Original ResearchEffectiveness of Mindfulness Intervention in Reducing Stress and Burnout for Mental Health Professionals in Singapore
Introduction
There are reports of relatively high levels of burnout among mental health professionals in the United States,1 Australia,2 and Singapore.3 This is of particular concern as burnout has been associated with high staff turnover4 and decreased patient care5 in samples of healthcare professionals. Although a number of studies have explored the prevalence of burnout in mental health professionals, there has been limited research into the outcomes of programs designed to reduce stress and burnout among mental health professionals.
Mindfulness training has been recognized to reduce stress and burnout, and promote positive attitudes among healthcare professionals more generally.6, 7 During mindfulness training, a range of mindfulness practices are used to teach participants to cultivate an observant, accepting, and compassionate attitude toward their own internal experiences including body sensations, emotions, and thoughts. The training sessions are usually conducted in groups and include teachings, group discussions, and practical exercises. One of the most widely used mindfulness programs is the mindfulness-based stress reduction (MBSR) course developed by Jon Kabat-Zinn.8, 9 This is an eight-week program with weekly group sessions of two and a half hours and daily 45-minute homework sessions.
In their review of twenty studies that examined the effectiveness of mindfulness-based interventions in improving the psychosocial health of healthcare providers, Escuriex and Labbé6 concluded that the efficacy of mindfulness-based interventions was tentatively supported. More studies examining the effect of mindfulness-based intervention with healthcare professionals have been conducted in recent years with promising results.10, 11, 12, 13 However, several limitations were reported in the reviews and papers, including small sample sizes, lack of consideration to therapist adherence to treatment protocol, lack of adjunctive physiological measures, and lack of follow-up data to determine whether gains made in intervention were sustained. For example, Pipe et al.14 conducted a randomised study in which 33 nurses were assigned to either a four week mindfulness course or a leadership course (control). They reported that participants in the mindfulness course showed significantly more improvement on the positive symptom distress index and global severity index, which assess symptom intensity and overall psychological distress, respectively. Despite the use of a gold standard study design, the study had several limitations including small sample size and lack of follow-up measure. In another larger study by Goodman and Schorling,11 93 healthcare providers in the United States participated in an eight-week MBSR intervention utilizing a pre–post study design. Their results indicated that the improvement in mental health, emotional exhaustion, depersonalization, and personal accomplishment scores among the healthcare providers after the intervention were all statistically significant. Despite a large sample size, no follow-up data was gathered; thus, it is not known if these gains were maintained.
Several studies with health professionals have considered follow-up after a mindfulness training program.13, 15 For example, Asuero et al.13 examined the effectiveness of MBSR with 29 healthcare professionals, and found that the significant reduction in self-reported psychological distress post-intervention was maintained three months later. Other studies have reported inconsistent results; for example, Cohen-Katz et al.15 investigated the effectiveness of mindfulness training in reducing burnout in 27 nurses. Using the Maslach Burnout Inventory, they reported significant improvement in emotional exhaustion post-intervention, which was maintained after three months; however, no significant change was noted for personal accomplishment and depersonalization either post-intervention or three months later. No research regarding the outcomes of mindfulness-based programs designed to reduce stress and burnout specific to mental health professionals was identified.
In addition to the limitations discussed above, all studies described earlier were conducted with western populations and the authors cautioned against the generalization of the results to different population groups. With improvements in technology and communication, cultural “levelling” is occurring, and the values of the Western world are being assimilated in Singapore.16, 17 Nevertheless, Singapore's healthcare professionals are predominantly of Asian origins, and might respond differently to mindfulness training compared to their Western counterparts. As the MBSR program was developed in the west, the course content and structure might be more appealing to a western population than an Asian population. Despite a rigorous search, no published research on the efficacy of a mindfulness program for healthcare professionals in Singapore was located. In the only published study pertaining to mindfulness in Singapore, Feng et al.18 examined the outcomes of a mindfulness program for 11 individuals with mild anxiety. They reported improvements in overall mental well-being and anxiety symptoms after the eight-week program. As only one mindfulness study conducted in Singapore had been found, there is a lack of evidence to suggest that mindfulness intervention will be effective in reducing stress and burnout among mental health professionals in Singapore.
Although evidence from empirical studies in western cultures tentatively supports the efficacy of mindfulness programs in promoting positive attitudes and reducing stress and burnout in healthcare professionals,11, 13 there was no literature examining its effectiveness with mental health professionals generally, or with health/mental health professionals in Singapore. Further, findings regarding the sustainability of gains from mindfulness training have been somewhat inconsistent. The aim of this study was to examine the effectiveness of a mindfulness program in promoting mindfulness and compassion, and reducing stress and burnout, among mental health professionals in Singapore. Study hypotheses were that, for a sample of mental health professionals in Singapore:
- (1)
Levels of mindfulness, self-compassion, and compassion for others would improve after a six-week mindfulness program, and this improvement would be maintained three months after the mindfulness program.
