Mindfulness

DOI 10.1007/s12671-014-0313-3

ORIGINAL PAPER

Health Care Workers’ Experiences of Mindfulness

Training: a Qualitative Review
Peter Morgan & Jane Simpson & Alistair Smith

# Springer Science+Business Media New York 2014

Abstract Evidence is accumulating that mindfulness training Introduction

is useful in reducing stress for health care workers and may
increase the quality of their interactions with patients. To A growing body of research reports positive outcomes from
evaluate how health care workers experience mindfulness mindfulness training for various populations (Fjorback et al.
training, a review was conducted, synthesising published 2011). Mindfulness is often defined as “paying attention in a
qualitative papers on the experiences of health care workers particular way: on purpose, in the present moment, non-
currently practising or those in clinical training who had judgmentally” (Kabat-Zinn 1994, p. 4). Mindfulness can be
attended mindfulness training. A systematic search yielded cultivated through formal practices which form the basis of
14 relevant studies. Quality appraisal using the Critical Ap- two evidence-based interventions: mindfulness-based stress
praisal Skills programme tool identified that four studies were reduction (MBSR, Kabat-Zinn 2005) and mindfulness-based
of a lower quality, and as they did not contribute uniquely to cognitive therapy (MBCT, Segal et al. 2002, 2013). MBSR
the analysis, they were omitted from the review. The synthesis was developed to reduce stress related to chronic illness and
describes health care workers’ experiences of overcoming MBCT, which combines elements of MBSR with cognitive
challenges to practice in mindfulness training, such as shifting therapy, to reduce the likelihood of depressive relapse. Both
focus from caring for others to self-care, leading to an expe- are group-based interventions with eight weekly sessions and
riential understanding of mindfulness and a new relationship daily home practice, teaching core mindfulness practices such
to experience. Perceived benefits of mindfulness training as a body scan, sitting meditations and mindful movement.
ranged from increased personal wellbeing and self- Although differing in their original intentions and some as-
compassion to enhanced presence when relating to others, pects of course delivery, they have been used in comparable
leading to enhanced compassion and a sense of shared contexts with a range of populations (Chiesa and Serretti
humanity. Outcomes are discussed in terms of training focus 2011; Praissman 2008). For the purposes of this review,
and participant motivation, clinical and theoretical implica- mindfulness training is used to refer to MBSR, MBCT or
tions and avenues for further research. adaptations to these interventions that contain the core mind-
fulness practices and underlying philosophies. For example,
other interventions developed within the third wave of psy-
Keywords Mindfulness . Health care workers . Qualitative . chological therapies (e.g. acceptance and commitment thera-
Review py: Hayes et al. 1999; dialectical behaviour therapy: Linehan
et al. 1999) include elements of mindfulness training as part of
P. Morgan (*) a wider syllabus but with less focus on formal practice of
Psychological Therapies, Pennine Care NHS Foundation Trust, Nye
mindfulness meditation; therefore, they are not included in
Bevan House, Rochdale, Greater Manchester, UK
e-mail: [email protected] this definition.
Alongside studies exploring the efficacy of mindfulness
J. Simpson training for various populations, mediation studies have
Division of Health Research, Lancaster University, Lancaster, UK
sought to identify the active ingredients through which mind-
A. Smith fulness training yields positive outcomes. For example, in
Darwen, Lancashire, UK MBCT increased mindfulness and self-compassion have been
 Mindfulness

found to mediate the reductions in depressive symptoms and care they can provide (Boorman 2009), making this an im-
the likelihood of depressive relapse and decouple the relation- portant issue to address for the wellbeing of health care
ship between cognitive reactivity and outcome (Kuyken et al. workers and the patients with whom they work.
2010). However, while mediation studies are useful in testing Recent quantitative reviews suggest that mindfulness train-
specific hypothesised relationships, other sources of evidence ing for this population may indeed reduce symptoms of stress,
such as qualitative research are needed to provide a more anxiety and depression, with other benefits reported such as
holistic assessment. increasing empathy, positive affect and self-compassion
Individual qualitative studies can provide a useful insight (Chiesa and Serretti 2009; Irving et al. 2009). Preliminary
into the experiences of particular populations. Furthermore, evidence also suggests that therapists with an ongoing mind-
they can also be systematically searched and synthesised. A fulness practice produce better patient outcomes (Grepmair
number of approaches to qualitative synthesis exist (Thorne et al. 2008). Bringing mindfulness into the therapeutic rela-
et al. 2004). For example, a meta-synthesis uses systematic tionship may directly increase therapists’ ability to be present,
search procedures to then compare and contrast studies to to be aware and to show genuine curiosity and acceptance
provide higher-level interpretations (e.g. Sandelowski et al. (Bruce et al. 2010; Hick et al. 2010). Similarly, there may be
1997). A qualitative meta-synthesis can complement quanti- related interpersonal benefits for health care workers through
tative findings of efficacy for an intervention by illuminating increasing empathy in relationships with co-workers and
underlying processes and providing interpretations around the patients.
meaning ascribed to measured change. For example, a recent In the last decade, several qualitative studies have explored
review synthesised patients’ experiences of mindfulness- health care workers’ experiences of mindfulness training, with
based approaches from 14 original research articles (Malpass intervention aims ranging from supporting staff and
et al. 2011). The meta-synthesis produced a model of patients’ preventing burnout (Cohen-Katz et al. 2005a, b) to increasing
experiences of the therapeutic process that included partici- the therapeutic presence of therapists in training (McCollum
pants opening up to experience then relating in a new way to and Gehart 2010). These studies have a different focus to
experiences, their presenting difficulties and their sense of those exploring patient experience and have not yet been
self. The model highlights participants’ shift in relation to their subject to review. Therefore, it was decided that a qualitative
experience as an important mechanism of change, sometimes synthesis of health care workers’ experiences of mindfulness
referred to as de-centering (Segal et al. 2013) or re-perceiving training would be a useful and timely addition to the evidence
(Shapiro et al. 2006). These therapeutic processes were aided base, to bring together and make sense of this growing body of
by group processes such as normalising early experiences of work. However, given the data constraints in many of the
challenges in meditation and reducing perceived stigma and studies identified (i.e. a lack of richness of participant data),
isolation. a meta-synthesis was not considered appropriate. Instead, this
Malpass and colleagues chose to “focus upon the patient review aimed to conduct a systematic search but to use less
experience” (Malpass et al. 2011, p. 2), and their review formal procedures (i.e. not the seven-stage process outlined by
provides fresh insights and a working model of patients’ Noblit and Hare 1988) to synthesise how health care workers
experiences. However, since health care workers are known perceive and experience mindfulness training as well as the
to be vulnerable to stress and burnout (Maslach and Goldberg perceived impact of mindfulness training on their wellbeing,
1998), research has also addressed the utility of mindfulness clinical skills and relationships with patients.
training for health care workers and those in training. It is well
established that under certain circumstances health care
workers can experience significant levels of stress or burnout Method
(e.g. Marine et al. 2006; Walsh and Walsh 2001). Various
factors have been identified as contributing to burnout in Literature Search
health care workers, such as feeling ineffective and
overwhelmed and seeing a need to “be selfless and put others’ A literature search was conducted in March 2013 using data-
needs first” (Maslach and Goldberg 1998, p. 63). Some factors bases and reference lists of related research papers and re-
such as experiencing organisational change and long working views (see Fig. 1). An initial search of the databases
hours are also present in other workplaces. In addition, work- PsycINFO, Academic Search Complete, AMED, CINAHL
ing in a physical or mental health care setting involves regu- and MEDLINE used variations on the terms “health care
larly encountering and working with individuals who are professional AND mindfulness AND qualitative” derived
experiencing distress or illness, which can have a significant from database thesaurus suggestions, relevant titles already
emotional impact (Michie and Williams 2003; Walsh and known to the first author and suggestions from a search
Walsh 2001). A deterioration in the mental and physical health specialist. The remaining papers were filtered manually by
of health care workers also has a detrimental impact on the the first author using the criteria set out below, excluding
Mindfulness

