INTRODUCTION AND PURPOSE
Caring for patients and families with regular frequency bears an emotional cost.1,2 The intent to help and offer compassionate care can become clouded by workplace stress and personal tension. The connection between compassion fatigue and burnout among health care providers is increasingly clear.1,3–6 Less understood is the physical therapist's (PT) perceptions about self-care and stress management using evidence-based strategies.6
Based on eastern teachings, mindfulness has become an evidence-based practice7,8 that cultivates the intrapersonal relationship to foster emotional resilience,9 strengthen coping strategies,10 and decrease stress.7–10 Although general relaxation strategies exist,11,12 mindfulness has been found to be a reliable, transportable, and simple strategy to manage stress in the health professions. It teaches one to “be with” difficult emotions such as anger, frustration, and sadness,13 and that the mind can heal the body.13–15 This concept is relatively new among PTs and may be difficult for them to embrace.
Epstein7 states that “mindfulness is integral to the professional competence of physicians” because it reduces psychological distress and promotes emotion regulation for clearer decision making and less medical error.7,14–17 To date, it is unclear how PTs perceive mindful practice and why it is underutilized in this group of professionals. The purpose of this study is to explore how PTs conceptualize the evidence-based practice of mindfulness following a series of practical applications.
LITERATURE REVIEW
Compassion, caring, and altruism are critical for patient-centered care,18 but self-care is equally valuable.19 No articles were found that discussed the self-care of PTs. One article explored the sources of stress on PTs’ emotional well-being, citing role conflict, job ambiguity, emotional exhaustion, depersonalization, and somatic tension as concerns.20 In contrast, the healing benefits of mindfulness have been well-documented in physicians,7,10,13–17 nurses,21 and occupational therapists.22 Additionally, mindfulness benefits people with depression,23,25 anxiety,24–26 chronic pain,27,28 fibromyalgia,27 psoriasis,26,27 hypertension,26 obesity,26 cancer,26 arthritis,26,27 obsessivecompulsivity,26 insomnia,26 human immunodeficiency virus,29 Parkinson's disease,30 multiple sclerosis,31 dementia,32 grey matter disorders,32 white matter disorders,33 attention deficit disorder,34 diabetes,35 autism,36 and posttraumatic stress disorder.37
Mindfulness Theory
Mindfulness is a secular practice of meditation and body awareness with origins from Buddhism.14 Unlike transcendental meditation, which teaches the use of mantras, imagery, and chanting, mindfulness meditation teaches stillness with focus on one's breathing to gain insight into the contents of the mind.14 Based on the medical model and the work of Kabat-Zinn,13,14 mindful practice is considered a way of being13 rather than a cognitive ability,14 so it has application in both professional and personal venues.
Mindfulness increases awareness of one's thoughts and emotions, objectifying these as simply “passing events.”19,26 Nonjudgment and curiosity are important elements of mindfulness.13,14 Nonjudgment allows kindness toward oneself which fosters openness and curiosity for all experiences. Naming or describing emotions restores them to their proper function rather than allowing them to dictate experience.14–16,19,38 Ultimately, reframing occurs as one's perspective is shifted to allow for a variety of viewpoints and choices.13–16,24,26
Mindful awareness has been shown to utilize a distinct neural pathway.39,40 Functional MRI (fMRI) scans show that the default mode, or resting mode of the brain utilizes midline connectivity, which is known for inattentiveness to one's thoughts. This allows for automaticity and emotional habits to influence actions.39,40 In contrast, the salience mode,39,40 or mindful mode, requires attending to one's body sensations. Functional MRI scans of experienced meditators show lateralized brain structures that transmit sensory data to the prefrontal cortex for processing.38–40 Recent studies suggest that the 2 modes are functionally connected, and with meditation training, the mindful mode actually sends inhibitory influence on the default mode, preventing reactivity from disrupting moments of mindful attention.41 In brief, habitual stress responses can only change if thoughts and feelings are regularly brought into awareness,7–9,13–17 thereby shifting the neural network.39–41
Mindfulness Practice
A core activity in mindfulness is seated meditation, while using one's breathing as an “anchor” to practice present moment awareness.13–16 Mindfulness is the exact moment in time when one notices that the attention is no longer on the breath, and focus is gently and deliberately returned to it.22,26,40 A regular practice of 5 minutes each day has been shown to promote emotional awareness under stress, increase resilience, improve decision making, and increase the accuracy of self assessment.14–17,26,40–47,49,50
Typical stress reduction techniques, such as relaxation training and exercise, offer only a temporary feeling of contentment and calm.11,48,58 They do not decrease rumination, which is a common by-product of worry.48 Two specific activities have been shown to provide tangible and easily accessible methods to practice mindfulness. The acronyms STOP (stop, take a breath, observe, proceed) and RAIN (recognize, accept, investigate, nonattach) help redirect the focus away from the stressful thought or event and return it to the breath, which decreases the sympathetic nervous system response to threat.45 With practice, threat perception decreases over time, as self-awareness becomes the default activity and emotion regulation becomes more automatic.40–43 Despite the positive research supporting mindfulness programs for stress reduction among health care professionals,15,16,19,22,24 research on physical therapy clinicians is lacking.
