Edited by: Giorgio Di Lorenzo, University of Rome Tor Vergata, Italy
Reviewed by: Eron Grant Manusov, The University of Texas Rio Grande Valley, United States; Esther Chow, City University of Hong Kong, Hong Kong SAR, China
This article was submitted to Public Mental Health, a section of the journal Frontiers in Public Health
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Physician burnout has significant adverse impacts on the wellbeing of individual physicians, and by extension the healthcare delivery systems of which they are part. Mindfulness is consistently cited as a pragmatic approach to effectively address burnout and enhance physician wellbeing. However, very few empirical studies have been published on Mindfulness Based Interventions (MBIs) for physicians. Moreover, the majority of these studies have been quantitative, leaving a gap in understanding the practical application of mindfulness in the context of physicians' daily lives.
This paper outlines the rationale, development and design of a novel prospective qualitative study examining the acceptability, feasibility, and pragmatic application of a mindfulness intervention for physician wellness.
The study will be conducted in three groups of at least 8 practicing physicians from a broad range of medical specialties at a tertiary care hospital in a large urban center in Eastern Canada. The intervention will consist of an innovative program based on the teachings of internationally renowned scholar and Zen Master Thích Nhãt Hạnh. It will include 5 weekly 2-h mindfulness sessions delivered by two health providers trained in mindfulness and in the teachings of Thich Nhat Hanh. The primary outcome measure will be an in-depth Thematic Analysis of post-program semi-structured interviews. Field data will also be collected through participant observation. The study will be theoretically grounded within the interpretive paradigm utilizing “the Mechanisms of Mindfulness Theory”. An external advisory committee formed by four senior members of Thích Nhãt Hạnh's community will provide guidance across all phases of the study.
Our innovative approach provides a new framework to further understand the mechanisms by which mindfulness interventions can impact physician wellbeing, and by extension their patients, colleagues, and broader healthcare systems. Through a clear articulation of the rigorous application of accepted procedures and standards used in our protocol, this paper seeks to provide a roadmap for other researchers who wish to develop further studies in this area. Lessons learned in the preparation and conduction of this study can be applied to other healthcare contexts including non-physician health provider wellbeing, clinical care, and population-level mental health.
Physician wellness can positively impact the quality of patient care, frequency of medical errors, patient satisfaction and clinician professionalism (
Physician burnout can lead to absenteeism, tardiness, reduced job commitment and increased physician turnover (
Mindfulness-based interventions are consistently recommended across the literature as a promising approach for addressing physician burnout and enhancing physician wellbeing (
Very few studies have been conducted that bring together mindfulness and physician wellbeing. In the broader literature, mindfulness has been shown to have a wide range of potential health benefits, including: reduced anxiety and stress, increased wellbeing, self-regulation, emotional-regulation, motor skills and empathy, along with greater connectivity between brain regions associated with prosocial behaviors (
This study will apply a qualitative research framework to support the study's central aim to understand the acceptability, feasibility, and pragmatic application of mindfulness in the context of physicians' daily lives. Qualitative methods are particularly well-suited for studying and understanding human behavior in the context of the social world (
This is a prospective qualitative study of physician wellbeing that will be conducted during and following the completion of a 5-week Applied Mindfulness training program. Through the rigorous application of high-academic research standards for qualitative healthcare research, this study aims to contribute new knowledge to prevent physician burnout by bringing together the following three pillars: (1) Physician wellbeing; (2) mindfulness; and (3) qualitative research.
The research question for this study, along with two guiding sub questions to help orient the process of analysis, are as follows:
Research Question: How do physicians experience, make sense of, and engage with a 5 week Applied Mindfulness program and what is the impact of the program on their personal wellbeing in the context of their daily lives?
Guiding sub-questions/further areas of inquiry: How, where and in what context(s), do participants apply mindfulness? How does mindfulness impact participants' perceived
The study will recruit physicians in active medical practice within the Greater Toronto Area (GTA), Canada. Medical students and other health care personnel (HCPs) will be excluded. Studies on MBIs conducted with physicians, medical students and HCPs show that, while there are some similarities across their experiences, there are also several areas of significant differences (e.g., how mindfulness impacts studying for exams, and different sets of power dynamics) (
Inclusion and exclusion criteria.