Potentially eligible articles core mindfulness practices such as sitting meditation, the body
identified through databases
PsycINFO, Academic scan and mindful movement. Papers were not excluded on the
search complete, AMED, basis of evaluating mindfulness training that was longer or
CINAHL and MEDLINE
(N = 2,322) Exclusion of non- shorter than the usual 8 weeks of MBCT or MBSR as adapting
peer reviewed training length has been recognised as appropriate to meet the
articles
(N = 1,097) needs of participants and comparative effect sizes have been
Peer-reviewed articles
found for some shorter interventions (Carmody and Baer
Additional (N = 1,225) 2009). Qualitative studies were included that used a content-
potentially eligible Excluded based on
articles from information in title based approach such as thematic analysis or grounded theory
EMBASE, Web of and abstract
(N = 1,169) and included some participant quotes; mixed-methods studies
Science, reference
lists, online first Full-text articles assessed that met this criterion were also included. Where papers were
and Mindfulness for eligibility
Research Guide that (N = 66) identified referring to the same participant group, the decision
were not excluded Exclusion based on was made not to include all of the papers to limit the possi-
based on information in full-
information in title text bility of one body of results disproportionately influencing the
and abstract (N = 57) synthesis. For example, the published work of Gockel and
(N = 5) Articles included in colleagues included a mixed-methods study with a qualitative
review
(N = 14) component (Gockel et al. 2012) and a more comprehensive
qualitative study (Gockel et al. 2013), and so the decision was
Fig. 1 Flow chart of the literature search process
made to include only the latter in this review. Moreover, data
by Christopher and colleagues were represented in four qual-
studies that were clearly irrelevant through evaluation of the itative studies (Christopher et al. 2006, 2011; Newsome et al.
title and abstract and, where necessary, after sourcing original 2006; Schure et al. 2008). The paper judged to demonstrate
papers (for example, if an abstract was unclear whether qual- the most comprehensive qualitative analysis was included
itative methods were used in an evaluation). Comparative (Schure et al. 2008) as well as a second paper that reported
searches were also made using Web of Science and EMBASE, additional data resulting from analysis of participants’ long-
and a second phase of searching took place, hand searching term perceptions of the effect of the mindfulness training
reference lists of related papers and those identified for the (Christopher et al. 2011).
review, screened using the same exclusion criteria. Finally, a
search was conducted using the Mindfulness Research Guide Papers Identified for Inclusion
(Black 2010), a comprehensive online database maintained
through monthly literature searches and communications with Fourteen papers were identified for inclusion in the synthesis
authors and journals. While this search identified all papers (see Table 1) reporting the experiences of 254 participants.
dated 2010 onwards that were already sourced through other Participants included both trainees and qualified professionals
searches and some further papers that were excluded, no new in social work, counselling, nursing and clinical psychology
articles were identified that met inclusion criteria for the as well as trainee occupational and family therapists and
review. qualified physicians. Four papers did not report gender; across
the other ten papers, 84 % of 181 participants were female.
Inclusion and Exclusion Criteria The purpose of training in most studies was to reduce stress or
increase wellbeing and to impact on the interpersonal skills of
Included papers were peer-reviewed, reported a qualitative the participants, although some papers focused on one element
methodology and focused on the experience of health care or the other in their intervention and/or reporting. The first
workers or those in clinical training who had taken part in three papers published used MBSR, and only one subsequent
mindfulness training. Health care workers were defined as paper explored experiences of the MBCT protocol. Instead,
those in paid work in physical or mental health provision or most papers described interventions that used the core mind-
taking part in clinical training within a health care profession. fulness practices alongside other didactic or practical content
It is beyond the scope of this article to elaborate upon the related to the intentions of the study, for example, exploring
differences in content and theoretical underpinnings between the use of mindfulness for clinicians through role-playing
comprehensive mindfulness programmes and those therapies therapeutic interactions (Gockel et al. 2013).
with a mindfulness component (see Chiesa and Malinowski The length of the initial mindfulness training ranged from 4
2011, for a detailed analysis). However, in order to synthesise to 15 weeks (eight studies kept an 8-week format), with one
a relatively homogenous set of articles, this review included study including ten individual monthly follow-up sessions
studies that used MBSR, MBCT or training programmes that after an 8-week course (Beckman et al. 2012). Most studies
explicitly drew upon these approaches with the integration of that deviated from the 8-week format used a higher number of
Table 1 Study characteristics of the 14 papers synthesised

