A Brief Mindfulness-Based Self-Care Curriculum for an Interprofessional Group of Palliative Care Providers

Abstract

Background:

Mindfulness-based interventions for health care providers have shown benefits for provider wellbeing and for their patients, but established programs are time-intensive.

Objective:

To establish the feasibility of a brief mindfulness-based curriculum focused on self-care for an interprofessional group of palliative care providers within the regular workday, and to evaluate the effectiveness of the curriculum in improving the levels of burnout, mindfulness, use of mindfulness meditation practices, and stress levels.

Design:

Pre-, one-week post-, and seven-month post-intervention survey assessment. The intervention was conducted in five monthly one-hour sessions.

Setting:

Participants were 29 mixed-professional-background usual-attendees of a monthly educational conference in a well-established palliative care group within an academic medical center.

Measurements:

Paired, confidential assessments using validated scales (the Five Facet Mindfulness Questionnaire, the Maslach Burnout Inventory, the Ten-item Perceived Stress Scale), report of use of informal and formal mindfulness techniques, narrative data, and satisfaction ratings.

Results:

Participants reported high satisfaction with the series and showed statistically significant improvements in dimensions of mindfulness and mindfulness practices, sustained for seven months. Burnout levels in this group were much lower than reported national rates; no statistically significant change was seen in burnout over the study period. Narrative data demonstrated retention of curricular content.

Conclusions:

Delivery of a mindfulness-based self-care series to an interprofessional group of palliative care providers within the regular workday was feasible, well received, and associated with increased mindfulness levels, mindfulness practices, and knowledge.

Introduction

Mindfulness, or “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally,”¹ has become of great interest in health care.^2–4 One reason is because mindfulness-based interventions are promising for addressing burnout.^5–10

Provider mindfulness also benefits patients. Mindfulness-based interventions for physicians increase empathy, psychosocial orientation to care, and conscientiousness.^7,8 Higher physician mindfulness level is associated with more patient-centered communication, a more positive emotional tone in recorded patient visits, and more satisfied patients.¹¹ Randomizing health care providers to a mindfulness-meditation intervention decreased their patients' psychological symptom burden, compared with control providers' patients.¹²

Established mindfulness teaching methods are time-intensive. The most highly-studied mindfulness training, Mindfulness Based Stress Reduction (MBSR), takes place in eight weekly three-hour sessions, an all-day retreat, and assigned daily home practice.¹³ Interventions targeting health care providers have been on this time scale, involving 18 to 52 hours of instruction.^6–8,14,15 There is less evidence about shorter interventions; one waitlist-control study targeting nurses involved four weekly 30-minute sessions and improved burnout, relaxation, and life satisfaction.¹⁶ The current study introduces mindfulness to a mixed group of palliative care providers in five one-hour sessions within the regular workday. We were interested in the effect of this course on provider burnout, mindfulness, and perceived stress levels.

Methods

Setting

This study took place in the palliative care section at an academic medical center, scheduled during a regular monthly educational session. Before the start of the mindfulness series, the authors invited potential participants to voluntarily enroll with a commitment to attend at least four of the five sessions.

The study was deemed exempt by the University of Pittsburgh Institutional Review Board.

Intervention

We based our intervention on previously-published curricula^8,16–18 and focused on active participation in a variety of exercises. We particularly emphasized application to informal practice within the clinical workday. For missed sessions, we offered 30-minute make-up classes. The series facilitator (the first author) is a palliative care group member who developed the curriculum in collaboration with a certified MBSR instructor (the second author). See Table 1 for a curricular outline.

Table 1.

Outline of the Intervention Curriculum

No.	Theme	Exercises	Additional activities
1	Mindful awareness	Mindful eating Three-minute breathing space	Reading excerpts from Thich Nhat Hanh's Miracle of Mindfulness with discussion²⁷ Handout: “21 ways to reduce stress in the workday”
2	Triangle of awareness Nonattachment	Mindful stretching Noticing pleasant and unpleasant Smiling meditation	Reflective writing Discussion
3	Being with suffering	Breathing meditation Mindful listening/sharing in pairs	Appreciative inquiry Small group discussion
4	Self-care practices	Breathing meditation Balancing yoga pose (tree)	Reflective writing Scientific self-care articles
5	Loving-kindness Pitfalls in practice	Breathing meditation Loving-kindness meditation	Jon Kabat Zinn reading: “Cat Food Lessons”¹

Outcome measures

We surveyed participants at baseline just before the start of the series, one week after series completion, and one year after baseline assessment (seven months after series completion). Authors were blinded to respondent identities; participants were assured of this at consent.

We chose three validated scales^19–21 that demonstrated significant improvements in previously-published mindfulness-based interventions.^7,8,16 We also asked participants to report their informal and formal mindfulness practice within the last month (yes/no and frequency per week). In the post-intervention assessments, we asked about lessons learned (open-ended) and satisfaction with the series (1–5 scale). See Table 2 for a summary of outcome measures.

Table 2.