METHODS
Procedures and Role of Coauthors
In their final graduate year, 8 students, under the guidance of the primary investigator (PI), enrolled in a qualitative research elective in which they studied grounded theory.51 They practiced interviewing, coding, and thematic development. Based on their interest in clinical instructor (CI) stress, they designed the study through the lens of mindfulness theory, creating a booklet of teachings and principles to share with their clinical sites (Table 1). As part of the research elective and because the students chose the theoretical framework of mindfulness, the principal investigator (PI) (AW) led weekly mindfulness classes that included each of the items in the booklet. The PI is certified in mindfulness-based stress reduction from the University of California, San Diego School of Medicine.
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Table 1: Contents of Mindfulness Booklet
The intent of the Mindfulness Booklet was for students to share an evidence-based introduction to mindfulness with PTs at their clinical sites. This would serve as a means for discussion, shared practice, and a resource manual for the site. It was decided that students would do the activities (eg, seated meditation) with the participant but that it was up to the participant to practice outside of the weekly student-led session (eg, eat lunch silently and mindfully each day). The student coauthors taught the participant PTs from the lower levels of Bloom's taxonomy (as compared to experienced mindfulness teachers), which may have prevented the clinicians from translating the information into a meaningful practice.
The PI emailed supervisors at each student clinician's site, inviting them to participate in this exploratory study. Upon beginning their final 12-week clinical education experience, student clinicians recruited PTs who were not their own CIs and who had no prior knowledge of mindfulness practices to participate in weekly information sessions (Table 1). Theoretical sampling was used to inform the theory of mindfulness in an unbiased and exploratory manner.51
Consent was secured and weekly meetings between student and participant at each site began. Using the Mindfulness Booklet, students introduced general concepts of mindfulness in sessions lasting from 10 to 15 minutes weekly, for 10 weeks. In week 12 of the clinical experience, each student completed 1 audio-recorded interview based on the interview guide (Table 2).
Table 2: Interview Guide
Participants
In all, 16 clinicians volunteered. Eight volunteers were excluded for the following reasons: 1 was a physical therapist assistant (PTA), 5 were students’ CIs, 1 had a language barrier, and 1 had extensive prior knowledge of mindfulness through yoga practice. Table 3 includes the participants’ practice settings (ie, inpatient, outpatient, private, all practice patterns), years of experience (2–37 years), locations (PA, NY, NJ, FL, CA), ages (26–60), and sex (2 male, 6 female).59,60 This sample was similar in size to other qualitative studies in physical therapy research.58 Investigators agreed that all 8 participants shared truthful responses, and as a whole, met the criteria for saturation.59
Table 3: Participant Demographics
Data Analysis
The research team, led by the PI, employed the constant comparative data analysis method.51 The group met for 2 hours each week via a WebEx60 platform so that individual verbatim transcripts from each interview could be viewed on a shared screen by all. Each coauthor had completed 1 transcript, so each took a turn as lead for the coding session. Open codes (discrete textual units that represent the meaning of the text verbatim) were discussed until consensus was reached and documented on a template.51 Next, axial codes (groupings of open codes that form categories) were assigned using the same process with group consensus.51 This process was repeated until all transcripts were coded.
The PI served as the methods expert and “devil's advocate.”55 Within-case analysis as well as across-case analysis51 continued for 8 weeks until completion. Investigator triangulation ensured trustworthiness, as each coauthor maintained memos to bracket biases, review transcriptions prior to meetings, and provide input throughout the analysis process. At each phase of the analysis process, consensus of all group members was critical before moving on to the next code.