Authors and Quality Population Type Length Sample and Methods of data collection Time of data Approach to data Aims
date appraisal (weeks) gender collection analysis

1 Young et al. Satisfactory 3rd year nursing MBSR 8 15 Focus groups Before, during References grounded Evaluate students’
(2001) students and after theory, states perceptions of the
course analysed data for programme, usefulness
“key themes and as stress reduction,
relationships” effects on health, stress
and school performance
2 Beddoe and Satisfactory Nursing students MBSR 8 18 (F=18) Journal entries and end- During and at Not stated, themes Explore whether
Murphy of-course end of course described decreases stress,
(2004) questionnaire with improves empathy
some open-ended and more meditation
questions leads to greater benefits
3 Cohen-Katz Key paper Over 80 % were MBSR 8 25 (F=25) Brief During and up Thematic analysis, Explore the impact of
et al. nurses, others questionnaires, to several coded MBSR on nurse
(2005a, b) were caring interviews with months post burnout and stress,
professions participants, observer course self-care, self-
and supervisor, focus awareness and
group \(only a therapeutic presence
proportion took part
in each data
collection, e.g. 4
were interviewed)
4 Schure et al. Key paper Counselling MBSR based, meditation, 15 33 (F=27) Journal entries End of semester Inductive content Examine trainees’
(2008) students yoga, qigong, with analysis perceptions of the
didactic elements (body influence of mindfulness
scan replaced by on their lives
qigong)
5 Moore (2008) Satisfactory Trainee clinical 14 10-min group-facilitated 4 10 (F=9) (Primarily quantitative) End of course Thematic analysis To explore whether a
psychologists practices questionnaire personal understanding
of mindfulness could be
developed without
significant practice time
6 Birnbaum Fatally flawed 3rd year social Didactic material (Kabat- 8 12 Process notes taken by During course Not stated, thematic To enhance self-awareness
(2008) work students Zinn 1994), guided and facilitator during analysis and increase emotional
independent meditation, sharing, stream of support while
sharing of experiences consciousness experiencing different
writing states of consciousness
7 McCollum Key paper Trainee family Based on MBSR with other Semester (15 13 (F=6) Weekly semi-structured During course Thematic analysis Explore the impact of
and Gehart therapists elements, e.g. mantra, approx) journal entries mindfulness on
(2010) over a semester, 5–30- developing therapeutic
min discussions in class presence (only this
each week and short aspect of data was
daily practice at home, explored in this study)
and readings
Mindfulness
Table 1 (continued)

Authors and Quality Population Type Length Sample and Methods of data collection Time of data Approach to data Aims
date appraisal (weeks) gender collection analysis
Mindfulness

8 McGarrigle Key paper 9 social workers, Meditation, body scan, 8 12 (F=11) Weekly journal, During and at Grounded theory Explore impact of
and Walsh 1 counsellor, relaxation, yoga, facilitator journal end of course mindfulness on wellness
(2011) 2 support informal mindfulness and focus group led and self-care
workers activities and some by other facilitators
didactic material
9 Stew (2011) Key paper Occupational Based on MBSR 4 26 (only 12 Interview (12), invited End of Hermeneutic Explore how perceive and
therapy interviewed, to reflect on journals programme phenomenological understand mindfulness,
students 23 in interviews, (questionnaires), approach, content responses to practice,
questionnaire author’s reflective 5–7 weeks post analysis how impacts on
responses) log, evaluation course academic, clinical and
questionnaires, (interviews) personal life
emails
10 Christopher Key paper Counsellors Loosely MBSR based, 15 16 (F=13) Structured phone 2–6 years after Inductive content To explore long-term
et al. who had meditation, yoga, interview course analysis effects of mindfulness
(2011) previously qigong, with didactic (average 4) training
attended elements
mindfulness
training
11 Irving et al. Key paper 27 % Mindfulness-based medical 8 27 (F=21) Small focus groups Within 3 weeks Grounded theory Explore if and how MBMP
(2012) physicians, practice (MBSR, plus (3–6 participants post course perceived to be
all caring emphasis on in each) beneficial and processes
professions communication with through which this may
colleagues and patients) have occurred.
12 Beckman Key paper Physicians Mindful communication- 8+retreat+10 20 Semi-structured Within 6 months Thematic analysis Understand what aspects
et al. meditation, written monthly interviews of a successful
(2012) narratives, appreciative sessions continuing education
inquiry, didactic programme in mindful
content, discussion communication
about stress in clinical contributed to
practice. physicians’ well-being
and the care they
provide.
13 De Zoysa Key paper Clinical MBCT 8 7 (F=5) Interview 18 months post Interpretative Explore the impact of
et al. psychologists phenomenological mindfulness on personal
(2012a) analysis and professional lives, to
inform discussions
regarding training for
instructors
 Mindfulness

Explore the potential utility

how it might help in the

classroom and clinician
of mindfulness training
shorter sessions to integrate the course content within an

practice instruction—
as part of a clinical
existing syllabus. Five studies did not report the level of
facilitator experience, and one study used self-facilitation

in the field
where participants read meditation scripts themselves
(Moore 2008). The remaining facilitators had a minimum of
Aims

2 years’ mindfulness experience and specific supervision or

training in MBSR or MBCT, with four studies reporting over
15 years of facilitator experience (Christopher et al. 2011;
Approach to data

Grounded theory

McCollum and Gehart 2010; McGarrigle and Walsh 2011;

Schure et al. 2008).
analysis

Most studies collected data during or just after the course,

with several collecting data up to 6 months afterwards and
only three looking at long-term data (10–16 months, 18
2–5 months post

months and 2 to 6 years after training). Results based on data

Time of data

from the time of course completion did not appear to differ

collection

course

significantly based on length of training; however, the studies

looking at long-term data which delivered more comprehen-
sive mindfulness training reported more ongoing benefits.
Methods of data collection

Eight studies also reported quantitative findings or had a

complementary research paper detailing quantitative findings
Semi-structured

with the same populations. Although many had small sample

interviews

sizes and reported other results that showed non-significant

trends towards related benefits, they found statistically signif-
icant reductions in scores on self-report measures of perceived
stress (Beddoe and Murphy 2004; McGarrigle and Walsh
2011), anxiety (De Zoysa et al. 2012b; Ruths et al. 2012),
Sample and

20 (F=15)

psychological or health-related symptoms (Young et al. 2001)

gender

or burnout (Cohen-Katz et al. 2005b; Krasner et al. 2009) and

improved mood, empathy (Krasner et al. 2009), and psycho-
logical wellbeing (De Zoysa et al. 2012b; Ruths et al. 2012).
One study also reported an increase in self-reported self-
(weeks)
Length

efficacy in counselling which has been linked to clinical skills

10

development (Gockel et al. 2012).

