8,9,10 |
Stress Management and Resiliency Training (SMART); 5-minute guided practice; brief home practice |
|
Anxiety: measured with a variety of specific scales |
4/5 studies reported reduced anxiety levels with P values < 0.057,8,9,10 |
SMART; brief home practice |
|
Burnout Symptoms: measured with Maslach Burnout Inventory |
1/4 studies reported reduced burnout symptoms with P value < 0.056,11,12,13 |
Guided daily practice; weekly practice; home practice |
|
Mindfulness: measured with Mindfulness Attention Awareness Scale or Cognitive and Affective Mindfulness Scale |
3/6 studies reported improved mindfulness with P values < 0.0114,6,15,16,9,13 |
5-minute guided daily practice; |
|
Tasks of Attention: measured with self-checklists; memory scale |
1 study only: results not significant17 |
20 minute guided daily practice |
|
Medication administration errors measured by observation |
1 study only: significance of results not reported (embedded in a multifaceted intervention)18 |
Mindful breathing prior to medication administration or med prep |
COMMENTARY
This effort to better understand the effect of brief mindfulness interventions on healthcare providers is a welcome approach to a poorly studied area of healthcare: how to best take care of the caregivers. It is tough to argue against the concept that better-functioning providers leads to better medical care, but the scientific connection is essential to explore, delineate, and document.
While looking at the combined results analyzed in this review, it is important to be cautious assigning causality. The heterogeneity of the included studies (in design, population, methodology, and outcomes) makes understanding and generalizing these results particularly challenging. This leads to the hope that the future will bring more robust and rigorously conducted investigations to best understand interventions that offer healthcare providers the maximum benefits.
Do healthcare providers need care? Results of multiple recent studies regarding the rise of burnout in this profession, as well as the association of an engaged and empathic provider to improved care outcomes, suggest the importance of addressing symptoms of stress, anxiety, and burnout in providers.19,20 It is interesting that this review was not able to identify any provider behaviors that were changed in association with the interventions, but important to note that only two studies attempted measurements in this area. Large-scale studies looking at specific targeted provider behaviors are needed before drawing conclusions regarding brief mindfulness interventions and these type of outcomes.
Prior to this publication, studies of the effect of mindfulness interventions for healthcare providers concluded that the techniques hold promise for the field, but that the time required to train, practice, and implement represented a significant barrier to use in hospital work.5,21 This review study helps bring some clarification to this area, suggesting that brief mindfulness training is associated with a reduction in healthcare providers’ perception of stress and anxiety. The results do not lean strongly toward any one type of training — it may be that the type of mindfulness training is not as important as accessibility to providers.
It is worth noting that although many studies measured lower rates of stress and anxiety, few studies showed an association of these brief measures with reduction in burnout symptoms. This is consistent with other studies in the area of provider burnout that have suggested the need for organizational interventions along with individual interventions to affect this syndrome.22
Criteria for inclusion in this review were limited to studies only involving inpatient settings; the results showed no evidence or implication that these brief measures have a place in outpatient settings. Healthcare providers work in many environments — even within the broad categories of inpatient and outpatient work specifics of job description — patient population, administrative strategies, and mission create unique, site-specific demands and challenges. It is not clear how to generalize results of studies (such as the ones included in this review) to all settings and to all healthcare providers, but it is important to clarify this point through future work. Even though data are lacking, there is little evidence of downsides to the use of brief techniques and time commitment, the only identified barriers to the use of the more comprehensive mindfulness interventions.
In the practice of medicine, we tend to rely on evidence-based studies to make recommendations to our patients. Make no mistake — we should expect no less for ourselves. Despite some limitations to the studies, the results point to clear potential benefits of incorporating a degree of mindfulness into the professional life of healthcare providers. Providers can be confident that trying a time-limited or more extensive mindfulness technique to help modulate stress and/or anxiety has merit and emerging evidence of effectiveness.
REFERENCES
- Hwang Y-S, Kearney P. A Genealogy of Mindfulness. In: A Mindfulness Intervention for Children with Autism Disorders. New York: Springer; 2015: 5-21.
- Sati. Hinduism. Encyclopedia Britannica. Available at: https://www.britannica.com/topic/Sati. Accessed Sept. 13, 2017.
- Mindful. Available at: https://www.mindful.org/jon-kabat-zinn-defining-mindfulness. Accessed Aug. 16, 2017.
- Khoury B, Lecomte T, Fortin G, et al. Mindfulness-based therapy: A comprehensive meta-analysis. Clin Psychol Rev 2013;33:763-771.
- Lamothe M, Rondeau E, Malboeuf-Hurtubise C, et al. Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies. Complement Ther Med 2016;24:19-28.
- Gauthier T, Meyer RM, Grefe D, Gold JI. An on-the-job mindfulness based intervention for pediatric ICU nurses: A pilot. J Pediatr Nurs 2015;30:402-409.
- Ratanasiripong P, Park JF, Ratanasiripong N, Kathalae D. Stress and anxiety management in nursing students: Biofeedback and mindfulness meditation. J Nurs Educ 2015;54:520-524.
- Sood A, Prasad K, Schroeder D, Varkey P. Stress management and resilience training among department of medicine faculty: A pilot randomized clinical trial. J Gen Intern Med 2011;26:858-861.
- Sood A, Sharma V, Schroeder DR, Gorman B. Stress management and resiliency training (SMART) program among department of radiology faculty: A pilot randomized clinical trial. Explore (NY) 2014;10:358-363.
- Warnecke E, Quinn S, Ogden K, et al. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels. Med Educ 2011;45:381-388.
- Mackenzie CS, Poulin PA, Seidman-Carlson R. A brief mindfulness based stress reduction intervention for nurses and nurse aides. Appl Nurs Res 2006;19:105-109.
- Poulin PA, Mackenzie CS, Soloway G, Karayolas BA. Mindfulness training as an evidenced-based approach to reducing stress and promoting well-being among human services professionals. Int J Health Promot Edu 2008;46:72-80.
- Taylor M, Hageman JR, Brown M. A mindfulness intervention for residents: Relevance for pediatricians. Pediatr Ann 2016;45:e373-e376.
- Chesak SS, Bhagra A, Schroeder DR, et al. Enhancing resilience among new nurses: Feasibility and efficacy of a pilot intervention. Ochsner J 2015;15:38-44.
- Kemper KJ. Brief online mindfulness training: Immediate impact. J Evid Based Complementary Altern Med 2017;22:75-80.
- Kemper KJ, Khirallah M. Acute effects of online mind-body skills training on resilience, mindfulness, and empathy. J Evid Based Complementary Altern Med 2015;20:247-253.
- Paholpak S, Piyavhatkul N, Rangseekajee P, et al. Breathing meditation by medical students at Khon Kaen University: Effect on psychiatric symptoms, memory, intelligence and academic achievement. J Med Assoc Thai 2012;95:461-469.
- Durham ML, Suhayda R, Normand P, et al. Reducing medication administration errors in acute and critical care: Multifaceted pilot program targeting RN awareness and behaviors. J Nurs Adm 2016;46:75-81.
- Bodenheime T, Sinksy C. From triple to quadruple aim: Care of the patient requires care of the provider. Available at: http://www.annfammed.org/content/12/6/573.full.pdf. Accessed Aug. 18, 2017.
- Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet 2009;374:1714-1721.
- Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. Int J Stress Manage 2005;12:164-176.
- Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205.
A review of studies regarding brief mindfulness interventions for healthcare providers found an association with improved measures of provider well-being and no evidence of behavioral changes.
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