Mindfulness-Based Stress Reduction for Health Care Professionals: Results Froma Randomized Trial

Mindfulness-Based Stress Reduction for Health
Care Professionals: Results From a Randomized
Trial
Shauna L. Shapiro
Santa Clara University
John A. Astin
California Pacific Medical Center
Scott R. Bishop
Centre for Addiction and Mental Health and University of Toronto
Matthew Cordova
Palo Alto Veteran Affairs Health Care System
The literature is replete with evidence that the stress inherent in health care
negatively impacts health care professionals, leading to increased depres-
sion, decreased job satisfaction, and psychological distress. In an attempt to
address this, the current study examined the effects of a short-term stress
management program, mindfulness-based stress reduction (MBSR), on
health care professionals. Results from this prospective randomized con-
trolled pilot study suggest that an 8-week MBSR intervention may be effective
for reducing stress and increasing quality of life and self-compassion in
health care professionals. Implications for future research and practice are
discussed.
Keywords: mindfulness, stress, health care professionals, meditation
Shauna L. Shapiro, Department of Counseling Psychology, Santa Clara University; John
A. Astin, California Pacific Medical Center, San Francisco, California; Scott R. Bishop, Centre
for Addiction and Mental Health, Toronto, Ontario, Canada, and Department of Psychiatry,
University of Toronto, Toronto, Ontario, Canada; Matthew Cordova, Department of Behavioral
Medicine, Palo Alto Veteran Affairs Health Care System, Palo Alto, California.
This work was supported by Canadian Institutes of Health Research Grant CIHR 49612.
Correspondence concerning this article should be addressed to Shauna L. Shapiro,
Department of Counseling Psychology, Santa Clara University, 500 El Camino Real, Santa
Clara, CA 95053-0201. E-mail: slshapiro@scu.edu
164
International Journal of Stress Management
Copyright 2005 by the Educational Publishing Foundation
2005, Vol. 12, No. 2, 164 –176
1072-5245/05/$12.00 DOI: 10.1037/1072-5245.12.2.164

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There is considerable evidence that the stress inherent in health care
negatively impacts health care professionals. Stress can lead to increased
depression (Tyssen, Vaglum, Gronvold, & Ekeberg, 2001), decreased job
satisfaction (Blegen, 1993; Flanagan & Flanagan, 2002), disrupted personal
relationships (Gallegos, Bettinardi-Angres, & Talbott, 1990), psychological
distress (V. Jain, Lall, McLaughlin, & Johnson, 1996); and even suicide
(Richings, Khara, & McDowell, 1986). Stress also may harm professional
effectiveness: It decreases attention (Smith, 1990), reduces concentration
(Askenasy & Lewin, 1996), impinges on decision-making skills (Klein,
1996; Lehner, Seyed-Solorforough, O’Connor, Sak, & Mullin, 1997), and
reduces providers’ abilities to establish strong relationships with patients
(Pastore, Gambert, Plutchik, & Plutchik, 1995).
Stress also may lead to increased burnout (Spickard, Gabbe, & Chris-
tensen, 2002), defined as a syndrome of depersonalization, emotional ex-
haustion, and a sense of low personal accomplishment. A recent study found
that burnout was significantly associated with suboptimal self-reported pa-
tient care (Shanafelt, Bradley, Wipf, & Back, 2002). Over a decade ago, the
field identified these problems and called for change, advocating better care
for health professionals (Butterfield, 1988). Despite this call for change,
dissatisfaction and distress have continued to increase. For example, a study
of U.S. physicians showed a decline in satisfaction with every aspect of their
professional life from 1986 to 1997 (Murray et al., 2001). It is clear that
health care professionals need support in addressing the numerous stressors
inherent in their work.
The current study attempted to address this need, by offering an inter-
vention to health care professionals to help cope with their considerable
stress. The intervention was modeled after a well-established, cost-effective
stress reduction program, mindfulness-based stress reduction (MBSR), de-
veloped by Kabat-Zinn and colleagues at the University of Massachusetts
Medical Center (Kabat-Zinn, 1982). MBSR is an educationally based pro-
gram focusing on training in the Eastern contemplative practice of mindful-
ness. Mindfulness is a form of meditation originally derived from the Thera-
vada tradition of Buddhism (Hanh, 1976). The 2,500-year-old practice
known as Vipassana was developed as a means to cultivate greater awareness
and insight (Goldstein, 1976). Mindfulness is often translated as “to see with
discernment.”
The MBSR intervention is designed to teach participants to become more
aware of, and relate differently to thoughts, feelings, and body sensations.
MBSR helps participants cultivate a nonjudging yet discerning observation
of all the stimuli that enter their field of awareness moment by moment.
Mindfulness practice allows for greater awareness of the “here and now,” as
the practitioner learns to let go of ruminations about the past and fears
regarding the future. In this way, practitioners learn to see their habitual