Based on MBSR, 15 min

weeks (7 h total time),

use of mindfulness in

Quality Appraisal
role play sessions
28 times over 10

The quality of studies was rated using the Critical Appraisal

Skills Programme (2010) which is used to assess aspects such
Type

as the aims, methodology, rigour of analysis and value of

results. Based on the approach of Dixon-Woods et al.
(2007), rather than giving papers a numerical score, papers
Social work
students

were identified by the first author as either KP (a key paper

Population

that is conceptually rich and could potentially make an impor-

tant contribution), SAT (a satisfactory paper) or FF (a paper
that is fatally flawed methodologically). Ten papers were rated
KP, three as SAT and one FF (Birnbaum 2008); the most
Key paper
appraisal
Quality

common issues were not reporting methods of data analysis

or reflecting on the impact of the researcher.
Table 1 (continued)

The issue of whether studies should be excluded from a

Gockel et al.
Authors and

review based on the quality of the methodology used or the

(2013)

way a study is reported is contentious (Carroll et al. 2012;

date

Sandelowski et al. 1997). It has been shown that disagree-

14

ments between researchers about whether a paper should be

Mindfulness

included in a review are common, regardless of whether or not in mindfulness training was encountering and responding
structured appraisal tools are used (Dixon-Woods et al. 2007). to challenges in formal mindfulness practice. Some par-
Therefore, the decision was taken to conduct the analysis with ticipants described feeling guilty about looking after
papers of all qualities and to determine whether those rated themselves, making a connection between this feeling
SAT or FF made differing contributions to the synthesis. This and their identities as health care workers. For example,
allows the opportunity for any unique findings in studies of a one participant said, “I’m having trouble focusing on
lower quality to be critically examined. myself and not others’ problems. It’s the nurse in me.”
(Cohen-Katz et al. 2005a). This was experienced as a
Analysis barrier to formal practice and using self-care more gener-
ally. Health care workers said that they treated themselves
The analysis process, conducted by the first author, began more positively as the course went on. For example,
with reading and re-reading the papers and the creation of Cohen-Katz et al. (2005a) reported, “a large increase in
brief summaries of main concepts and conclusions. Themes comments related to self-acceptance, self-awareness and
and concepts from each paper were collated into a Microsoft self care” from week five onwards. This provides evi-
Excel spreadsheet using the original language of the study dence to suggest that health care workers were able to
authors, as well as contextual factors such as study aims, incorporate the value of self-care into their identity.
content, participant motivation and goals and time of data Just as patients attending mindfulness training often
collection relative to the intervention. Sorting the themes and recognise that they are not alone in facing their illness or
concepts allowed for the creation of over-arching categories. mental health issues (Malpass et al. 2011), a key factor in
A brief narrative summary was then written that captured the changing health care workers’ attitudes was being able to
essence of each of the categories as they appeared across the witness and understand that they were not alone in
review papers. None of the papers rated as SAT or FF con- experiencing difficulties: “the most meaningful part was
tributed uniquely to a narrative summary, and so the decision being with other physicians, sharing and discussing some
was made not to draw from them further as the analysis of our experiences, and being able to have the immediate
progressed. The narrative summaries were then used to create understanding of peers with respect to the struggles that
a coherent narrative reflecting participants’ experiences of we all have” (Beckman et al. 2012). This benefit could be
mindfulness training and subsequent benefits. Where experi- considered non-specific to mindfulness training as, in
ences differed between or within papers, moving between the theory, attending any group and sharing experiences
narrative summaries and the original papers allowed for inter- may have resulted in similar realisations. However, there
pretations to be made regarding possible sources of variation. were other benefits that appeared to be more specific to
mindfulness training such as cultivating self-compassion:
“To hear somebody in my professional sphere say ‘have
compassion towards yourself’… To hear it in this context,
Results it’s a very powerful facilitator of the message” (Irving
et al. 2012).
Concepts from the papers were grouped into 61 categories Other challenges experienced were comparable to pa-
which were then refined by writing narrative summaries and tients’ experience ranging from practical issues, such as
amalgamating complementary categories, resulting in the 33 finding time to practice at home or work, to psychological
categories listed in Table 2. Although the papers reported the issues such as restlessness, sleepiness or intense emotions
experiences of a number of different professions as well as during meditation practice. The degree to which partici-
health care workers in training, similar constructs were iden- pants were able to navigate past these barriers varied
tified across the papers without a clear distinction, and so they between and within studies. However, the majority of
are reported together. The constructs identified were organised studies suggested that most participants had done so suc-
into themes to make sense of participants’ experiences: (1) cessfully. For example, Cohen-Katz et al. (2005a) used
experiencing and overcoming challenges to mindfulness prac- weekly journal entries during the course as a source of
tice and (2) changing relationship to experience in (a) personal data and reported that “comments about restlessness
and (b) interpersonal domains. Each of these areas are con- peaked in week two however, and declined thereafter”
sidered below followed by a discussion of implications for and similarly that comments about physical challenges in
theory, practice and future research. practice stopped after week 5.
Participants’ motivations are known to affect the way
1. Health care workers experiencing and overcoming chal- in which they engage with training and subsequent out-
lenges to mindfulness practice comes (Noe and Schmitt 1986). Most studies reported that
A significant aspect of health care workers’ experience participants had elected to attend the mindfulness training
 Mindfulness

Table 2 Concepts and narrative summaries

Themes and concepts Narrative summary that has meaning for all the papers in which it appears Papers where the concept appears
(bold=key paper). Numbers refer to
papers as listed in Table 1