Outcome Measures

Outcome	Assessment tool
Burnout	Maslach Burnout Inventory, Human Services version^a
Mindfulness levels	Five Factor Mindfulness Questionnaire^a
Mindfulness practice	Participant self-report, formal and informal separately
Mindfulness knowledge	Open-ended question about lessons learned
Stress	10-item Perceived Stress Scale^a

Validated scales.

Data analysis

We used Stata, version 13.0 for statistical testing. In the initial planned analysis comparing baseline and one-week post-intervention surveys only, we used paired t-tests for normally-distributed data and Wilcoxon signed-rank tests for skewed data, with two-tailed tests. After delayed follow-up data became available, the mindfulness, burnout, and perceived stress score analyses were conducted using repeated-measures ANOVA with post hoc t-tests for pairwise significant differences with Sidak adjustment for multiple comparisons. The final analysis of the mindfulness practice questions was done using McNemar's test for paired analysis for categorical variables and Skillings-Mack test for nonparametric and unbalanced repeated-measures data for continuous variables.

We analyzed the narrative data on lessons learned qualitatively with a coding scheme developed by the primary author, independently recoded by the third author with proportion agreement of 0.89. Discrepancies were resolved by discussion.

Results

Participants

Forty-one providers were invited to participate, and 29 enrolled (71%). Of those that declined, two reported being too busy, two had upcoming maternity leave, and eight no longer attended palliative care events (two former fellows, six others with nonpalliative care appointments). Demographic characteristics are shown in Table 3.

Table 3.

Background Characteristics of Participants

	n (out of 29)	%
Gender
Female	24	83
Male	5	17
Age
<35 years	9	31
35–44 years	8	28
45–54 years	5	17
≥55 years	7	24
Type of provider
Advanced practice nurse	4	14
Physician assistant	4	14
Physician	17	61
Nurse	2	7
Social worker	1	4
Years of experience in palliative care
0–3 years	14	48
3–6 years	7	24
7–10 years	3	10
>10 years	5	17
Years of clinical experience, total
0–4 years	2	7
5–9 years	15	52
10–14 years	1	3
15–19 years	2	7
≥20 years	9	31
Prior mindfulness training
Yes	7	25
No	21	75

Attendance

We conducted the intervention between January 2014 and May 2014. Three participants attended four of five sessions, and the other 26 attended all five sessions. All 29 completed the baseline and one-week post-intervention surveys (100%), and 27 completed the seven-month post-intervention survey (93%).

Baseline burnout rates

Our burnout rate before the intervention was 18.5%, defining burnout as high-range score on either emotional exhaustion or depersonalization.^22,23 By subscale, 17.2% of participants had high emotional exhaustion, 3.7% had high depersonalization, and 24.1% scored high on low personal accomplishment.

Burnout scores

There was no significant change in burnout scores in the final analysis. In the original planned analysis comparing burnout at baseline versus one week after the intervention, we saw a marginally-significant (p = 0.05) improvement in the sense of personal accomplishment. After repeating the analysis with the addition of the seven-month follow-up data (Table 4), this was no longer significant.

Table 4.

Maslach Burnout Inventory Burnout Scores, by Subscale

	N	Baseline	One week post	Seven months post	ANOVA p-value
Emotional exhaustion^a	27	18.9 (9.2)^b	19.1 (9.5)	17.6 (8.9)	0.479
Emotional exhaustion^a	27	17 [14–23]^c	17 [13–22]	15 [12–22]	0.479
Depersonalization^d	23	5.7 (4.4)	4.4 (3.4)	4.8 (4.5)	0.243
Depersonalization^d	23	5 [1–9]	4 [2–6]	3 [1–8]	0.243
Personal accomplishment^e	24	37.1 (8.0)	39.3 (8.1)	38.8 (6.9)	0.348
Personal accomplishment^e	24	38.5 [32.5–43]	41.5 [34.5–45.5]	39 [33–46]	0.348

High emotional exhaustion is defined as ≥27.

Mean (standard deviation).

Median [interquartile range].

High depersonalization is defined as ≥13.

Higher scores in the personal accomplishment subscale indicate less burnout. High sense of low personal accomplishment is defined as ≤31.

Mindfulness levels

In the final analysis, three of five mindfulness factors improved significantly (Table 5). Participants improved in the Observe and Nonreact factors from baseline to one-week post-intervention (p = 0.003 and 0.001); this was sustained at seven-month post-intervention (p = 0.022 and 0.001). For the Describe factor, participants showed statistically-significant improvement from baseline to seven-month post-intervention (p = 0.047).

Table 5.