• Able to independently consent to study |
• Planning to participate in another mindfulness training program during the delivery of the AMP-MP |
The minimum sample size for this study (three groups of eight participants) is based on the theory of information power, which establishes that sample size for a qualitative study can be based on the amount of information a sample holds in relation to the aims of the study, rather than being based on a formula or perceived redundancy (
A purposive sampling approach will be applied to enhance the sample specificity and information power. Purposive sampling allows the researcher to increase the sample specificity by selecting participants who hold specific characteristics (e.g., experience and knowledge) that are particularly relevant to the study aims, as guided by the research question (
Participants will be recruited through a combination of electronic email, poster and in-person announcements. Electronic mail-outs will be sent through hospital leadership and university channels. Responses will be screened for inclusion/exclusion criteria and the purposive sampling approach will be applied to prioritize the order of enrolment.
The intervention is called the Applied Mindfulness Program (AMP) for physicians. The mindfulness content to be delivered within this study represents an underexplored area within the field of MBIs. It is based on the teachings of internationally renowned scholar, Zen Master and Noble Peace Prize Nominee Thích Nhãt Hạnh (see
AMP-MP weekly themes and content.
1 | Orientation and foundations for practice | Admin (including consent forms) |
2 | Identifying and transforming habits | |
3 | Nourishing our mind | |
4 | Skillful communication | |
5 | Integration and application |
To inform the rigorous and authentic use of Thích Nhãt Hạnh's work, an iterative reciprocal relationship was established at the outset of this research study with his international Plum Village community. This was done through the establishment of an advisory committee made up of four senior monastic teachers in the tradition of Thích Nhãt Hạnh and Plum Village. This committee will provide guidance and feedback across all phases of the study. This approach was informed by precedents from Ingenious Research Methods (
Program sessions will be scheduled to take place on a weekly basis on the same time and day for each group for five consecutive weeks (2 h per session) and will have a minimum of 8 and a maximum of 23 participants in each group. Each program session consists of a mixture of didactic lectures, hands-on experiential Applied Mindfulness practices and group discussions. An overview of program structure can be found in
Overview of program structure.
Program length | 1 session per week over 5 weeks |
Session length | 2 h (30 min added to the first session for study administration) |
Booster session | 1 × 2 h (3 months after program) |
Focus group | 1 × 1.5 h focus group (16 months after program) |
In-session content/delivery | Mixture of learning styles, including didactic lectures, group discussion/sharing, hands-on practices |
Additional content/delivery | Take home activities, journaling prompts and audio recordings of the in-session didactic lectures |
Visual representation of study flow.
Although the mindfulness intervention was designed to be delivered in-person, it can be adapted to a fully online setting using video-conferencing technology, should public health measures (e.g., related to COVID-19) prevent the delivery of an in-person intervention. Both authors have extensive experience delivering and studying mindfulness interventions delivered online (
The mindfulness intervention will be delivered to three distinct groups (
Study groups.
Tuesday | 6:00 p.m.−8:00 p.m. |
Wednesday | 6:00 p.m.−8:00 p.m. |
Friday | 12:00 p.m.−2:00 p.m. |
The mindfulness training program will be led by two facilitators who are not part of the primary research team and have professional training in mindfulness, along with a committed personal practice rooted in the tradition of Thích Nhãt Hạnh and Plum Village. The facilitators will use a program manual as a guide for each session's structure and content. The same facilitators will facilitate all of the program sessions and a manual checklist will be used by a participant observer to track the content presented across the different sessions.
A mindfulness-based program is not generally seen as entailing any significant risks to the physical and psychological safety of participants (
The primary data for this study will be generated through qualitative semi-structured post-program interviews. All participants will be invited to participate in a post-program interview. The interviews will be conducted with participants within 4 weeks of the final session of the 5-week AMP-MP program. Semi-structured interviews have been chosen as they allow for a clear sequence of themes and questions, while also accounting for the necessity to adapt the order and wording of questions throughout the interview process based on participants' specific responses (
The study's interview guide was developed with the aim to generate richly detailed data that will get at the “essence or inner core” of participants' experience. High-quality interview guides keep in mind both the bigger picture/arc of the interview (e.g., the overarching sequence of questions) along with the more granular elements (e.g., individual probes) (
Participant observation will be conducted to better understand the lived experience of participants within the context of the program, rather than only from participants' post-program interviews (
Reflexivity is central to the work of qualitative research. The researcher's position is influenced and shaped by a multiplicity of factors that include the institutional, cultural, historical and interactional contexts (
This section discusses the specific processes and strategies that will be applied across the study to develop rigor. Qualitative methodologists have argued the need for qualitative studies to have their own approaches to rigor, as there is a concern that a proceduralist orientation to rigor can over-simplify the complex dynamic nature of qualitative inquiry (
The application of theory throughout the research process is central to the development of rigor and congruence across a qualitative study. The interpretative paradigm will be mobilized across all phases of this research study. The interpretive paradigm is well suited to this study's research aims as it seeks to
Three key strategies will be used to produce transcripts that reflect the original nature of the verbal accounts and minimize potential transcription errors. These included: (1) Providing detailed transcription guidelines to the transcriptionist (see
Thematic Analysis (TA) will be applied to analyze and interpret the data. The six steps of TA outlined by Braun and Clarke provide a robust framework that allows for a clear and systematic approach (
Within each step of TA there are a multiplicity of analytic choices that reflect the interplay of method and theory. A primarily inductive approach will be applied, with the themes remaining strongly linked to the data, or “data-driven”, rather than fitting into a preconceived coding format based on a priori assumptions. NVivo software will be used to manage the coding process but will not be seen as a tool for analysis or interpretation.