1. Experiencing and overcoming challenges

Group experience: cohesion The group context meant that participants felt more connected to others in 3, 6, 11, 14
the group, creating a supportive and encouraging environment. Groups
that already knew each other began with existing cohesion
Group experience: normalising The group context increased understanding that others were experiencing 3, 10, 11, 12
stresses
Group experience: increasing Through discussing experiences and challenges this led to normalisation 5, 7, 9, 11, 12
benefits through discussion of process and increased self-compassionate/acceptance. Facilitators
could add to this process by modelling imperfection
Isolation pre/post course Feeling isolated professionally then isolated as professionals using 10, 11, 12
mindfulness
Emotional and physical barriers to Experiencing frustration, impatience, boredom, pain or discomfort, 1, 3, 4, 5, 7, 9, 11, 13
practice sleepiness
Time as a barrier to practice Difficulty finding time to practice, some seeing as unsupported at work or 1, 2, 3, 5, 8, 9, 11, 13
contrary to work culture, examples of reducing length of practices to fit
in
Working through barriers Progressing through initial emotional and physical barriers 3, 4, 8, 9
Difficulty facing strong emotions Experiencing strong emotions and the difficulty of staying with them 2, 3, 6, 10, 11
2. Changing relationship to experience
(a) Personal domain
Interacting with spirituality Enhancing or reflecting on spirituality, minority of experiences of being 1, 3, 4, 6, 7, 8, 10
told conflicts with religion
Overcoming guilt and making Developing an awareness of guilt associated with taking time for self-care 1, 2, 3, 4, 8, 11, 12
time for self-care and starting to value self-care more, some seeing course as permission
or responsibility to engage in self-care
Self-acceptance and Developing more self-acceptance and self compassion, letting go of self- 3, 4, 7, 8, 10, 11
compassion criticism
Confidence Developing more confidence e.g. Public speaking or job interview, letting 3, 4, 6, 8, 9, 10, 14
go of fears/anxiety, accepting limitations in ability and more
comfortable seeking supervision
Seeing potential uses for Considering how mindfulness might be useful for own stress, supporting 1, 4, 5, 9, 10, 13
mindfulness clients with difficult emotions or illness, increasing concentration or
being a more effective professional. Some awareness this may be
difficult for clients due to exposure to strong emotions
Calming and slowing the mind Developing the ability to feel calmer and let go of having a busy mind, 1, 2, 3, 4, 5, 7, 8, 9, 10
choosing what to attend to
Awareness, self and Developing increased self-awareness of body and mind, coupled with 3, 4, 6, 9, 10, 11, 14
surroundings feeling more comfortable with exploring ideas of self or becoming less
self-focused
Stepping back Developing the ability to be patient and step back from thoughts, feelings 1, 2, 3, 9, 10, 11, 13
or situations preventing an automatic response
Returning to the breath Developing the ability to return to the breath when stressed, shifting focus 2, 6, 8, 10, 11
or letting go
Changing relationship to the Developing the ability to open up to emotion or thoughts, sitting with it or 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 13
difficult stepping back from it, dis-identifying, letting go or putting it in
perspective. Minority unsure whether mindfulness is avoiding/
distracting from fully experiencing emotions
Response flexibility Developing the ability through awareness to choose how to respond in a 1, 4, 5, 7, 8, 9, 10, 11, 13
considered way rather than react
Physiological improvements Experiencing reductions in physical pain or symptoms of illness, opening 1, 2, 3, 4, 8, 9, 10
to pain, improved sleep, eating habits, flexibility and strength
Appreciating the pleasant Increased awareness and appreciate of pleasant experiences 2, 3, 11, 12, 13
Beliefs about formal practice Most seeing formal practice as essential to continued or further benefits 1, 3, 5, 7, 8, 9, 10, 11, 12, 13, 14
and seeking support with this, minority preferring informal practice
Informal practice as continued Integrating mindfulness into activities, hard to identify when drawing on it 9, 10, 14
connection
Accepting and prioritising Accepting and prioritising workload, seeking more creative solutions 1, 3
workload
Mindfulness

Table 2 (continued)

Themes and concepts Narrative summary that has meaning for all the papers in which it appears Papers where the concept appears
(bold=key paper). Numbers refer to
papers as listed in Table 1

Focus and grounding Developing the ability to increase focus and concentration, such as for 2, 4, 5, 6, 7, 9, 10, 13, 14
academic work, to refocus throughout the day or between seeing clients
(b) Interpersonal domain
Present with others Developing ability to be more present with others, feeling centred and 1, 3, 4, 7, 9, 10, 11, 12, 13, 14
tuned in to self, other and the interaction (mind and body)
Self-care: interpersonal context Developing the ability to express own needs in relationships, increased 3, 4, 10, 11, 14
interpersonal confidence and stability through attending to own needs.
Listening Developing more awareness in conversation, managing own anxiety, 3, 4, 5, 8, 11, 12
listening and recognising others’ needs
Reduced interpersonal Developing the ability to reduce reactivity in interactions, or to explore 3, 4, 6, 9, 10, 12
reactivity own feelings or reflect on a relationship then choosing to respond
Changing relationship to the Developing ability to stay with emotions or difficulties when with clients, 4, 7, 10, 12, 14
difficult: interpersonal coming to the breath or observing and staying present.
From needing to fix to being Developing a new understanding of role, valuing being with others 3, 4, 7, 10, 11, 14
with without needing to problem solve or fix
Shared humanity: Empathy and Sense of shared humanity in experiencing suffering, leading to less 3, 4, 7, 8, 9, 10
acceptance of others judgement of others and increased empathy and acceptance
Teaching mindfulness Experiences of teaching mindfulness to family or clients, grounded in own 3, 7, 10, 13, 14
techniques practice. Some had further training in specific approaches, some were
less comfortable teaching directly and avoided or gave as self-help
materials. Some with previous experience of mindfulness felt specific
teaching helped to transfer to clinical context

for stress management or as part of clinical skills devel- quantity. In some instances, health care workers simply
opment. Only two studies reported that participants had may not have practiced enough to develop further in their
no choice about attending mindfulness training as it was understanding and integration of mindfulness. Yet even if
incorporated into their clinical training (McCollum and they continue to practice for the duration of the course and
Gehart 2010; Gockel et al. 2013); however, this did not beyond (as results of the quantitative study that comple-
appear to reduce their engagement or subsequent benefits. ments De Zoysa et al.’s paper suggest: Ruths et al. 2012),
Participants in De Zoysa et al.’s study (De Zoysa et al. if barriers are still in place, the quality of practice and
2012a) were recruited from a group who attended training subsequent benefits may be limited. Therefore, an impor-
“not only for their own well-being, but also to learn about tant factor in mindfulness training for health care workers
a new therapy likely to be of potential use with their may be addressing initial motivation and communicating
clients” (Ruths et al. 2012). Quotes from participants the need to develop a personal understanding of mindful-
suggested that perhaps they had not progressed beyond ness, in order to shift the focus away from helping others.
initial challenges and thus may not have engaged with Participants in the longer-term studies by Christopher
mindfulness at a deeper level: et al. (2011) and Beckman et al. (2012) appeared to have
continued to engage with and use mindfulness. The mind-
All the time I’ve got that secondary conversation going fulness training they had was more in depth, with greater
on ‘what am I getting from this, what am I achieving at contact time over longer periods and highly experienced
the end of this?’ and I think that that’s what [the barrier facilitators, and so these factors may be important in
to regular practice] is. (De Zoysa et al. 2012a) establishing a “deep, rather than surface, understanding”
(Barnett and Ceci 2002, p. 616) associated with greater
Indeed, it may be that participants focused on learning transfer of learning from training into other contexts.
techniques they could use with clients were less motivated Once initial challenges have been passed, there may also
to navigate around barriers than those interested primarily be a requirement for some form of ongoing support to
in self-care. Shapiro and colleagues suggested that “the maintain practice. Indeed, the study by Beckman et al.
effects of practice on psychological outcomes may only (2012) demonstrates that having monthly drop-in sessions
appear when some critical threshold of practice time has (even though attendance was variable) may have allowed
been met” (Shapiro et al. 2007) yet acknowledged that participants to keep in touch with what they had learned
quality of practice time is potentially as relevant as and to continue using mindfulness. Authors of most
 Mindfulness

studies suggested that ongoing practice should be sup- I have more compassion for myself… it feels good. I’m
ported through organisational support, providing access to prone to recover from down days faster… I realized,
further group sessions, integrating mindfulness into clin- you know, I have a choice in how I’m going to treat
ical supervision and considering general reminders. myself… it has been freeing, empowering, and liber-
Again, this relates to the recognition in the training liter- ating. (Christopher et al. 2011)
ature that organisational support is an important part of
facilitating the transfer of learning from training to the Being able to be more aware and attend to emotions
workplace (Noe and Schmitt 1986) as well as an expec- also had direct implications in terms of engaging with
tation that participants will put what has been learnt into work: for example, one occupational therapy student said,
practice (Kraiger and Culbertson 2013). “when I was struggling with completing an essay last
week… I was aware of my mind wandering off and
2. Beyond the barriers: health care workers changing their finding excuses… I was able to accept the situation and
relationship to experience then focus more readily on the task in hand” (Stew 2011).
Health care workers’ accounts support the theory that Similarly, some qualified nurses reported being able to
through mindfulness training participants change their accept and prioritise their workload (Cohen-Katz et al.
relationship to experience, dis-identifying with the con- 2005a).
tent of the experience (such as thoughts), and have more A further outcome for health care workers involved
clarity to observe what is there (Segal et al. 2013). Where- their confidence in decision making. For example, one
as studies of patients’ journeys often illustrate the personal participant said, “I feel more grounded and I’m trusting
origins of changing relationships to experience, studies of my own perceptions more.... feel more confidence in my
health care workers’ have explored shifts in both personal decision making” (Schure et al. 2008), while another
and interpersonal domains. reflected on self-acceptance, recognising one’s limits
and letting go of getting everything right: “It allows me
(a) Benefits for health care workers in relating mindfully to reach out and consult, and be okay with not having all
towards individual experiences: “freeing, the answers… what’s going to make me more competent
empowering and liberating” is if I recognize when I’m feeling stuck” (Christopher
et al. 2011).
Health care workers experienced shifts in the way Benefits were also reported in terms of physical
they coped with emotions and how they related to wellbeing. Just as participants were approaching emotions
themselves which, for some participants, led to im- in a different way, some reported changing their relation-
provements in self-care, confidence, decision making ship to physical pain. Many participants also reported that
and productivity. Some studies also reported increases their physical health had improved in terms of reducing
in physical wellbeing and ability to cope with pain as symptoms of illness and improving sleep, eating habits,
well as providing an opportunity to reflect on spiritu- flexibility and strength. This highlights that mindfulness
ality. Although all studies contributed to the data on training can produce holistic changes that are not always
personal benefits of mindfulness training, the extent to measured in quantitative studies if they are not the prima-
which participants were reported to have benefitted in ry target of the intervention, yet in many studies, mind-
this domain varied both within and between papers. fulness training is targeted at physical health (Carmody
This issue will be returned to after discussion of et al. 2009).
interpersonal benefits as it is relevant to both domains. Finally, some participants reported that they felt mind-
Through attending to their experiences with an fulness training integrated well with their religious or
accepting attitude, health care workers were able to spiritual beliefs. For example, one participant said, “By
gain insight into their intrapersonal processes, step adding the element of prayer to my meditation it was
back from them and gain more composure to respond easier to connect with my true self… I entered the clinic
rather than react. Participants felt more able to cope with a greater sense of patience for my progress and
with difficult thoughts and “to an extent note and let compassion for my struggles” (McCollum and Gehart
go of arising emotions” (Schure et al. 2008) as well as 2010). Although some brief references were made to
opening to and appreciating pleasant experiences. participants’ initial scepticism about the religious con-
Health care workers felt increasingly comfortable with notations of meditation or being told by others that it
self-acceptance and self-care. This quote from a coun- might conflict with existing beliefs, the majority of
sellor in Christopher’s long-term follow-up study references described participants having positive ex-
shows how these changes have the potential to have periences when reflecting on their spirituality in rela-
lasting and profound effects: tion to mindfulness training.
Mindfulness