- (2)
Levels of stress and burnout would decrease after a six-week mindfulness program, and this decrease would be maintained three months after the mindfulness program.
Section snippets
Methods
Ethical approval for this study was granted by the National Healthcare Group Domain Specific Review Board in Singapore, and The University of Queensland Behavioral and Social Science Ethical Review Committee in Australia.
Participants
The study sample was drawn from healthcare professionals employed at the Institute of Mental Health (IMH), Singapore. e-Mails were sent to all mental health professionals working in one mental health setting in Singapore to invite them to participate in the study. Inclusion criteria for the study was that participants must be: (1) psychiatrists, doctors, allied health professionals, case managers, pharmacists, researchers, or nurses working at the Institute of Mental Health, Singapore, (2)
Intervention
The MBSR program developed by Jon Kabat-Zinn8 was used as a guide in the development of the mindfulness program employed in this study. However, the length of the program was shortened as a longer program is associated with a higher attrition rate.7 This was of particular concern for mental health professionals in Singapore with a high caseloads and tight schedules. To better suit the needs of busy staff members, one author (Y.S.) designed a shorter program. As participants were all mental
Data Analysis
The data were analyzed using SPSS (Version 17.0). Bivariate analyses were used to check for any between group differences at baseline and after intervention. No significant differences were noted. Repeated measures analysis of variance (ANOVA) was used to determine whether scores of mindfulness (FFMQ), self-compassion (SCS-S), compassion for others (CS), stress (PSS-10), and burnout (OLBI) changed post-intervention and whether these changes were maintained three months after the intervention.
Attendance
A total of 37 (84%) participants completed the program: 20 (45%) attended all six sessions, 14 (32%) attended five sessions, and 3 (6%) attended four sessions. All 37 participants also attended the 3 months follow-up assessment.
Changes in Mindfulness
Friedman's ANOVA revealed that there was a significant change across the three time points in four of the five mindfulness facets: observe (χ2(2) = 21.5, P < .001), describe (χ2(2) = 12.01, P = 002), non-judge (χ2(2) = 11.51, P = .003), and non-react (χ2(2) = 32.08, P < .001). There was no significant change with act with awareness (χ2(2) = .10, P = .95) score. Results of post hoc analyses, using Wilcoxon tests, for the five facets are reported below:
- (1)
Observe: there was a significant increase in
Changes in Compassion
There was a significant change in self-compassion scores (F(2,72) = 15.69, P < .001) across the three time points as determined using repeated measures within group ANOVA. Post hoc test using Bonferroni correction revealed that there was an increase in self-compassion scores from pre- (M = 36.57, SD = 7.55) to post-intervention (M = 40.0, SD = 6.37), which was statistically significant (P = .001). The difference in self-compassion scores between pre-intervention and three months follow-up (M =
Changes in Stress
A repeated measures, within-group ANOVA showed that there was a significant change in stress scores across the three time points (F(2,72) = 4.52, P = .01). A post hoc test using Bonferroni adjustment revealed a statistically significant reduction of stress scores from pre- (M = 18.64, SD = 5.53) to post-intervention (M = 15.59, SD = 5.80, P = .02). Although there was a slight reduction of stress from pre-intervention to three months follow-up (M = 17.03, SD = 5.33), it was not statistically
Discussion
The aim of the present study was to investigate the effectiveness of a mindfulness intervention in reducing stress and burnout in mental health professionals in Singapore. In support of the first hypothesis, participants reported significant improvement in levels of mindfulness, self-compassion, and compassion for others after a six-week mindfulness program. Improvements in mindfulness and self-compassion scores were maintained three months later. However, the second hypothesis was only
Limitations
The study had several limitations. Firstly, although randomised control is considered the gold standard when examining the efficacy of an intervention, a non-experimental one-arm study without control was chosen for two main reasons: (1) the sample size required for a randomised control trial was unlikely to be achievable in the setting from which the sample were drawn, and (2) all participants for the study were drawn from the same institution. Thus, the use of a control group would result
Conclusion
Overall, results suggest that mindfulness training was associated with improvement in mindfulness and compassion, and reduction in stress, among this sample of mental health professionals in one health care setting in Singapore. These results extend existing evidence from the United States,11 Spain,12 and Sweden.32 Our findings also showed that positive gains in mindfulness and self-compassion levels made after the mindfulness training program were sustained at three months follow-up. However,
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