Thematic development required an additional 4 weekly WebEx meetings. To ensure congruence and clarity of the constructs expressed by the transcripts, codes were categorized by subject and by research question to ensure that themes generated were representative of the data collected.51 Code words and phrases that reflected related categories became preliminary themes, and with consensus, final themes for the resultant theoretical model.51 Themes were traced back to participant transcripts at regular intervals and quotes were selected to support themes.51 Reflexivity was given regular discussion and was documented to provide an audit trail at each phase of the data collection and analysis process.52 Member-checking was completed by the PI for credibility and transparency.52 Each participant confirmed that the themes generated matched their intended responses.
RESULTS
Four main themes emerged from the data. Theme 1 (I Need to Fix This) characterized early openness to learning and wanting to have a tool to “address” and “fix” the stress, which was conceptualized as “inevitable” and “heavy.” Participants were unaware that a practice in mindfulness existed and commented on the qualitative nature of the study, sharing a preference to know, have facts, and be told what to do, rather than turn inwards and become curious about the contents of their mind. For example, 3 participants made the following statements:
We're in a very high-stress, demanding job, and working with people can be difficult… any technique that could help work better with patients, work better with students, and just reduce stress. (1)
I find the practice to be very, very difficult… things get in your way. Especially as a woman, we tend to multitask so much that…you're trying to do one thing, but you're thinking about something else…I do have trouble sleeping… just because I have a constantly running mind. I will get up in the middle of the night and jot down um, the grocery list that just popped into my head…it's always running in the background. (3)
I could focus on myself and my body… It was a release of…stress and energy. So this was a way not to focus on the things I had to do at work or reports I had or who I had to call, I could focus on myself and my body. (5)
Each participant cited the presence of stress to varying degrees and shared that they benefitted from pausing to notice their regular stress-related habits. Some of these included multitasking, seeing patients as frustrating, seeing students as a chore, poor sleep, and having a constantly running mind.
Each participant described their favorite tool to help them decrease mind wandering and gain awareness of their body and mind. Responses included breath-awareness, mindful eating, seated or walking meditation, and using the STOP and RAIN methods to notice thoughts.
I like the grape eating one because I'm more of a ‘do-er’. If I am given something to do…it doesn't give my mind so much room to wander… to question or to judge or to do what it wants. It really gives me a point to focus….I stopped dwelling on my negative emotions. (4)
The concept that your emotions and feelings are not the same. That really made a lot of sense. We tend to react to a situation without really giving focus on why you are reacting that way. When things are going well, then it's positive feedback and everything is nice. But when you react to anger or frustration it becomes negative feedback…I really liked RAIN. Just stop ‘Ok, how am I feeling? What's the emotion that's driving it? It's OK. I can be angry.’ But then identifying what is making you angry because sometimes it's not actually the person or a situation, it's actually your values - the way you were brought up - or the way you think things should be. So you're actually feeling frustrated because you're taking things too personally. So say ‘OK well this is going on, but truthfully that doesn't define who I am’…because that's what makes you feel worse. (2)
I haven't ever meditated and I rarely ever just stop…it was good to actually have a moment to realize that you can do that and not let your mind wander. (6)
I go home and I'm tired…I grab something and make it as quick as possible… I put the TV on, eat while I'm checking voicemail…If you asked ‘what did you have to eat last night?’ I would have to stop and think. There's nothing memorable because I wasn't in the moment. (8)
Participants shared that they rarely pause to notice the contents of their minds and that it was difficult to maintain a “nondoing” mode.
Theme 2 (I Pause and I Notice, but this is Hard) characterized awareness of thoughts and emotions. This was the moment when participants realized the work related to mindfulness is not easy because the mind wants to run, wander, and be busy. Participants began to practice the tools offered to them and noticed mind wandering, negative thought processes, past-oriented thoughts, and future-oriented worry. They shared feelings of anger, self-doubt, defensiveness, and irritation.