(b) Benefits for health care workers in relating mindfully Finally, through their own journey with mindfulness,
with others: the power of empathy and “genuine health care workers were able to feel more hopeful about
compassion” the potential for therapeutic change: “We all have so much
more power and ability to heal ourselves and take care of
Participants benefitted interpersonally through be- ourselves than we even know. So, I think that instilled
coming more aware when relating to others (of them- some hope in me at a time when I really needed that”
selves, the other person and the interaction) and being (Christopher et al. 2011).
able to choose how to act. For example, many par- Where participants were confident in teaching mind-
ticipants spoke about using mindfulness to ground fulness, they were careful about when to do so; however,
themselves or gain focus prior to seeing patients or some may not have had sufficient grounding in mindful-
clients, “the mindfulness practice has helped me to ness practice which resulted in some confusion with cli-
center myself between each session… it has become ents, “I think [the client] just got confused between things
increasingly important for me to leave each client in like whether he should be suppressing thoughts or not
their time slot and not take them with me into the next suppressing them or being mindful towards them or dis-
session” (McCollum and Gehart 2010). Health care tract himself, it all became a bit muddled really” (De
workers also learnt how to bring mindfulness into Zoysa et al. 2012a). The results support the reasoning that
interactions with patients or clients. For example, one in order to teach mindfulness successfully, a strong foun-
participant spoke about the impact of sitting with a dation in personal practice is needed as well as specific
client when they were highly agitated. skills in teaching mindfulness (McCown et al. 2010;
Segal et al. 2013).
My ability to draw upon my own peaceful sense
inside helped me not only maintain control in the
session, but impart something to the client that Making Sense of Variations
words alone could not have communicated.
(McCollum and Gehart 2010) It is important to note that the range of personal and
interpersonal benefits was not experienced by all partici-
This was part of a conceptual shift whereby health care pants and there were variations both within and between
workers were exploring the value of being with patients papers. In contemporary conceptual models of the transfer
and feeling “less pressure to fix” (Schure et al. 2008). of learning from training, individual differences are ex-
pected in what participants learn based on their interpreta-
I always felt that… my patients were coming to me to tions of and engagement with the training (Kraiger and
have something fixed, and that my expectation of Culbertson 2013). Indeed, many study authors referred to
myself was that I was supposed to do something… a distinction between participants who engaged with mind-
And I think I came to realize… just being there in the fulness as a set of tools to help with self-care or to apply to
present moment and with their experience is, is very improve their work and participants who engaged with
powerful. (Irving et al. 2012) mindfulness as a way of being. The likelihood of a more
superficial engagement with mindfulness may increase
Many of the studies explored whether mindfulness based on the initial intentions of participants (as was
training cultivated empathy in health care workers. discussed earlier) or the way in which a course is taught.
McCollum and Gehart reported that participants experi- For example, Beddoe and Murphy suggested that there was
enced increased empathy for clients through a sense of an untapped potential for interpersonal benefits from their
“shared humanity” (2010, p. 351). Participants’ accounts training because “the intervention content emphasised self-
suggest that this may be as a result of understanding and care but did not directly encourage empathy for others”
accepting themselves and their own experiences of (Beddoe and Murphy 2004). Similarly, Gockel et al. pos-
suffering: ited in an earlier paper that focusing on using mindfulness
in clinical practice may have benefitted clinical learning
I have been noticing my capacity for empathy has “but detracted from the overall impact of the training on
increased as I have been engaged in this class. I have their well-being and their development of mindfulness
a notion this is the result of becoming aware when I am itself by introducing a competing and, in fact, a superordi-
being judgmental of others or myself. I have increased nate focus for the course” (Gockel et al. 2012). Indeed,
my compassion, which in turn, has given me an in- some participants did appear to gain insight into the use of
creased capacity to have more genuine compassion for mindfulness interpersonally rather than basing their under-
others. (Schure et al. 2008) standing on intrapersonal experience.
 Mindfulness

I was sort of ambivalent about the mindfulness activities Factors to Consider in the Implementation of Mindfulness
in the beginning. And towards the end, I just sort of Training for Health Care Workers
really realized how much those activities helped me to
be present and really helped to facilitate the role-plays The degree to which health care workers benefit from mind-
that we did in the class (Gockel et al. 2013). fulness training as individuals and interpersonally may relate
to their initial intentions, whether the mindfulness training has
The contrasting results of these two papers suggest
specific or more general aims, the amount and quality of
that mindfulness can be developed in either the intraper-
practice and whether there is support for ongoing engagement
sonal context (in terms of self-care) or the interpersonal
with mindfulness over time. Moreover, in the studies
context (as a way of interacting with patients or clients)
reviewed, participants who were using mindfulness as a set
without necessarily overlapping. Nevertheless, the com-
of tools primarily applied it in the way it was taught to them
ments of both authors suggest that neglecting either the
whereas those who adopted mindfulness as a way of being
intrapersonal or interpersonal applicability of mindful-
were more likely to be able to use mindfulness across con-
ness reduces the possible benefits of a more holistic
texts. This resonates with the findings in wider literature
and comprehensive understanding.
pertaining to the transfer of learning from training, which
suggests that it is common for learning to be restricted to use
in the way in which it was taught, yet participants who gain a
deeper understanding may be able to generalise their learning
Discussion (Barnett and Ceci 2002).
Therefore, facilitators should consider carefully what the
Through engaging in formal mindfulness practice and over- aims of the mindfulness training are (such as self-care or
coming challenges to practice, health care workers were some- interpersonal development) and whether the content and de-
times able to increase their level of awareness and relate to livery reflect these aims, as well as monitoring the motivations
themselves and patients in a more accepting and compassion- of participants. Care should be taken to adequately address
ate way. At a time when compassion is high on political challenges to formal practice and provide an intervention with
agendas in the UK with recommendations for more attention enough practice time to give participants the opportunity to
to compassionate care in the selection, training and evaluation develop a deeper understanding of mindfulness. Encouraging
of health care workers (Francis 2013), this review highlights participants to explore mindfulness on a personal level (as
several relevant points. Firstly, health care workers participat- opposed to simply looking for skills to apply) may increase
ing in mindfulness training have been shown to develop a the likelihood of this occurring. Specific training such as the
greater sense of “shared humanity” (McCollum and Gehart use of role play may be an important tool in increasing
2010) with patients through coming to terms with their own understanding about how mindfulness can be used interper-
vulnerabilities, accepting themselves and seeing how their sonally as well as giving health care workers the opportunity
experience of suffering related to that of patients to practice and build up confidence in using mindfulness in a
(Christopher et al. 2011). As an experiential training, mind- non-clinical environment. Actively supporting participants to
fulness training provides the opportunity for health care continue to practice over time may be an important part of
workers to understand shared humanity both conceptually maintaining benefits or continuing to develop understanding.
and through developing a greater meta-cognitive awareness, Although two studies in this review reported positive find-
exploring and accepting themselves (Bruce et al. 2010). Sec- ings having incorporated mindfulness training into clinical
ondly, health care workers felt an increasing capacity to be training without participants opting in, no studies examined
present in a compassionate way with patients through attend- the experience of health care workers conscripted to mindful-
ing to their own self-care needs. As one participant said, ness training. Health care providers may consider mindfulness
“When you take care of yourself, you just have more to give. training to be a useful remedy to stress in the workplace;
I’m more focused on my patients now” (Cohen-Katz et al. however, it is unclear how making the training mandatory
2005a, b, p. 84). This attitudinal shift away from the need to might change both the experience and perceived outcomes.
“be selfless and put others’ needs first” (Maslach and If indeed this is an option considered, further research is
Goldberg 1998, p. 63) may be a significant factor in reducing needed to explore to what extent conscription impacts on the
health care workers’ vulnerability to burnout as well as an experience of mindfulness training.
indirect yet effective way of increasing compassionate care
across health care services. Further evidence for the reduced Implications for Theory
risk of burnout was identified through health care workers
feeling more able to manage strong emotions and experience Shapiro et al. (2006) posit that mindfulness is comprised of
distress without needing to “fix” it. intention, attention and attitude. Intention refers to an
Mindfulness

