Julene Campion MBSR in Healthcare

Running head: MINDFULNESS-BASED STRESS REDUCTION IN HEALTHCARE

PROFESSIONALS

Mindfulness-Based Stress Reduction in Healthcare Professionals

And the Relationship to Burnout and Empathy

A Capstone Submitted to Saint Joseph’s University

By Julene Campion

In Partial Fulfillment

Of the Requirement for the Degree Master of Science in

Organization Development and Leadership

September, 15 2014

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MINDFULNESS-BASED STRESS REDUCTION IN HEALTHCARE PROFESSIONALS

Abstract

Objective: Healthcare professionals are under a tremendous amount of pressure given the

changes of healthcare reform. As a result, many healthcare professionals experience burnout and

decreased empathy. Mindfulness-Based Stress Reduction (MBSR) has been shown to reduce

stress and improve overall well-being in healthy populations. The purpose of this study is to

determine if an eight-week MBSR program designed for healthcare professionals can decrease a

burnout tendencies and increase empathy. Design: A quantitative and qualitative method were

utilized for this study. For the quantitative method, the Maslach Burnout Inventory (MBI) and

the Jefferson Scale of Empathy (Healthcare Professionals version) were administered pre and

post-treatment. For the qualitative method, an open-ended class evaluation created by the

program facilitators was administered post-treatment. Participants: Healthcare professionals

from a large healthcare network in Pennsylvania were recruited for the MBSR program through

postings on the organization’s intranet and internet sites. The eight-week MBSR course met for

2.5 hours for eight weeks plus a seven-hour retreat at the end of the program. Participants were

offered continuing education credits and received a $200.00 stipend. The course was offered

from 2010-2014. Hypothesis 1: Healthcare professionals who complete an eight-week MBSR

program experience lower burnout tendencies as measured by the Maslach Burnout Inventory

(MBI) in the subscales of emotional exhaustion, depersonalization and lack of personal

accomplishment. Hypothesis 2: Healthcare professionals who complete an eight-week MBSR

program experience an increase in empathy as measured by the Jefferson Scale of Empathy (HP

version) which measures key dimensions of empathy including perspective-taking,

compassionate care and standing in the patient’s shoes. Results: (Hypotheses 1) Participants

post-test mean scores indicate a lower frequency of emotional exhaustion (-2.3) and

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depersonalization (-1.8) along with an increased frequency of personal accomplishment (1.8).

The combination of each subscale results indicate that the MBSR program positively affected

burnout in the participants. (Hypotheses 2) Participants post-test mean scores on the Jefferson

Scale of Empathy indicate a stronger level of agreement on the non-flipped questions (1.5) and a

higher level of disagreement on the flipped questions (-1.9). The results indicate that the MBSR

program positively affected the levels of empathy in the participants.

Key Words: Mindfulness-Based Stress Reduction, MBSR, Mindfulness, Healthcare

Professional, Burnout, Empathy

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Acknowledgments

I would like to dedicate this paper to my son, Pierce Campion who inspires me,

challenges me to think more deeply, and makes me laugh out loud! I would like to thank my

amazing husband, John who encourages me to chase my dreams and gives me loving support in

so many ways. I could not have completed this program without his unwavering reassurance.

Finally, I want to thank my Lehigh Valley Health Network colleague, Susan Wiley, MD for her

passion, commitment, knowledge and for making this study possible.

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Table of Contents

Chapter I: Introduction

1.1 Problem Statement

1.2 Need for Research

1.3 Purpose of the Study

Chapter II: Literature Review

2.1 Overview

2.2 Mindfulness-Based Stress Reduction (MBSR)

2.3 MBSR in Healthcare Professionals and the Relationship to Burnout and Empathy

2.4 Summary

Chapter III: Methodology

3.1 Research Questions

3.2 Research Hypothesis

3.3 Research Design

3.4 Operational Definitions and Variables

3.5 Participants

3.6 Instruments and Materials

3.7 Procedure

Chapter IV: Results

4.1 Introduction

4.2 Descriptive Data

4.3 Analysis of Research Questions

4.4 Other Findings

Chapter V: Discussion

5.1 Summary

5.2 Interpretation of Findings

5.3 Additional Analysis

5.4 Limitations

5.5 Recommendations

5.6 Conclusion

References

Appendices

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Chapter I: Introduction

1.1 Problem Statement

Passage of the Affordable Care Act (ACA) dramatically increased accountability for

acute hospitals in the United States. The Centers for Medicare & Medicaid Services (CMS)

developed a national standardized survey called the Hospital Assessment of Healthcare Providers

and Systems survey (HCAHPS and pronounced “H-CAPS”) to measure and publicly report

patients’ perceptions of the care they received while in hospital (The Hospital & HealthSystem

Association of Pennsylvania , 2013). In addition to the patient’s perception of care, the

Affordable Care Act mandates a value-based purchasing program. A value-based purchasing

program is similar to a pay-for-performance program. Under ACA, Medicare and Medicaid

reimbursements will be based on the perception of care, quality and outcomes of patient care

(The Hospital & HealthSystem Association of Pennsylvania , 2013).

In the rapidly changing healthcare environment, healthcare professionals (physician,

nurse practitioner, physician assistant, registered nurse and psychologist) are under a tremendous

amount of pressure to provide safe, effective and quality care while reducing costs and creating a

positive perception of the care delivery experienced by their patients. Healthcare professionals

need stress-coping skills in order to avoid burnout and to communicate in a caring and

empathetic way to their patients. Healthcare professionals may experience an inner conflict

between their personal values to heal and care for their patients while meeting the increasingly

demanding regulatory and economic requirements of the workplace (DiGiacoma & Adamson,

2001).

The pay-for-performance or value-based purchasing program places millions of dollars at

risk for acute care hospitals in the United States. In Pennsylvania alone, approximately $90

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million in annual CMS reimbursements will be at risk by 2017 (The Hospital & HealthSystem

Association of Pennsylvania , 2013).

1.2 Need for Research

The concept of burn-out refers to “the process in which the professional’s attitudes and

behaviors change in negative ways in response to job strain” (Cherniss, 1980). Some symptoms

related to burn-out in healthcare professionals include emotional exhaustion, depersonalization

or disregard for others, and a low sense of accomplishment (Krasner, et al., 2009). Burn-out in

healthcare professionals has been linked to poorer quality of care, increased medical errors,

decreased patient satisfaction, increased malpractice claims and a decrease in the healthcare

professional’s ability to express empathy.

Stress in the clinical environment can lead to irritability and negative attitudes toward the

patient and colleagues, rationalization and blame or lack of empathy. Patient care,

communication, friendliness, creativity and support for other colleagues decline as stress

increases (DiGiacoma & Adamson, 2001). During burnout, both professional performance and

personal health and well-being are negatively affected (Cherniss, 1980). A lack of genuine

interest, pessimism, and emotional irritability are perceived negatively by the patient and impact

the progression of care (Cherniss, 1980). Burnout leads to irritability, negative attitudes and a

lack of empathy which also negatively impact the patient’s perception of care delivery,

progression of care and quality of outcomes.