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Shapiro, Astin, Bishop, and Cordova
reactions to stress and to cultivate healthier, more adaptive ways of respond-
ing. The essence of mindfulness involves awareness and acceptance of
whatever is occurring in the present moment.
Research demonstrates that mindfulness interventions can effectively
reduce stress, anxiety, and depression in both clinical and nonclinical popu-
lations (Miller, Fletcher, & Kabat-Zinn, 1995; Shapiro, Schwartz, & Bonner,
1998). Further, research suggests that MBSR is an effective intervention for
prevention of relapse of major depression (Teasdale et al., 2000; Teasdale,
Segal, & Williams, 1995). Evidence also suggests that MBSR may be an
effective intervention for psoriasis (Kabat-Zinn, Wheeler, Light, & Cropley,
1998), chronic pain (Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney,
1985), and fibromyalgia (Kaplan, Goldberg, & Galvin-Nadeau, 1993) and has
been associated with significant decreases in general medical symptomatol-
ogy (Kabat-Zinn et al., 1992).
Specifically related to health care professionals, two previous studies
have demonstrated the beneficial effects of MBSR for medical students and
prehealth students. In a randomized control trial of MBSR for medical and
premedical students, findings indicated significant decreases in depression
and anxiety and significant increases in empathy in the MBSR intervention
group as compared with controls (Shapiro, Schwartz, & Bonner, 1998).
These findings were replicated in a recent randomized controlled trial of
prehealth students (S. Jain, Shapiro, Swanick, Bell, & Schwartz, 2004).
Although these studies contribute significantly to the literature on preparing
health care students in training, they do not directly test the effects of MBSR
for health care professionals actively engaged in clinical practice. The current
study aimed to do this by examining the effects of MBSR on job burnout and
psychological distress in health care professionals currently involved in
clinical work.
AIMS AND HYPOTHESES
The primary purpose of the current study was to replicate and extend
initial research demonstrating the value of MBSR for medical students
(Shapiro et al., 1998) and prehealth students (S. Jain et al., 2004). To date, no
study has examined the effects of MBSR for health care professionals
actively engaged in clinical practice. To address this gap in the literature, the
current study examined the effects of MBSR in a population of health care
professionals who were currently involved in clinical work, as opposed to
being “in training” as with the previous student populations studied. The
primary hypotheses of the study were that MBSR would (a) decrease overall
psychological distress, (b) decrease stress, and (c) decrease job burnout. We

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167
also hypothesized that MBSR intervention would have positive benefits of (a)
increasing overall life satisfaction and (b) increasing self-compassion.
METHOD
This pilot study used a randomized controlled study design that imple-
mented a 2 (experimental vs. wait-list control group)
2 (baseline, post-
treatment) study design, yielding a between-groups comparison condition.
Participants were randomly assigned to an 8-week MBSR group or a wait-list
control group. The control group received the identical MBSR intervention
after the experimental group completed the program.
Participants
All health care professionals (e.g., physicians, nurses, social workers,
physical therapists, and psychologists) from the Palo Alto and Menlo Park
Divisions of the Veterans Affairs Palo Alto Health Care System were eligible
for the study. Recruitment consisted of posting flyers around the hospital and
sending out e-mails describing the free stress management program for health
care professionals. The flyers and e-mails explained that the intention of the
program was to reduce stress, decrease burnout, and increase overall well-
being. Fifty-one participants responded to the e-mail and flyer recruitment.
Inclusion criteria included (a) being a current health care professional, (b)
having an age greater than 18 years, and (c) being English speaking. (The
reason for this criterion is that the MBSR intervention, including all patient
material, is currently only available in English, and we are neither funded for
nor capable at the time of translation.) Exclusion criteria included having (a)
current substance abuse problems and (b) current suicidal ideation. Thirty-
eight health care professionals aged 18 – 65 enrolled in the study, gave
informed consent, and were randomly assigned to the MBSR group (n
18)
or wait-list control group (n
20).
Measures
Baseline and postintervention measures were taken on both the experi-
mental and control groups; however, the control group did not complete
postintervention measures after they received the same treatment. Psycho-
logical distress was assessed with the Brief Symptom Inventory (BSI;
Derogatis, 1993). The BSI yields 10 reliable subscales reflecting different

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Shapiro, Astin, Bishop, and Cordova
mood states, including Anxiety and Depression, as well as a Total Mood
Disturbance scale. The Maslach Burnout Inventory (MBI; Maslach, & Jack-
son, 1986) measures three facets of job-related burnout: emotional exhaus-
tion, depersonalization, and reduced personal accomplishment. This is the
most widely used measure of burnout in the field, and its psychometrics and
validity are well supported (see Maslach & Jackson, 1986). Stress was
measured with the Perceived Stress Scale, a global measure of perceived
stress (see Cohen, Kamarck, & Mermelstein, 1983).
We also examined two positive outcomes—satisfaction with life and
self-compassion. Life satisfaction was measured with the Satisfaction With
Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985). This is a
measure of global life satisfaction in the field and is supported by strong
psychometrics. The Self-Compassion Scale created by Neff (2003) was used
to measure self-compassion among the participants. The scale is designed to
measure three components of self-compassion on separate subscales: Self-
Kindness Versus Self-Judgment, Common Humanity Versus Isolation, and
Mindfulness Versus Overidentification. This scale has been shown to be
psychometrically sound (Neff, 2003). In an effort to further assess the
subjective experiences of participants, the following two questions were
administered at the end of the intervention:
1. “On a scale from 1–10, how meaningful has the MBSR program been
in your life?”
2. “What do you feel you gained from the MBSR program?”
Intervention
Mindfulness has been conceptualized as a state in which one is highly
aware of the present moment, acknowledging and accepting it, without
getting caught up in thoughts about the present experience or in emotional
reactions to it (Bishop et al., 2004). Mindfulness involves paying attention to
one’s present experiencing in a nonjudgmental, nonevaluative way. Although
mindfulness requires a certain degree of calm and equanimity, it is not to be
confused with relaxation techniques. Mindfulness approaches and relaxation
techniques differ significantly. Mindfulness is a form of mental training
intended to enhance awareness and the ability to disengage from maladaptive
patterns of mind that make one vulnerable to stress responses and psycho-
pathology. Training in mindfulness attempts to increase awareness of
thoughts, emotions, and maladaptive ways of responding to stress, thereby
helping participants learn to cope with stress in healthier, more effective
ways (Bishop et al., 2004).

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Mindfulness-Based Stress Reduction
169
The current MBSR intervention consisted of eight 2-hr sessions, 1
session per week. Participants received training in the following meditative
practices: (a) sitting meditation, involving awareness of body sensations,
thoughts, and emotions while continually returning the focus of attention to
the breath; (b) body scan, a progressive movement of attention through the
body from toes to head, observing any sensations in the different regions of
the body; (c) Hatha yoga, which consists of stretches and postures designed
to enhance greater awareness of and to balance and strengthen the muscu-
loskeletal system, and (d) three-minute breathing space, a “minimeditation”
that focuses on the breath, the body, and what is happening in the present
moment (Segal, Williams, & Teasdale, 2002). Inherent in all these techniques
is an emphasis on mindfulness, continually bringing attention to the present
moment. In addition to the mindfulness exercises, a “loving kindness”
meditation was introduced, in an attempt to help health care professionals
develop greater compassion for themselves, their coworkers, and their pa-
tients.
The atmosphere of the group was safe and open, facilitating an environ-
ment where participants could share their direct experience with the prac-
tices. The environment was not, however, similar to that of a support group,
in that participants shared about their experiences of mindfulness, instead of
difficulties in their lives. The intervention was led by a clinical psychologist
with extensive training and experience in MBSR. The same instructor led the
intervention for the control group as well.
Control Group
Participants assigned to the wait-list control condition received the
equivalent MBSR intervention immediately after the experimental group
completed the intervention.
Statistical Analyses
Baseline analyses revealed a trend indicating that study participants
assigned to the treatment group reported more distress than controls. To
control for possible regression to the mean, we carried out regression anal-
yses for each of the five primary study outcomes— burnout, perceived stress,
psychological distress, satisfaction with life, and self-compassion— control-
ling for baseline levels of those same variables. Owing to the pilot nature of
this study and the small sample size, we did not perform intent-to-treat
analyses but compared only those participants who did not drop out.

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Shapiro, Astin, Bishop, and Cordova
RESULTS
Of the 18 participants randomized to the mindfulness intervention, 8 did
not complete the intervention. Reasons included health issues (n
2), family
problems, resignation from job, insufficient time (n
4), and other (n
2).
At baseline, there was a trend in the direction of study completers being
slightly more distressed than dropouts on some measures. However, these
differences were not statistically significant. Of the 20 participants random-
ized to the control group, 2 individuals failed to complete end-of-study
assessments.
As shown in Table 1, significant between-group differences were ob-
served for the Perceived Stress (p
.04) and Self-Compassion Scales (p
.004). Compared with controls, the intervention (MBSR) group demonstrated
a significant mean reduction (27% vs. 7%) in perceived stress and increase in
self-compassion (22% vs. 3%). In the MBSR group, 88% of the participants
improved their stress scores while 90% demonstrated increases in self-
compassion. In addition, the MBSR condition demonstrated trends toward
greater positive changes in all of the dependent variables examined. Com-
pared with controls, intervention participants reported greater satisfaction
with life (19% vs. 0%), decreased job burnout (10% vs. 4%), and decreased
distress (23% vs. 11%; see Table 1).
Owing to the significant changes observed on the self-compassion mea-
sure, we examined the extent to which changes in this variable mediated
changes in perceived stress and/or satisfaction with life. Separate regression
analyses were performed using changes in self-compassion as a covariate.
Changes in self-compassion significantly predicted positive changes in per-
ceived stress but did not have predictive power for satisfaction with life.
Although these findings must be interpreted with caution given the small
sample size in this study, they do point to the value of examining self-
compassion as a potentially important mediating mechanism in future studies
of mindfulness.
DISCUSSION
The results of this study suggest the potential benefits of a meditation-
based intervention for health care professionals. Those who participated in
the MBSR intervention reported decreased perceived stress and greater
self-compassion when compared with controls. Reported psychological dis-
tress, satisfaction with life, and job burnout were decreased; however, the
differences between experimental and control groups along these dimensions
were not significant. This may be understandable given the small numbers in

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Mindfulness-Based Stress Reduction
171
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172
Shapiro, Astin, Bishop, and Cordova
the study and the likelihood that the study was therefore insufficiently
powered.
In addition to the findings of the quantitative data, responses to our
open-ended question suggest further benefits of the mindfulness intervention,
perhaps not so easily captured through the use of traditional psychological
inventories. The anonymous participant responses to the question “What
effects did the MBSR program have on your life?” suggest that the inter-
vention had a significant positive impact on their lives (see the Appendix).
Adding support to this are the anonymous participant responses to the
question “On a scale of 1–10 what impact did the MBSR program have on
your life?” The mean rating of the impact of MBSR was 9.2, indicating that,
according to subjective report, the 8-week MBSR program did substantially
impact participants’ lives. The qualitative responses in conjunction with the
high rating of the program suggest that MBSR may indeed prove beneficial
for those health care professionals who are able to participate in and complete
the intervention.
Given the reported benefits and satisfaction with the intervention, the
significant dropout rate seen in the intervention group is a concern. Forty-four
percent of the MBSR group did not complete the intervention. Typically,
dropout rates are less than 20% for an MBSR intervention (Kabat-Zinn,
1982; Kabat-Zinn et al., 1985; Shapiro et al., 1998). Although these partic-
ipants may not have felt they were deriving benefits from the intervention, all
8 of them reported that dropping out was due to lack of time and increased
responsibility rather than to lack of interest in or need for stress management.
Supporting this is the fact that 90% of the control group completed the
postassessment measures, indicating their strong desire and commitment to
participate in the next MBSR program. We suggest that the high dropout rate
in this study does not indicate a lack of need or interest but instead indicates
that adding a 2-hr intervention plus daily home practice to an already
demanding schedule may not be feasible for a substantial number of health
care professionals.
Future research could improve on this study by exploring ways to offer
stress management interventions without adding additional time-commitment
and strain. Creative means of incorporating the 8-week MBSR intervention
into work schedules may be an important way to prevent burnout and
increase job (and life) satisfaction in health care professionals. Future re-
search could also address a limitation of this study: lack of a credible placebo
control. Future research could also benefit by including follow-up assessment
to determine whether the benefits of MBSR are enduring. Finally, future
research could include additional forms of assessment that extend and
strengthen the self-report measures used in the current study, for example,
examining whether the positive effects of MBSR translate into enhanced
patient care.

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Mindfulness-Based Stress Reduction
173
CONCLUSION
MBSR offers a well-established model for providing a brief, cost-
effective program that can be implemented easily in hospitals and health care
clinics. In light of the significant stress reported by health care professionals,
and the deleterious consequences of this stress on their lives, it seems
important to begin to seriously explore more effective means of supporting
them. Further, given that job burnout and distress have been significantly
associated with decreased patient satisfaction (Garman, Corrigan, & Morris,
2002) and suboptimal self-reported patient care (Shanafelt et al., 2002),
incorporating MBSR interventions for health care professionals also has the
potential to enhance patient care. It is hoped that this research will contribute
to changes in the field of medicine, leading to enhanced care for health
professionals and ultimately for the patients they serve.
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