individual’s reasons for cultivating mindfulness, which may relevant to how they may have engaged differently with the
vary from person to person and over time, and this review has training process.
considered some of the ways in which intention may impact It could be considered a limitation that more strict criteria
upon outcomes. Attention in mindfulness refers to moment- were not applied when selecting studies to include as this then
to-moment awareness of experiences, both internal and exter- limited the application of more interpretative synthesis
nal, and this review supports the theory that cultivating atten- methods (e.g. Noblit and Hare 1988). It is recommended that,
tion is as an essential step towards experiencing perceived when further studies are carried out with improved methodol-
benefits. Attitude refers to “the heart aspects of practice” ogy, a further synthesis is carried out using more formal
(Bruce et al. 2010, p. 84), bringing qualities such as curiosity, procedures. Involving more researchers in the process may
openness, acceptance and love (Siegel 2007) to the present also support a more comprehensive analysis.
moment experience. Health care workers’ experiences reaf-
firm that it is the shift towards this attitude in relating to Future Research
experience, coupled with de-centring or re-perceiving
(Shapiro et al. 2006), that underpins both intrapersonal and This review highlights some of the complexity regarding how
interpersonal benefits (Bruce et al. 2010). Indeed, initial em- health care workers engage with mindfulness training and the
pirical evidence suggests that it is the combination of in- range of potential benefits they might report. For example,
creased levels of mindfulness and the ability to re-perceive future research in this area, both quantitative and qualitative,
that mediate outcomes of mindfulness training (Carmody et al. could consider what the aims of a given intervention are and
2009). how this is communicated through the actions of the facilitator
The results of this review suggest, both in the accounts of and the course content, how best to capture participants’
health care workers and the interpretations of study authors, motivations, how this might impact upon their experience
that while mindfulness can be cultivated in either the personal and engagement and how best to support the process of
or interpersonal domain, there are further benefits to be gained overcoming challenges to practice. Relatively few papers
through the knowledge and application of relating mindfully examined the effects of training over time, and so further
to both self and others. For example, using mindfulness to research with a longitudinal component may be useful to
relate to patients differently may enhance clinical skills better understand what increases the likelihood of maintaining
(Gockel et al. 2013), yet it is necessary to relate to both self reported benefits. Finally, whilst the majority of research has
and other with compassion in order to experience a sense of focused on if and how mindfulness training is beneficial to
shared humanity (Christopher et al. 2011). Although the way health care workers, as the evidence for benefits grows, there
of relating is essentially the same whether focused on self or is a need to further compare the outcomes and cost-
other, and individuals can begin to explore crossing into the effectiveness of mindfulness training with other training
opposite domain themselves, if there are barriers to relating programmes (e.g. relaxation training, Jain et al. 2007).
mindfully to self or other, then providing training in both
domains may be most beneficial. While there is a focus in
the UK on developing compassion in health services, espe-
cially as a result of well-publicised failures of NHS staff to Conclusions
provide high-quality care (e.g. Francis 2013), the expected
course of action may be to try and teach health care workers to Through engaging in formal mindfulness practice and over-
care more for their patients. However, the evidence in this coming challenges to practice, health care workers were some-
review suggests that rather than needing to teach compassion times able to increase their level of awareness and relate to
for others, supporting health care workers to engage in self- themselves and others in a more accepting and compassionate
compassion and self-care can act as a stronger foundation on way. The degree to which health care workers benefitted from
which to maintain an existing ability to care for others. mindfulness training varied based on factors such as their
initial intentions, whether they moved past initial challenges
to practice and whether they engaged with mindfulness at a
Strengths and Limitations deeper level. This review demonstrates the range of potential
benefits of mindfulness training for health care workers and
This review provides evidence to suggest that mindfulness those in training, to reduce stress and increase wellbeing, as
training can result in positive outcomes for a range of health well as to further develop and enhance the way they relate to
care disciplines. It is important to note that not all participants patients or clients. Some evidence also suggested that health
reported all of the outcomes discussed. Instead, the review care workers were more confident in decision making as well
demonstrates the range of experiences health care workers as recognising the limits of their competency and asking for
have had with mindfulness training and discusses the factors help. Therefore, mindfulness training is a promising option for
 Mindfulness

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