The main thing is the stress of multitasking and pressure of trying to get things done. But after some of the exercises and discussing what mindfulness entails. It's just stopping to realize what is actually happening. (7)
I struggle with self-confidence problems and work stress…because I always feel like I'm not doing as good a job as maybe I can with my patients…mindfulness at work, as well as at home, [can help me] be a little more fair to myself and be a little less judgmental towards myself, and have a little less stress, then my professionalism and my work effectiveness can only improve. (1)
I tend to…take things more personally… when I am questioned or sometimes I'm defensive or angry…[but] I'm recognizing that I'm angry…or feeling defensive and…take a step back, and not have it eat at me so much. (2)
Participants practiced nonreacting, presence, pausing, or “stepping back.” They noticed that the contents of the mind could create negative responses to workplace management and barriers to patient care. They discovered that accurate self-awareness was powerful in itself because it yields unbiased and truthful information. Several participants shared the desire to reconnect with their patients, see their patients as individuals, and to “bring the practice home.” Three participants began to understand that the perception of the stressful event could be reframed to see “what is actually happening.”
I think mindfulness helps to remind people that it's your perception of what's going on that makes something stressful or not stressful…if you try to keep that in mind that most of the stress is selfinflicted, then that can help cut down on the stress…so I can think more logically versus just emotional reaction. (8)
Theme 3 (Mindfulness Works) emerged as participants shared direct benefits from pausing to notice their thoughts. Benefits included improved overall attitude, awareness that emotions are transient events, feelings are “real but not always true,” reactions are different than responses, noticing food intake, relational awareness, emotional balance, selfacceptance, positive self-talk, improved sleep, slowing down to reduce errors, and awareness that “I'm still a good therapist, even if….”
We're getting a lot of pressure to get things done…but a lot of it I think is just taking a look at why are we so angry? It's because we're professionals. Every coworker here has high ethics and expects to give a lot to their patients. So because of the emphasis on documentation being a reflection on your care…[the new documentation system] fuels that anger and frustration. So, just stepping back and saying “listen, I'm still a good therapist, the system is not working with how I want to document. (2)
It was one of the first teachings—identifying your emotion and don't judge it but then learning later on how are you going to deal with it or change it in a way that is constructive. (5)
I tend to carry work stuff home and just word vomit all over my boyfriend - and I would carry a lot more emotion with it…I think I've been better at separating that emotion and saying to myself: this is what happened…but it's my reaction to it that's making me angry or frustrated. (7)
It made me more aware if I was binge eating which I do when I get stressed. (2)
It helped me sleep. I could tune into my body and slow my mind down. (6)
Things that would bother me didn't as much. (7)
Theme 4 (I Need Support) represented participants’ responses noting that skilled mindfulness teachers should lead clinicians for consistency and accountability. The statement below, “we all need this practice,” was made by all participants in response to question 1, but was followed with, “but there is no time.” This theme illustrated participant desire to be supported by a formal practice among colleagues.
Probably together is better because individually I think people would be like “oh yeah, I did it” but I don't think they would really get it. We all need this practice. (2)
I think other therapists may think it's another kind of like silly, psychotherapy thing…it would have to come from someone who's practiced mindfulness and can share [their experiences]. (4)
All 8 participants shared a desire to continue a mindfulness practice led by an experienced individual. It was equally important for participants to feel supported in their ongoing practice, be reminded of the value of the practice, and practice alongside colleagues who shared their struggles.
As participants learned about mindfulness, each gained awareness by noticing their thoughts and feelings throughout the day. They responded openly to the unfamiliar topics, finding the practice challenging but rewarding. They noticed changes at work and at home, and shared some of the activities with family members. All participants preferred tangible tools to practice the activities, such as focusing on the breath as “anchor.”13–16 They all suggested ongoing small group work led by a mindfulness expert.
DISCUSSION
To illustrate the process of PTs exploring mindfulness in their own lives, Figure 1 represents a sequential progression grounded in the theory of mindfulness and represented by each theme. The sequence of pictures depicts participants’ initial thoughts and reactions of learning about mindfulness as illustrated by varying configurations of stones. In the first picture, the stones are in disarray, representing the disordered, distressed, and self-critical thinking expressed by participants, revealed by comments such as having a “constantly running mind” and “feeling pressure to get things done.” Participants in this early stage demonstrated awareness that stress was very real but felt helpless to manage it because “there is no time.”