Although there is a substantial amount of research related to burnout in healthcare

professionals and the impact on the patients’ perception of care and quality outcomes, there are

few studies examining the effects of a Mindfulness-Based Stress Reduction program for

healthcare professionals related to decreasing burnout and enhancing empathy. If MBSR can be

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shown to decrease burnout and enhance empathy in healthcare professionals, there is strong

evidence to support the residual effects of a positive perception of care delivery by the patient,

progression of care and quality outcomes.

1.3 Purpose of the Study

The main purpose of this study is to determine if there is a positive correlation between

completion of an eight-week Mindfulness-Based Stress Reduction course by healthcare

professionals and a decrease in burnout tendencies along with enhanced empathy. If a positive

correlation can be determined, this study will help healthcare organizations evaluate their current

health and wellness strategy to better identify programs such as MBSR which can decrease

burnout and positively impact the healthcare professional’s level of empathy. Ultimately, this

may positively impact the patient’s perception of care, progression of care and outcomes.

As the healthcare industry morphs from a pay-for-service model to a value-based-

purchasing model, consumers gain more control and greatly influence the bottom line of a

hospital’s financial health. The consumer’s voice will be heard through the HCAPPS survey and

their in-hospital experiences with healthcare professionals will significantly impact the

percentage of payment from CMS. It is essential that healthcare professionals practice self-care

to avoid emotional exhaustion, irritability, negative attitudes and a lack of empathy (Krasner, et

al., 2009).

The scope of this study will focus on a large health network in Pennsylvania, Lehigh

Valley Health Network (LVHN). In 2014, LVHN was recognized by U.S. News and World

Report’s Best Hospital list for the 19th consecutive year. The network received a grade of “A”

from The Leapfrog Group. (Leapfrog collects information from hospitals across the United

States and grades efforts to provide quality, safety and customer value.)

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The Center for Mindfulness at LVHN was co-founded by Susan Wiley, MD and Joanne

Cohen-Katz, PhD. In 2010, 2012, 2013 and 2014, the co-founders facilitated an eight-week

MBSR program for healthcare professionals (physicians, nurse practitioners, physician

assistants, registered nurses and psychologists). Two surveys were administered during the pre

and post periods of each eight-week program. The Maslach Burnout Inventory (MBI) was

utilized to measure burnout with the subscales of Emotional Exhaustion (EE), Depersonalization

(DP) and Personal Accomplishment (PA) (Appendix I). The Jefferson Scale of Empathy (HP

version) was utilized to measure empathy with a focus on perspective taking, delivering

compassionate care and the ability to stand in the patient’s shoes (Appendix II). The quantitative

portion of this study will examine the data from the pre and post surveys to determine if the

completion of the eight-week MBSR program resulted in a decrease in burnout and an increase

in empathy. Additionally, the qualitative portion of this study will include free-form responses

to three questions (Q8, Q9 and Q10) from the post-treatment class evaluation (Appendix III).

Limitations to the study include the small number of matched pre and post surveys

(n=22), the low number of completed class evaluations (n=20) and the low number of completed

demographic information (n=15) which limits the ability to determine correlations to gender,

role, specialty and age. A second limitation is the period of time passed when the post survey

was administered. The post survey was administered immediately following the final class. The

addition of a post survey following a nine or twelve month maintenance period may reveal

additional information about the effects MBSR has on burnout and empathy.

The overall goal of this study is to understand how the completion of a Mindfulness-

Based Stress Reduction course by healthcare professional’s impacts burnout and empathy which

are key drivers of a positive perception of care delivery by the patient, progression of care and

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quality outcomes. If a health network can influence more healthcare professionals to enroll in a

MBSR program, then it is possible that the patient’s perception of care would be improved along

with the progression of care and quality outcomes. Ultimately these improvements affect the

financial viability and future of the health network’s continued operation under the new

guidelines of healthcare reform.

Approval from Susan Wiley, MD, Vice Chair Department of Psychiatry at Lehigh Valley

Health Network was granted to analyze the survey data and class evaluations of participants who

participated in a MBSR program for healthcare professionals during the period of 2010 – 2014

(Appendix IV).

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Chapter II: Literature Review

2.1: Overview

An electronic search was conducted using Google Scholar and the Saint Joseph’s

University online database Discover which includes journals from key sources such as PubMed

(MEDLINE), ISI Web of Knowledge and PsycINFO. The database search included only peer-

reviewed studies published in English from 1980-2014. The main search terms were

Mindfulness-Based Stress Reduction, MBSR, Mindfulness, Healthcare Professional, Burnout and

Empathy in various combinations as needed. Other sources include websites for The Hospital &

HealthSystem Association of Pennsylvania and the Lehigh Valley Health Network and books by

Jon Kabat Zinn.

2.2: Mindfulness-Based Stress Reduction (MBSR)

In 1979, Kabat-Zinn and colleagues at the University Of Massachusetts Medical Center

in Worcester, MA introduced Mindfulness-Based Stress Reduction or MBSR (Kabat-Zinn,

1990). In addition to being the founding director of the Center for Mindfulness in Medicine,

Health Care, and Society at the University of Massachusetts Medical School, Kabat-Zinn was

also a student of Zen Master Seung Sahn for many years. His practice of yoga and studies with

Buddhist teachers led him to integrate their teachings with those of Western science. Kabat-

Zinn’s original intention was to evolve MBSR into a public health intervention, which led to

individual and societal transformation (Kabat-Zinn, 2011).

MBSR was originally developed for use in a clinical setting to introduce training in

mindfulness-meditation to patients experiencing stress (Kabat-Zinn J. , Mindfulness-based

interventions in context: Past, present and future, 2003). However, today MBSR is frequently

used as an intervention for a healthy population experiencing everyday stressors to help maintain

http://en.wikipedia.org/wiki/University_of_Massachusetts_Medical_School

http://en.wikipedia.org/wiki/Zen

http://en.wikipedia.org/wiki/Seung_Sahn

http://en.wikipedia.org/wiki/Buddhist

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a positive state of mind. MBSR provides participants with training in formal and informal

practices to approach stressful events mindfully in order to intentionally choose a response rather

than responding in automatic pilot mode (Bishop, 2002). A study conducted with a healthy

population concluded there is evidence to support MBSR reduces stress (Chiesa & Serretti,

2009). In this study, comparisons between groups suggested that there was “a significant

positive nonspecific effect compared to the absence of treatment (waiting list)” (Chiesa &

Serretti, 2009, p. 596). MBSR has also been shown to be an effective intervention on positive

states of mind and overall psychological well-being (Chang, et al., 2004).

Mindfulness-meditation techniques used in MBSR help people to cope with stress,

anxiety, pain and illness. Participants learn to observe the triangle (thoughts, body sensations,

emotions) in motion from various starting points without judgment, labels, resistance or striving

to change or stop it (Kabat-Zinn, 1990). MBSR is a highly structured program consisting of an

eight-week course. Participants meet weekly for two-and-one-half hours during the eight weeks

and conclude the program with an all-day (eight hours) retreat. The principle mindfulness-

meditation techniques taught in MBSR contain three broad elements (Crane, 2008):

1. The development of awareness through formal and informal practice

2. Adopting an intentional awareness and attitude of curiosity, acceptance, kindness and

openness to be with the present experience without judgment, labeling, or striving for

it to be different or better

3. A new acceptance and understanding of human suffering in others and in

ourselves which is further realized mindful-meditation is experienced more deeply.

http://en.wikipedia.org/wiki/Mindfulness_(psychology)

http://en.wikipedia.org/wiki/Stress_(medicine)

http://en.wikipedia.org/wiki/Anxiety

http://en.wikipedia.org/wiki/Pain

http://en.wikipedia.org/wiki/Illness

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In addition to the group meetings during the eight-week session, the MBSR program

includes daily homework assignments including reading, journaling, meditation, body scan, yoga

and triangle of awareness exercises for 45 minutes (Carmody & Baer, 2008).

Researchers in the San Francisco Bay area recruited forty-three participants to measure

the effects of a MBSR program on perceived levels of stress, positive state of mind and

mindfulness self-efficacy in healthy adults (Chang, et al., 2004). Of the 43 participants recruited,

only twenty-eight of the participants completed all follow-up measures. The participants were

students enrolled in a private university continuing education program. Self-reported measures

collected demographic data and information related to previous experience with meditation. The

Perceived Stress Scale (PSS) was used to measure perceived levels of stress in the most recent 30

days. The PSS uses a five-point Likert scale from 0 (never) to 4 (very often). A short version of

the PSS was used for the study. A six-item scaled called the Positive States of Mind (PSOM)

was used to measure six domains of satisfying states of mind: focused attention, productivity,

reasonable caretaking, restful repose, sensual/non-sexual pleasure, and sharing (Chang, et al.,

2004). The PSOM uses a 3-point Likers scale ranging from 0 (unable to have it) to 3 (have it

easily). Levels of perceived stress were measured using the Mindfulness self-efficacy (MSE).

The MSE is comprised of 15 items that measure whether or not the participant can remain

impartial (non-judgmental) during various situations. Participants indicate their confidence level

on a percentage scale between 0 percent (no confidence) to 50 percent (moderate confidence) to

100 percent (complete confidence) (Chang, et al., 2004). Following the 8-week MBSR program,

there was a significant decrease in the perceived level of stress score and a significant

improvement in the positive state of mind and mindfulness self-efficacy score.

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2.3: MBSR in Healthcare Professionals and the Relationship to Burnout and Empathy

A randomized trial by Shapiro, Astin, Bishop, and Cordova (2005) studied the effects of

MBSR in healthcare professionals who are currently working in a clinical environment. The

purpose of the research was to determine if MBSR would decrease overall psychological

distress, stress, and job burnout. Additionally, the researchers were interested in measuring the

positive benefits of MBSR related to overall life satisfaction and increased self-compassion. The

study design involved randomly assigning the participants to two groups, experimental and

control group. A baseline and post-treatment measurement was used for a between-groups

comparison. Participants included healthcare professionals (nurses, social workers, physical

therapists and psychologists) from a Veterans Affairs organization in California. Participants

were recruited through flyers and e-mail messages. All participants were required to be a current

health care professional, age of 18 years or older and English speaking (MBSR program

materials are only available in English at this time). Participants were not accepted into the trial

if they had current substance abuse problems or suicide ideation. The Brief Symptom Inventory

(BSI), the Total Mood Disturbance scale, the Maslach Burnout Inventory (MBI) and the

Perceived Stress Scale were used to measure stress levels and mood pre and post the MBSR

program (Derogatis, 1993) (Maslach & Jackson, 1986). Additionally, satisfaction with life and

self-compassion were measured using the Satisfaction with Life Scale (SWLS) and the Self-

Compassion Scale (Diener, Emmons, Larsen, & Griffin, 1985; Neff, 2003). Although the

sample size was small (n=18), the study found that the changes in self-compassion significantly

influenced positive changes in perceived stress (Shapiro, Astin, Bishop, & Cordova, 2005).

Participants indicated that the MBSR program had a significant positive effect on their life and

suggested that MBSR may be beneficial for healthcare workers who participate in the program.

Unfortunately, the dropout rate of 44% for this study was significantly higher than the average

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rate of most MBSR programs (20%). All participants who dropped out indicated it was due to

lack of time or increased responsibilities so this may be a barrier to introducing the eight-week

MBSR program to health care professionals in the current format. Health care professionals

already have a demanding and stressful schedule so adding two and a half hours each week with

daily home practice may be difficult to accomplish.

The Shapiro et al., (2005) study suggests that creative ways to deliver the MBSR program

to healthcare workers should be further explored such as incorporating in work schedule or

finding other ways to reduce time commitment. The study further suggests that additional forms

of self-report measures, follow-up assessments should be considered in future studies.

A pre-post study conducted in a university medical center with healthcare workers using

the Maslach Burnout Inventory offered the MBSR course for continuing education credits and

paid participants $400. (Note: not all participants were healthcare professionals and not all

participants were affiliated with the university medical center.) The course was advertised

through email announcements and local print media. The study found that burnout scores

improved significantly following the eight-week MBSR course (Goodman & Schorling, 2012).

Another study involving primary physicians and the eight-week MBSR program was

designed to determine if the program improved the physician’s sense of well-being,

psychological distress, burnout and capacity for relating to patients (Krasner, et al., 2009). The

study was offered to 70 primary care physicians as a Continuing Medical Education (CME)

course in Rochester, NY. Physicians who participated did not pay a fee, received CMA credits

and $250 upon completion of five self-administered surveys. The eight-week MBSR program

was followed by a 10-month maintenance phase. The objective of the study was to determine if

an MBSR program combined with communication and self-awareness education and practice

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would reduce physician’s burnout and psychological distress while improving well-being and

patient relationships. In addition to the informal and formal practices taught in the MBSR

program, the physicians participated in narrative discussions about clinical experiences and used

appreciative interviews with each other to better understand the importance of listening.

Participants were coached to listen to the personal stories with intention and non-judgment while

practicing focused questions to deepen understanding. In larger group discussions, participants

shared experiences related to using the mindfulness-based practices, narrative writing and

appreciative inquiry exercises and discussed the overall sense of well-being (Krasner, et al.,

2009).

The five self-administered surveys were completed according to the following schedule:

1. Time of registration

2. Beginning of the first session

3. End of the eight-week MBSR program

4. End of the 10-month maintenance phase

5. Three months after the 10-month maintenance phase ended

Several assessments were used in this study including the 2-Factor Mindfulness Scale,

Maslach Burnout Inventory, Jefferson Scale of Healthcare Professional Empathy, Physician

Belief Scale Mini-markers of the Big Five Factor Structure and Profile of Mood States (POMS)

(Krasner, et al., 2009). Scores were analyzed for each instrument and the changes in burnout,

empathy and other outcomes were associated with mindfulness. Measurable improvements in

well-being were found along with enhanced interpersonal characteristics related to a patient care.

A study involving Medical and Premedical Students examined the effects of an eight-

week MBSR program to determine if scores on overall empathy levels (among other items)

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increased following the program (Shapiro, Schwartz, & Bonner, Effects of Mindfulness-Based

Stress Reduction on Medical and Premedical Students, 1998). The study used the Empathy

Construct Sales (ECRS) to measure overall empathy. The participants reported increased scores

on overall empathy following the MBSR program. The study also suggested that the MBSR

program may have helped the students develop better listening skills and the awareness of higher

compassion for themselves and their future patients.

A pilot study of 30 primary care clinicians involved an abbreviated version of a

mindfulness program which included a total of 18 hours versus a typical MBSR program of 29-

33 hours. The abbreviated program included a weekend immersion (Friday evening: three hours;

Saturday: seven hours and Sunday: four hours) and two 2-hour follow-up evening sessions. The

study used a single sample and consisted of pre-post design using the Maslach Burnout

Inventory, Depression Anxiety Stress Scales-21, Perceived Stress Scale, the 14-item Resilience

Scale and the Santa Clara Brief Compassion Scale (Fortney, MD, Luchterhand, MSSW,

Zakletskaia, MA, Zgierska, MD, PhD, & Rakel, MD, 2013). Participants were surveyed four

times: survey one was sent two weeks before the program began; survey two was sent the day

following the last course; survey three was sent eight weeks after the last session and survey four

was sent nine months following the course. The participants reported a significant improvement

in scores on all Maslach Burnout Inventory subscales (Emotional Exhaustion, Depersonalization

and Personal Accomplishment). The effects of the program were maintained over 9 months with

no formal intervention. The class size was 15 individuals and there was no cost to the

participants.

A study conducted with 84 employees from a university hospital involved three pre/post

test questionnaires and an eight-week Mindfulness Meditation (MM) program utilizing materials

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from Jon Kabat-Zinn’s MBSR program and cognitive therapy (Galantino, Baime, Maguire,

Szapary, & Farrar, 2005). The program was delivered in two-hour weekly increments over eight

weeks. The course was adapted to address burnout, compassion, communication and work/home

balance. The questionnaires used for the study were the Profile of Moods States-Short Form,

Maslach Burnout Inventory and Interpersonal Reactivity Index. Participants completing the

Maslach Burnout Inventory reported improvements in the Emotional Exhaustion scale. This

study also reported improved patient satisfaction scores for participants the quarter following the

intervention.

2.4: Summary

The literature review confirmed that MBSR is an effective and safe treatment for

reducing medical and psychological symptoms in chronically ill individuals and for increasing

well-being in healthy populations (Carmody & Baer, 2008). The literature review also revealed

a growing interest in MBSR to reduce stress and anxiety in healthcare workers. However, very

few studies were found which evaluate the relationship between MBSR in healthcare

professionals and the impact on burnout and empathy. There are several common limitations to

the studies related to pre and post MBSR:

1. Lack of a control group

2. Small sample size

3. Population may be predisposed to register for the MBSR program as in the case

of offering CME credits

4. Since the MBSR program materials are only available in English, the sample

population does not include a diverse group

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Chapter 3: Methodology

3.1 Research Questions

Two research questions were utilized for this study.

Question 1: Do healthcare professionals who complete an eight-week Mindfulness-

Based Stress Reduction (MBSR) program experience reduced burnout tendencies?


Based Stress Reduction (MBSR) program experience an increase in empathy?

3.2 Research Hypotheses

Two research hypothesis were utilized for this study.

Hypothesis 1: Healthcare professionals who complete an eight-week Mindfulness-Based

Stress Reduction (MBSR) program experience lower burnout tendencies (emotional exhaustion,

depersonalization and lack of personal accomplishment) as measured by the Maslach Burnout

Inventory (MBI).


Stress Reduction (MBSR) program experience an increase in empathy (perspective-taking,

compassionate care and standing in the patient’s shoes) as measured by the Jefferson Scale of

Empathy (HP version).

3.3 Research Design

The research approach used for this study are both quantitative and qualitative. A

quantitative method will be undertaken using Maslach Burnout Inventory and the Jefferson Scale

of Empathy (HP version). The qualitative method will be undertaken by reviewing written

answers to three open-ended questions from the class evaluation to gain additional personal

insight from participants. The data was gathered from files stored by the lead facilitator of the

20


MBSR program at LVHN, Dr. Susan Wiley. The Maslach Burnout Inventory and Jefferson

Scale of Empathy were organized by each participant’s pre and post survey. To ensure each

subject’s confidentiality and protect the integrity of the information gathered, a unique identifier

was used for each participant. Class evaluations were not organized by subject as unique

identifiers were not recorded on the forms. The evaluation contained 13 questions. However,

after consultation with Dr. Susan Wiley, the qualitative study was limited to questions 8, 9 and

10 as these questions aligned most closely with the research hypothesis.

The Maslach Burnout Inventory and Jefferson Scale of Empathy were provided to the

participants at the beginning of the first class and again at the end of the last class. The class

evaluation was provided to participants at the end of the last class. All items were collected prior

to the participants leaving the classroom.

3.4 Operational Definitions and Variables

Mindfulness: Mindfulness is often associated with a specific method of meditation with

the qualities of paying attention, accepting, and self/other caring and compassion. It has also

been referred to as the awareness that arises through intentionally attending to one’s moment-to-

moment experience in a nonjudgmental and accepting way (Kabat-Zinn J. , Full Catastrophie

Living, 1990).

Mindfulness-Based Stress Reduction (MBSR): MBSR was originally developed by Jon

Kabat-Zinn at the University Of Massachusetts Medical Center for use in a clinical setting to

introduce training in mindfulness-meditation to patients experiencing stress (Kabat-Zinn & Jon,

2011). However, today MBSR is frequently used as an intervention for a healthy population

experiencing everyday stressors to help maintain a positive state of mind. MBSR provides

participants with training in formal (meditation) and informal practices (body awareness, mindful

http://en.wikipedia.org/wiki/Jon_Kabat-Zinn

http://en.wikipedia.org/wiki/Jon_Kabat-Zinn

21


eating, mindful walking and yoga) to approach stressful events mindfully in order to intentionally

choose a response rather than responding in automatic pilot mode (Bishop, 2002). MBSR has

also been used as an intervention on positive states of mind and overall psychological well-being

(Chang, et al., 2004). While MBSR has its roots in spiritual teachings, the program is not

affiliated with any religious belief system (Kabat-Zinn J. , Mindfulness-based interventions in

context: Past, present and future, 2003).