Change in Mindfulness Levels (Five-Facet Mindfulness Questionnaire Scores, by Factor)

	N	Baseline	One week post	Seven months post	ANOVA p-value
Observe	24	26.2 (4.4)	28.7 (4.6)	28.3 (5.5)	0.004^*
Describe	26	28.3 (5.6)	30.0 (5.6)	30.1 (5.1)	0.044^*
Act with awareness	21	24.6 (5.1)	26.0 (2.9)	25.0 (6.1)	0.362
Nonjudge	25	29.8 (6.3)	31.1 (5.6)	31.3 (5.8)	0.173
Nonreact	21	20.4 (3.6)	23.0 (3.1)	22.6 (3.4)	<0.001^*

The observe, describe, active with awareness, and nonjudge factors each have a score range of 8–40. Nonreact has a score range of 7–35. Results reported as mean (standard deviation).

Statistically significant.

Mindfulness practice

Informal

The proportion of participants reporting informal mindfulness practice in the preceding month increased from baseline (54%) to one week post-intervention (89%; p = 0.0039). This was not sustained at seven-month follow-up (76%; p > 0.05). For those endorsing informal mindfulness practice, frequency increased from an average of <1 time per week to 1–2 times per week in both follow-up assessments (p = 0.0069).

Formal

The proportion of participants reporting formal meditation practice in the preceding month also increased from baseline (24%) to one week after the intervention (62%; p = 0.0023). At delayed follow-up seven months later, this had decreased back down to 37%, significant when compared with one-week follow-up (p = 0.0114). For those endorsing formal practice, neither frequency nor duration changed significantly over time.

Mindfulness knowledge

In the open-ended question about lessons learned from the series, participants described several relevant mindfulness concepts (Table 6).

Table 6.

Mindfulness Concepts Described by Participants in Narrative Data

Theme	Representative quote	No. of participants mentioning
Breathing meditation	“the value of slowing down, conscious breathing”	13
Using mindfulness informally	“Practice mindful meditation in brief moments available during the day. (before eating lunch, sitting at traffic light)” “Reminder to pause before entering a room”	12
Nonbreath-focused meditation practices	“smile exercises” “Loving kindness towards others”	9
Noticing own reactions (physical, emotional, or cognitive)	“taking a moment to identify what I am feeling can be helpful” “I learned to give attention to my emotions and the physical connection to my body”	4
Nonjudgement	“I learned it is good not to judge my feelings”	3
Reference readings	“the work of Thich Nhat Hahn”	3
Noticing others' experiences in the group	“I learned that others are interested in similar ways to process their work and life and feel grounded”	2
Nonreactivity	“you may not have control over events that occur but you do have control over your response”	1
Being with suffering	“Being present with suffering”	1
Mindful listening	“active listening without interruptions”	1

Perceived stress

There was no statistically-significant change seen in perceived stress levels over the study period.

Satisfaction

Participants were highly satisfied with the series—93% indicated 4 or 5 on a five-point scale. Ninety-three percent also said they would definitely or probably recommend the series to a colleague. When asked about continuing elements of the series as a group, 86% expressed interest in brief breath-focused guided meditation; only one participant did not have interest in continuing any elements.

Discussion

This study demonstrates that a five-hour mindfulness-based self-care curriculum for an interprofessional group of palliative care providers in an academic medical center improved participant mindfulness levels and mindfulness practices. Changes were sustained seven months after series completion, despite being dramatically less time-intensive than most established mindfulness interventions. Participants were highly satisfied with the program and could describe mindfulness concepts after attending. Given the known connections between mindfulness, burnout, and improved patient care, this study suggests that even brief interventions can have meaningful impact.

We did not see an improvement in burnout. A likely explanation is that the low baseline rate of burnout in this group (18.5%) produced a floor effect; the nationally-reported rate in palliative care is 62%.²³ This explanation is consistent with a randomized controlled trial applying MBSR in Dutch residents in which mindfulness training benefits were greatest in the trainees with the highest burnout levels.⁶ It is also possible that our series was too brief to impact burnout. Another potential explanation is that this intervention primarily targeted individual-level factors; the latest models for promoting provider well-being emphasize the need to address both individual- and systems-level factors.^5,24–26

The study has limitations. First, it was conducted in a single institution and thus may not be generalizable. Second, there was no control group. The design of the intervention within the group's regular educational activities did not allow for exclusion of a portion of the group. Third, the intervention was facilitated by a novice instructor, compared with some published interventions that were run by lifelong meditation experts^8,12; while this may have decreased our intervention's impact, it also makes it more generalizable to other health care sites.

This study adds to growing evidence that mindfulness-based training improves mindfulness levels and practices. It was accepted within a regular workday in an interprofessional group. The brief nature of this intervention allowed for its continued applicability at our institution, where it has been adapted as an annual series of three 90-minute sessions for hospice and palliative medicine fellows. As we all continue to wrestle with strategies for supporting provider wellness, this study provides evidence that brief interventions incorporated into the workday have potential.

Footnotes

Acknowledgments

Doris Rubio, PhD; Elan Cohen, PhD; and Scott Rothenberger, PhD provided statistical support, funded by the University of Pittsburgh Department of General Internal Medicine Grant. Michael Krasner, MD, graciously offered early consultation on curricular content and shared curricular materials.

Author Disclosure Statement

No competing financial interests exist.

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