With the use of mindfulness tools and activities, the second picture illustrates stones placed along a continuum, with spaces between each to symbolize purposeful pauses and focus on breathing. Participants shared mindfulness benefits such as noticing their thoughts, words, and actions, sleeping better, awareness of tasting food, and responding rather than reacting to negativity. This follows the theory of mindfulness which emphasizes addressing stress one moment at a time, with awareness of one's body sensations to remain present focused, rather than past or future-focused.13,14
Participants’ thoughts and feelings led to frequent epiphanies that began with “I noticed” and served to dampen the habitual stress response, especially as they learned that they could regulate their emotions by labeling them (eg, “here is anger,” “mind wandering,” “self-doubt”).8,53 Nonjudgmental awareness offered participants a renewed feeling of control over random life stressors for improved equanimity and feelings of hope.53 The second picture of stones represents a neverending journey and an ongoing practice, as stress does not stop, but one's relationship with stress can change dramatically.53,54 This journey is rarely linear, as depicted by the winding placement of the stones in the picture. This follows the theory of mindfulness, which states that regular, daily practice is required.13,14 Seated meditation, walking meditation, eating meditation, and other forms of formally tuning in to the body assist the individual later, as they manage daily, recurring stressors with more awareness.13,14,53–58
The third picture in Figure 1 illustrated participants’ ability to clearly express and confirm the benefits of the practice in their own lives. In this picture, the stones are arranged on top of one another in an erect fashion, depicting emerging personal empowerment for participants in this sample. The insightful statement “…it's your perception of what's going on that causes stress…” illustrates the ability to influence stress by regulating the influx of emotions that habitually accompany it.13,14,40,43,53–58 This follows the theory of mindfulness, which states that it is not the stress itself that is harmful, it is one's negative perceptions of stress that causes harm for the body and mind.13,26,53
Limitations
This study controlled for the influence of the CI-student relationship. However, participants may have offered positive interview responses in an effort to be helpful to the student clinician. This was addressed by member checking59 and through voluntary participation. Researchers regret not asking participants more directly about the influence on their personal lives, although this may have prevented authentic responses due to the sensitivity of such a question. Questions about direct patient care and productivity would have added valuable information for employers.
Furthermore, the brief, informal mindfulness activities (Table 1) were inconsistent with formal mindfulness practices with a skilled teacher. Had the student coauthors been formally trained, they may have had an even greater influence on their participants because they could have offered more breadth and depth to the teachings. Likewise, the participant clinicians may have been biased toward positivity with mindfulness since they actively sought out participation and “wanted” to reduce stress using these methods.
Given the exploratory nature of this study, investigators were curious how mindfulness would be perceived by PTs. Of interest, recent evidence shows that short, informal practices within the scope of daily life have direct benefits (sustained after 12 months) on positive affect, wellbeing, job satisfaction, quality of life, and compassion.54 In this study, a followup (1–3 months) would have added valuable information about whether or not participants continued to practice the activities or continued to seek out mindfulness resources.
Recommendations
Stress among physical therapy practitioners is inevitable given the landscape of health care in the United States. Mindfulness is an easily accessible, transportable practice that has a solid evidence base,7–10,15–17,19,23–47 but it has not yet reached recognition and acceptance among PTs. A recent randomized controlled trial of 42 physicians who completed an 8-week (1 hour per week) mindfulness-based stress reduction program showed significant improvements in heart rate, measures of peace/ease, energy, optimism, happiness, and accepting difficult emotions.58 After 1 year of a maintenance program, effect size significantly increased in magnitude. This demonstrates ongoing evidence for a lasting, efficient, cost-effective stress reduction program that requires little time and effort.58
Ideally, mindful practice should be introduced to PT students before they enter the workforce. Students can elect to further explore mindfulness by providing in-services to their clinical sites on mindfulness for chronic pain, workplace stress, and athletic performance. Alternately, creative methods, such as utilizing teaching assistants (TAs) from other campus-wide disciplines (eg, psychology, social work), can introduce students to the tenants of mindfulness, just as TAs are used in physical therapy courses like anatomy and orthopedics.
For practicing clinicians, site directors and supervisors can approach local professionals to more formally support mindfulnessbased stress reduction initiatives. Employers who foster such initiatives, such as the Mayo Clinic, can only benefit from clinicians who are productive, patient-centered, safe, and who manage stress effectively.17 Likewise, department administrators are in a position to include mindfulness materials in orientation documents, open weekly meetings with mindful practices, and provide space to allow PTs to commit to decreasing stress in the workplace. Finally, the American Physical Therapy Association (APTA) can lead efforts to offer continuing education courses and share resources for evidence-based stress reduction. Future research should focus on the impact of mindfulness on compassion fatigue, burnout, workplace productivity, patient care outcomes, and patient satisfaction.
ACKNOWLEDGEMENT
Thank you to the physical therapists who shared their experiences with us.
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