Healthcare Professionals: For the purposes of this study, defined as Physicians, Advance

Practice Clinicians, Registered Nurses and Psychologists.

Healthcare Professional Burnout: Healthcare professional burnout is defined as

emotional exhaustion, a feeling a lack of personal accomplishment and depersonalization by

Maslach Burnout Inventory.

Healthcare Professional Empathy: Healthcare professional empathy is defined as the

ability to assume the patient and/or family members’ perspective, stand in the patient’s shoes and

to provide compassionate care.

Independent Variable: Participation in an eight-week MBSR course at Lehigh Valley

Health Network designed for healthcare workers. The program name is Mindfulness Training

for Medical Professionals (MTMP).

Dependent Variables: There are two dependent variables - Burnout and Empathy.

3.5 Participants

Male and female healthcare professionals (Physicians, Advance Practice Clinicians,

Registered Nurses and Psychologists) from Lehigh Valley Health Network (LVHN) in

Pennsylvania were invited to participate in an eight-week Mindfulness-Based Stress Reduction

22


program specifically for healthcare professionals entitled Mindfulness Training for Medical

Professionals (MTMP). The program’s objectives include (Network, 2013):

Mitigate the stress of work and home life

Reduce negative moods and distress; promote well-being

Learn a broad set of skills useful in the work-day and in building relationships

through empathy and connection

Manage existential stressors of suffering and mortality without being sectarian

The availability of the program was posted on the organization’s internet and intranet

sites. Healthcare professionals who participated in the program were eligible for CME credits

and a $200 reimbursement from the Office of Medical Affairs (Network, 2013). Participants

were also eligible to receive a 100% refund of the cost through the organization’s Wellness

benefit program if they participate in the health coverage plan. All participants were required to

read and understand English. The program was sponsored by LVHN’s Center for Mindfulness.

3.6 Instruments and Materials

To measure burnout, the participants completed the Maslach Burnout Inventory pre and

post treatment, which includes three subscales of Emotional Exhaustion (EE), Depersonalization

(DP) and lack of Personal Accomplishment (PA). Three scores are calculated for each

respondent and there is no overall score. The Maslach Burnout Inventory consists of 22

questions and uses a 6-point Likert ranging from 0 “never” to 6 “every day”. Participants who

score high on the EE and DP scales while scoring low on the PA score exhibit a high level of

burnout. The Maslach Burnout Inventory is a validated assessment described frequently in the

literature review to measure burnout in healthcare professionals (Worley, Vassar, Wheeler, &

Barnes, 2008).

23


To measure empathy, the participants completed the Jefferson Scale of Healthcare

Professional Empathy pre and post treatment which measures the dimensions of perspective-

taking, compassionate care and standing in the patient’s shoes. The Jefferson Scale of

Healthcare Professional Empathy consists of 20 questions and used a 7-point Likert scale with 1

being “strongly disagree” and 7 being “strongly agree”. Ten of the questions are flipped or

presented in a negative context – reversing the Likert scale values. The Jefferson Scale of

Healthcare Professional Empathy is a validated assessment described frequently in the literature

review to measure empathy in healthcare professionals (Hojat, et al., 2001).

The class evaluation was created by Dr. Susan Wiley and Joanne Cohen-Katz, PhD. The

evaluation consisted of 13 open-ended questions.

3.7 Procedure

All MBSR classes for the study were conducted annually in 2010, 2012, 2103 and 2014

in a conference room on a LVHN hospital site. Dr. Susan Wiley was the lead facilitator for all

classes. Classes were held on a Tuesday evening from 6:00-7:30 PM once a week for six weeks

followed by a seven-hour Saturday retreat. A typical room set up included chairs in a circle.

Floor mats and pillows or blankets were used as well. Pre and post surveys were administered to

all participants using Maslach Burnout Inventory and Jefferson Scale of Empathy for Healthcare

Professionals. The pre-test was administered at the beginning of the first course. The post-test

and class evaluation were administered the evening of the last course prior to participants’

dismissal. Access to the pre-test, post-test and class evaluations were provided by Dr. Susan

Wiley.

The practices taught in the eight-week MBSR at program are listed below courtesy of the

Lehigh Valley Health Network website (Network, 2013):

24


Body scan – You’ll learn to slowly focus on each part of your body and be in

tune with the physical sensations. You develop greater familiarity and confidence

with your body.

Meditation – You’ll learn to incorporate meditation into your life in practical

ways. You can meditate while lying down, sitting, standing, eating and walking.

Mindful movement – You’ll learn to stretch and move without forcing your body

into complicated or difficult positions. You accept your body as you find it.

Group discussion – There’s so much power in sharing your experiences and

listening to the experiences of others in a nonjudgmental way. You learn your

experiences are not unique and help each other cope with life’s chaotic moments.

Awareness calendar – You’ll record the details of significant events – a pleasant

or unpleasant moment, a stressful communication. The exercise helps you become

in touch with your thoughts, moods and feelings, and resolve any issues.

Communication – You will learn how mindful awareness can improve

communication skills, cultivating both a greater presence in listening and clarity

of speech

25


Chapter 4: Results

4.1: Introduction

The purpose of this study was to determine if the completion of an eight-week MBSR

program decreases a healthcare professional’s burnout tendencies and increases empathy.

Participants’ response to the Maslach Burnout Inventory and the Jefferson Scale of Empathy

were entered into an Excel workbook. The data was analyzed by determining the difference in

the average responses to each question.

4.2: Descriptive Data

Demographics were collected using the Jefferson Scale of Empathy (HP version). Data

collected included age range (<21, 21-30, 31-40, 41-50, 51-60, 71-70 and >70); gender; primary

specialty, medical or surgical sub-specialty. Of the 22 participants, demographic data was only

provided by 15 individuals. (Note: Participants in the 2010 cohort did not receive the

demographic survey.)

Gender % of

Total

Female 59%

Male 41%

n=15

Age

Range

% of

Total

31-40 7%

41-50 40%

51-60 27%

61-70 27%

n=15

26


Primary Specialty

% of

Total

Anesthesiology 8%

Hospice 8%

Internal Medicine 25%

Palliative Medicine 8%

Pathology 8%

Psychiatry 17%

Psychology 25%

n=12

Medical or Surgical

Sub-Specialty

% of

Total

Cardiology 33%

Critical Care

Pulmonary

33%

Geriatrics 33%

n = 3

4.3: Analysis of Research Questions


Stress Reduction (MBSR) program experience lower burnout tendencies as measured by the

Maslach Burnout Inventory (MBI) in the subscales of emotional exhaustion, depersonalization

and lack of personal accomplishment. Comparisons between pre and post survey data using the

MBI supported the first hypothesis. Positive changes related to burnout were reported for all

subscales post treatment.

Figure 1 compares the mean pre and post-test MBI scores for the Emotional Exhaustion

(EE) subscale and Figure 2 displays the results in a chart. Overall, the EE subscale post test

indicated that participant’s felt emotionally exhausted less frequently following the program.

Participants reported a decrease frequency for all questions with the exception of Q20 (end of

rope) which saw no change from pre to post test and was reported during both as a frequency of

1.3 or “a few times a year or less”. The questions reflecting the biggest change in frequency

(-0.4) were Q2 (used up), Q8 (burned out) and Q13 (frustrated).

27


Maslach Burnout Inventory

Emotional Exhausted (EE)

Question Description Pre-Treatment Post-

Treatment Difference

Q1 Emotionally drained 3.6 3.3 -0.3

Q2 Used up 3.9 3.5 -0.4

Q3 Fatigued in the morning 2.8 2.5 -0.3

Q6 Working with people 2.2 1.9 -0.3

Q8 Burned out 2.4 2 -0.4

Q13 Frustrated 3.5 3.1 -0.4

Q14 Working too hard 3.2 3.1 -0.1

Q16 Stress 1.6 1.5 -0.1

Q20 End of my rope 1.3 1.3 0

Summary (EE) 24.5 22.2 -2.3

Figure 1

28


Figure 2

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Emotionallydrained

Used up Fatigued inthe morning

Working withpeople

Burned out Frustrated Working toohard

Stress End of myrope

Q1 Q2 Q3 Q6 Q8 Q13 Q14 Q16 Q20

Emotional Exhausted (EE)

Pre-Treatment Post-Treatment

29


Figure 3 compares the mean pre and post-test MBI scores for the Personal

Accomplishment (PA) subscale and Figure 3 displays the results in a chart. Overall, the PA

subscale post-test indicated that participant’s experienced a feeling of personal accomplishment

more frequently following the MBSR program. Participants reported an improvement on all

questions with the exception of Q4 (I can understand) and Q21 (deal with emotional problems

at work) which saw an unexpected decline in frequency of 0.1 and 0.2 respectfully. The

questions reflecting the biggest improvement in frequency were Q12 (feel very energetic), Q17

(easily create a relaxed atmosphere for patients) and Q19 (accomplish worthwhile things in this

job) with differences of 0.5, 0.4 and 0.5 respectfully.


Personal Accomplishment (PA)

Question Description Pre-Treatment Post-Treatment Difference

Q4 I can understand 5.3 5.2 -0.1

Q7 I deal effectively 5.0 5.3 0.3

Q9 I’m positively influencing 5.3 5.4 0.1

Q12 I feel very energetic 4.1 4.5 0.4

Q17 Easily create a relaxed

atmosphere for patients 4.9 5.4 0.5

Q18 I feel exhilarated 4.5 4.8 0.3

Q19 Accomplished many

worthwhile things in this job 4.7 5.2 0.5

Q21 Deal with emotional problems

at work 5.0 4.8 -0.2

Summary (PA) 38.8 40.6 1.8

Figure 3

30


Figure 4

0

1

2

3

4

5

6

I can

understand

I deal

effectivelyI’m positively

influencing

Energetic Relaxed

atmosphere

I feel

exhilarated

Accomplished Deal with

emotional

problems

Q4 Q7 Q9 Q12 Q17 Q18 Q19 Q21

Personal Accomplishment (PA)


31


Figure 5 compares the mean pre and post-test MBI scores for the Depersonalization (DP)

subscale and Figure 6 displays the results in a chart. Overall, the DP subscale post-test indicated

that participant’s experienced feelings of depersonalization less frequently following the MBSR

program. Participants reported a decreased frequency for all questions with the exception of two

questions. Question 5 (I feel I treat recipients as impersonal objects) saw a slight increase in

frequency from pre-test (0.7) to post test (0.8). Question 11 (this job is hardening me

emotionally) also reported a slight increase in frequency from 1.0 pre-test to 1.2 post-test. The

question reflecting the greatest decrease in frequency was Q10 (more callous toward people

since taking this job) decreasing from 1.1 to 0.1 in frequency. This question had the greatest

improvement in all subscales. Question 15 (I don’t really care what happens) decreased in

frequency by -0.5 and Q22 decreased by -0.6.


Depersonalization (DP)

Question Description Pre-Treatment Post-Treatment Difference

Q5 I feel I treat recipients as

impersonal objects 0.7 0.8 0.1

Q10 More callous toward people

since taking this job 1.1 0.1 -1.0

Q11 This job is hardening me

emotionally 1.0 1.2 0.2

Q15 I don’t really care what happens 0.5 0.04 -0.5

Q22 Recipients blame me 1.8 1.2 -0.6

Summary (DP) 5.1 3.3 -1.8

Figure 5

32


Figure 6

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Impersonal objects More callous toward

people since taking this

job

Hardening me

emotionallyI don’t really care Recipients blame me

Q5 Q10 Q11 Q15 Q22

Depersonalization (DP)


33



Stress Reduction (MBSR) program experience an increase in empathy as measured by the

Jefferson Scale of Empathy for Healthcare Professionals (HP version) which measures key

dimensions including perspective-taking, compassionate care and standing in the patient’s shoes.

Comparisons between pre and post survey data using the Jefferson Scale of Empathy supported

the second hypothesis. Positive changes related to empathy were reported post treatment.

Figures 7 compares the mean pre and post-test scores for the Jefferson Scale of Empathy,

non-flipped questions and figure 8 compares the mean pre and post-test scores for the flipped

questions. The data in figure 7 suggests that participants reported an increase in level of

agreement (1 = Strongly Disagree and 7 = Strongly Agree) for all questions with the exception of

Q5 (I have a good sense of humor and contribution to outcomes) which decreased by -0.4 and

Q20 (I believe that empathy is an important therapeutic factor in treatment) which decreased by

-0.1. The questions reflecting the biggest change in frequency for the non-flipped questions were

Q2 (patients feel better when I understand their feelings) with a 0.4 increase in agreement; Q13

(try to understand by paying attention to non-verbal cues) with a 0.5 increase in agreement and

Q17 (try to think like my patient to render better care) with a 0.4 increase in agreement.

34


Jefferson Scale of Empathy

(Questions - Not Flipped)

Question Description Pre-

Treatment

Post-


2 Patients feel better when I

understand their feelings 6.3 6.7 0.4

4

Understanding body language

as important as verbal

communication

6.6 6.7 0.1

5 I have a good sense of humor

and contribution to outcomes 5.7 5.4 -0.4

9 Imagine in patient's shoes 5.8 6.1 0.3

10

My patients value my

understanding of feelings

which is therapeutic

6.5 6.5 0.1

13 Try to understand by paying

attention to non-verbal cues 6.0 6.5 0.5

15 Empathy is a skill to

successfully treat 6.0 6.1 0.1

16

It is important to our

relationship to understand

patient and family emotional

status

6.5 6.6 0.1

17 Try to think like my patient to

render better care 5.3 5.7 0.4

20

I believe that empathy is an

important therapeutic factor in

treatment

6.9 6.7 -0.1

Overall Average 61.6 63.1 1.5

Figure 7

35


The data in figure 8 (flipped questions) suggests that participants reported an increase in

level of agreement (7 = Strongly Disagree and 1 = Strongly Agree) for all questions with the

exception of Q12 (asking patients about their personal lives is not helpful in understanding

physical complaints) and Q19 (I don’t enjoy reading non-medical literature of the arts) which

both increased in agreement by 0.1. Two questions indicated no change in level of agreement

from pre-test to post test. The questions were Q11 (emotional ties to my patients don’t influence

outcomes) and Q14 (emotion has no place in treatment of medical illness). The questions

reflecting the most positive increase in the level of agreement for the flipped questions were Q2

(patients feel better when I understand their feelings) with a -0.4 decrease in agreement; Q13 (try

to understand by paying attention to non-verbal cues) with a -0.5 decrease in agreement and Q17

(try to think like my patient to render better care) with a -.4 decrease in agreement.

36



(Flipped Questions)

Question Description Pre-

Treatment

Post-


1 Understanding of how

patients and families feel 1.9 1.6 -0.3

3 Difficult to view from

patient's perspective 2.4 1.9 -0.5

6

People are different so hard to

see things from other

perspectives

1.9 1.8 -0.1

7

Try not to pay attention to

emptions in asking about

physical health

1.5 1.2 -0.3

8

Attention to patients

experience does not influence

outcomes

1.7 1.4 -0.3

11 Emotional ties to my patients

don’t influence outcomes 1.2 1.2 0.0

12

Asking patients about their

personal lives is not helpful in

understanding physical

complaints

1.2 1.3 0.1

14 Emotion has no place in

treatment of medical illness 1.2 1.2 0.0

18

I do not allow myself to be

influenced by strong bonds

between patient and family

member

3.2 2.5 -0.7

19 I don’t enjoy reading non-

medical literature of the arts 1.2 1.3 0.1

Overall Average 17.3 15.3 -1.9

Figure 8

37


Figures 9 and 10 represent the Jefferson Scale of Empathy data in chart form.

Figure 9

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0P

atie

nts

fee

l b

ette

r w

hen

I u

nder

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r fe

elin

gs

Un

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od

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angu

age

as i

mpo

rtan

t as

ver

bal

com

mun

icat

ion

I hav

e a

goo

d s

ense

of

hum

or

and c

ontr

ibu

tio

n t

o o

utc

om

es

Imag

ine

in p

atie

nt's

sh

oes

My p

atie

nts

val

ue

my

un

der

stan

din

g o

f fe

elin

gs

whic

h i

s th

erap

euti

c

Try

to u

nd

erst

and b

y p

ayin

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tten

tion

to n

on-v

erb

al c

ues

Em

pat

hy

is

a sk

ill

to s

ucc

essf

ull

y t

reat

It i

s im

port

ant

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ur

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tio

nsh

ip t

o u

nd

erst

and p

atie

nt

and f

amil

y

emoti

on

al s

tatu

s

Try

to t

hin

k l

ike

my p

atie

nt

to r

ender

bet

ter

care

I bel

iev

e th

at e

mpat

hy i

s an

im

po

rtan

t th

erap

euti

c fa

cto

r in

tre

atm

ent

2 4 5 9 10 13 15 16 17 20


(Not Flipped)


38


Figure 10

1.0

1.5

2.0

2.5

3.0

3.5U

nder

stan

din

g o

f how

pat

ients

and f

amil

ies

feel

Dif

ficu

lt t

o v

iew

fro

m p

atie

nt's

per

spec

tive

Peo

ple

are

dif

fere

nt

so h

ard t

o s

ee t

hin

gs

from

oth

er p

ersp

ecti

ves

Try

not

to p

ay a

tten

tion t

o e

mpti

ons

in a

skin

g

about

physi

cal

hea

lth

Att

enti

on t

o p

atie

nts

exper

ience

does

not

infl

uen

ce o

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om

es

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oti

onal

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atie

nts

don’t

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om

es

Ask

ing p

atie

nts

about

thei

r per

sonal

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es i

s not

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cal

com

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ints

Em

oti

on h

as n

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lace

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reat

men

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illn

ess

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ot

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o b

e in

fluen

ced b

y s

trong

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bet

wee

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atie

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amil

y m

ember

I don’t

enjo

y r

eadin

g n

on

-med

ical

lit

erat

ure

of

the

arts

1 3 6 7 8 11 12 14 18 19


(Flipped)


39


4.4: Other Findings

The qualitative data from the class evaluations adds richness to the quantitative data.

Common themes discovered from the participant’s responses include:

More accepting of personal limitations

Self-forgiveness

Self-compassion

Non-judgment

Less reactive/less stressed

Appreciation for the present moment (people, nature, sights, smells, sounds, etc.)

Desire to listen (active listening, paying attention to verbal and non-verbal’s)

Questions 8: Please describe an example of how you might treat yourself with more

gentleness and tenderheartedness, even in moments of challenge.

“Try not to dwell on shortcomings of situations and to be more accepting of my limitations.”

“Instead of guilt, reflecting on all the ways that I am a good mom, wife, friend, daughter and

CRNP.”

“This is a tough one…I think relax, opening to oneself and realizing that I am doing the best I

can at this time. For example, if I order a medicine for a patient in error, show myself

compassion as a human and learn from it.”

“Take a few seconds before responding.”

“Pause and mentally say the words: This is hard/trying, etc. You’re human – don’t need to be

so hard on yourself/expect so much. Or after the fact, stop re-guessing/reevaluating and offer

compassion.”

“Practice mindful meditation formally every day to center and balance self and build stress

resilience.”

“I hope to be able to tell myself that it is okay to feel stressed and anxious while at work

especially b/c I’m, so new to medicine and it’s okay to ask for help and to not always have the

answers b/c it challenging but also learn to accept to work through these feelings so that I can

continue to learn to be productive.”

“Tell yourself you are human, other people experience similar situations, all things will pass

learn to deal with present situation with mindfulness.”

“Not to judge self and others. Breathing mindfulness. Cradle the heart.”

“I remember to direct feeling of compassion toward myself and then get the immediate benefit

of seeing that compassion extended to people around me.”

“Remind myself that I am human and that what is meant to be will happened. Trust in the

future.”

“To be more forgiving.”

40


“I actually feel very gentle toward myself most of the time.”

“By recognizing and reassuring myself that I am human and do the best I can.”

“Time out (quiet time) lunch.”

“Stop beating myself up when I don’t get something exactly right - accepting the situation and

moving past it.”

“Let go of striving. Value where I am in this moment. Acknowledge the triangle of

awareness.”

“Acknowledge my feelings of stress/overwhelming but not allowing it to control my

response.”

“Reactivity – tolerate contradictions.”

“Taking a deep breath and handle gently.”

Q9: Please name one way in which you use mindfulness practice to be more intimate

with your own experience, to feel more alive.

“Mindfulness – listening and experiencing each moment.”

“Positive thinking/sense of well-being. I am able to stop ruminating and focus better.”

“Awareness of breath.”

“It rejuvenates me when tired, I awaken better rested in AM.”

“Appreciate of the colors, odors and textures of food.”

“Pausing focus/on appreciations of strengths/those around me.”

“Mindfulness focus during exercise.”

“I will maintain more presence while walking the woods trail.”

“Attention to attention – listening.”

“Mindful movement allows me to re-connect with my body. The more I do that, the more I

will put myself as my own priority.”

“I give myself the gift of being fully present for moments full of sensations I can savor (e.g.,

when I indulge in rich dark coffee from the coffee cart, I start with my eyes closed, inhaling

and savoring the aroma, wrapping my cold hands around the cup, savoring the sensation of

warmth and I listen to the player piano, savoring the beauty of the musical sound filling my

head – it’s moments of bliss in the middle of an often crazy day).”

“I personally suffer from hurrying around living in the future. This is stressful and unhealthy.

Living in the moment is the appropriate answer. BEING not DOING.”

“I find myself practicing both formally and informally and realizing the importance of being

present and treating myself more kindly/not judging in stressful situation and to realize all the

positives that I have.”

“By stopping and being mindful, taking in sights, sounds, smells, sensations, allows us to feel

joy and beauty of life right now – without focusing on past and present.”

“Attention to breath, sounds, colors – this moment.”

“Enjoy the moment – see what is around me.”

“Enjoy the small things that I may take for granted everyday i.e. my food, my health, my

family, my work, my environment.”

“By breathing in fresh air and felling the rush of smells, calmness floods me.”

“Be more present.”

41


Q10: Please name one way to use mindfulness to be more present to the lives of others.

“Be more attentive to others’ needs.”

“Listening without judging.”

“Focusing on the here and now. Forget the laundry for a while and sit, listen and laugh with

my kids.”

“Attempting to be present with my children e.g. giving a bath, reading a book, playing

checkers, feeding my son…the experiences are so much richer if I am not in the past or

planning for the future.”

“Tune in to someone’s needs.”

“Awareness of their nonverbal cues there’s more authentic exchange/connection.”

“Pause and allow other person to speak without jumping in or fixing.”

“One way to use mindfulness to be more present to others is to practice mindful listening –

meaning that you are focused on what the other person is saying opposed to what your

response is going to be or your perception/judgment of what they are talking about.”

“Appreciate other people’s perspectives - learn to really listen fight the urge to talk all the

time.”

“Positive listening without judgment, less anxious with self and others.”

“Listen fully as a child speaks.”

“Allow focus and clear thought creating more presence toward the moment and others.

Making each moment more real.”

“Listening to words, tone, meaning of words, body language.”

“Stay present more consistently,”

“Active listening and less reactivity.”

“Focus/listen be really present with people.”

“Shut up and really listen.”

“Helps attend to what is happening in the moment, hear what they say, see their

express/movement, feel their experiences.”

“Allowing me to better ignore distractions of my own thoughts when being with my

kids/husband.”

“Active listening with an open mind. Awareness of the present moment with acceptance says

it all.”

42


Chapter 5: Discussion

5.1: Summary

The main purpose of this study was to determine if there is a positive correlation between

completion of an eight-week Mindfulness-Based Stress Reduction (MBSR) course by healthcare

professionals and a decrease in burnout and an increase in empathy. A combination of

quantitative and qualitative and methods were used. For the quantitative method, pre and post

surveys were utilized using the Maslach Burnout Inventory and the Jefferson Scale of Empathy.

The data for each question of the pre and post surveys was entered into an Excel workbook and

analyzed using the difference between the average mean from the pre-test and post-test. For the

qualitative method, answers to three open-ended questions from a course evaluation were

reviewed. These answers provided additional insights from the participants related to burnout

tendencies and empathy.

5.2: Interpretation of Findings

Two research questions were utilized for this study.


Based Stress Reduction (MBSR) program experience reduced burnout tendencies?

Participants post-test mean scores indicate a lower frequency of emotional exhaustion

(-2.3) and depersonalization (-1.8) along with an increased frequency of personal

accomplishment (1.8). The combination of each subscale results indicate that the MBSR

program positively affected burnout in the participants (Worley, Vassar, Wheeler, & Barnes,

2008).


Based Stress Reduction (MBSR) program experience an increase in empathy?

43


Participants post-test mean scores on the Jefferson Scale of Empathy indicate a stronger

level of agreement on the non-flipped questions (1.5) and a higher level of disagreement on the

flipped questions (-1.9). The results indicate that the MBSR program positively affected the

levels of empathy in the participants (Hojat, et al., 2001).

5.3: Additional Analysis

The literature search revealed other potential opportunities of research:

1. MBSR in healthcare workers and patient’s perspective of care as measured by

HCAHPS and/or Press Ganey.

Does MBSR improve the patient’s perceived experience and patient

satisfaction?

2. A modified version of the MBSR program has been shown to be effective in

healthcare workers.

Is a modified version as effective and more feasible?

5.4: Limitations

1. Lack of a control group

2. Small sample size

3. Population may be predisposed to register for the MBSR program as in the case

of offering CME credits

4. Since the MBSR program materials are only available in English, the sample

population does not include a diverse group

5.5: Recommendations

1. Repeat study at LVHN with a control group and larger number of participants

44


2. Repeat study adding an additional survey during the maintenance phase to

determine how long the effects last following the course – 10 months post course

3. Evaluate patient satisfaction scores pre and post MBSR program to determine if

scores improve in the area of communication with physician and nurse

5.6: Conclusion

MBSR is well-established as an effective model for reducing stress in healthy

populations. This study supports that healthcare professionals who participate in an 8-week

MBSR program experience decreased burnout as measured by the Maslach Burnout Inventory

and increased levels of empathy as measured by the Jefferson Scale of Empathy. Burnout and

lack of empathy have been associate with decreased patient satisfaction, poor quality and

outcomes. Given the increasing levels of stress that healthcare professionals are facing under the

Affordable Care Act and the importance of providing safe, effective and high quality care while

reducing costs and creating a positive perception of the care delivery experience by their

patients, leadership at LVHN should further explore the potential benefits of the MBSR program

for healthcare professionals through additional research.

45


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Appendix

I. Maslach Burnout Inventory

II. Jefferson Scale of Empathy (HP version)

III. Class Evaluation

IV. Sponsor’s Letter

Julene Campion MBSR in Healthcare

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Transcript of Julene Campion MBSR in Healthcare