This study has several noteworthy features that might be seen as limitations in some contexts. The sample will be based on physicians who choose to respond to the recruitment efforts, therefore self-selecting to participate in the mindfulness program. Self-selection can be viewed as a practical approach for delivering MBIs in healthcare settings, as an individual's
While a purposive sampling approach was selected to enhance the specificity of the sample and increase the sample's information power, there is also an element of convenience sampling as the sample will be based on those who respond to the recruitment efforts. The purposive sampling approach (e.g., physicians with greater years of medical practice and fewer years of mindfulness experience) helps focus the study on the population of physicians. Therefore, it will not be known how medical students or other healthcare personnel (HCPs) would experience the Applied Mindfulness program.
The two program facilitators have been selected based on having an ideal set of credentials to deliver the Applied Mindfulness Program. While this will support the successful delivery of the program, it will limit the understanding of whether the program could be effectively taught and scaled into other contexts that may not have access to facilitators with the same level of expertise.
The use of semi-structured interviews as the primary data outcome may be considered by some as a limitation. This data set can be seen as best suited to answer the aims of this study's research question and also address gaps in the current literature regarding the acceptability and pragmatic application of mindfulness in physician's daily lives.
This study seeks to add pragmatic resources to the field through a prospective qualitative study that brings together the phenomena of physician wellbeing and mindfulness. Very few empirical studies have brought together these phenomena, with almost none using qualitative methods. To our knowledge, at the time of this publication, no research studies have used the teachings of Thich Nhat Hanh as the explicit basis for an MBI. Therefore, our innovative study design aims to answer calls from both the literature and international medical associations to determine the acceptability and feasibility of an Applied Mindfulness intervention for the improvement of physician wellness.
Our study design takes into account how this modality can be delivered in an accessible way for both the participants (e.g., delivering the program onsite, length of program/sessions, allowing participants to select the time/day that suits their schedules etc.) and the institutions that may wish to implement it (e.g., low-cost, approaches to curating a mindful space onsite etc.). As such, our results also aim to provide recommendations on best approaches for implementing this type of training and research within hospital and healthcare settings.
Burnout amongst physicians has been recognized across the literature as highly prevalent, and increasingly so in the context of major public health crises such as the COVID-19 pandemic. Therefore, if results from this study show our Applied Mindfulness intervention to be an acceptable and feasible modality, it could support trainings in Applied Mindfulness being incorporated into hospital settings as an effective means to improve individual physicians' wellbeing. In addition to this, findings in this study will address the question of whether training physicians in Applied Mindfulness can simultaneously benefit their patients and the wider healthcare system.
The studies involving human participants were reviewed and approved by The Hospital for Sick Children (HSC) and the University of Toronto. The patients/participants provided their written informed consent to participate in this study.
EW was the primary contributor to the conception, design of the study, and wrote the first draft of the manuscript. NC contributed to the conception, design of the study, and provided critical revisions and checked the manuscript for important intellectual content. All authors approved of the final version of the manuscript as submitted.
This study was funded by a Supervisor's Research Grant through The Hospital for Sick Children and the Institute of Medical Sciences, University of Toronto (EW). NC is supported by a Junior 1 Career Development Award from the Fonds de Recherche du Québec—Santé.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
The authors wish to acknowledge, with deep gratitude, the insights and support provided by Blake Poland, Sara Ahola Khut, Brenda Toner, and Paula Gardiner (Academic Advisory Committee from the University of Toronto), Brother Phap Huu, Brother Phap Dung, Brother Phap Linh, and Sister Hien Nhgiem (Monastic Advisory Committee from Plum Village), along with the ongoing support of Dr. Agnes Wong.
The Supplementary Material for this article can be found online at: