TYPE Original Research PUBLISHED 07 November 2022 DOI 10.3389/fpsyg.2022.1009266 Feasibility of a brief OPEN ACCESS mindfulness-based program for burnout in pain healthcare EDITED BY Petra Hanson, University of Warwick, United Kingdom REVIEWED BY professionals Manuel Villarreal, University of Warwick, United Kingdom Anna Server 1,2, Carlos Suso-Ribera 3,4*, Johannes Fendel, Marcos Pérez-Carrasco 2,5, Javier Medel 1,2, Ángela Mesas 1,2, University of Freiburg Medical Center, Germany Alfonso Ayora 6 and Rosa Maria Gracia 2,5 *CORRESPONDENCE 1 Department of Anesthesiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain, 2 Vall d’Hebron Carlos Suso-Ribera Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain, 3 Department of susor@uji.es Personality, Assessment and Psychological Treatments, Universitat Jaume I, Castelló, Spain, SPECIALTY SECTION 4 Institute of Health Carlos III, CIBERObn CB06 03/0052, Madrid, Spain, 5 Department of Critical This article was submitted to Psychology Care, Hospital Universitari Vall d'Hebron, Barcelona, Spain, 6 Department of Occupational Health, for Clinical Settings, a section of the journal Hospital Universitari Vall d’Hebron, Barcelona, Spain Frontiers in Psychology RECEIVED 01August 2022 ACCEPTED 18 October 2022 PUBLISHED 07 November 2022 Introduction: Stress inherent to health care, which is characterized by work CITATION overload and shortage of specialized staff, is associated with decreased quality Server A, Suso-Ribera C, Pérez-Carrasco M, of life and suboptimal patient care. Mindfulness-based programs have proved Medel J, Mesas Á, Ayora A and Gracia RM (2022) Feasibility of a brief to be effective in reducing stress in healthcare providers. This study aims to mindfulness-based program for burnout in assess the feasibility of an 8-week mindfulness program to reduce the burnout pain healthcare professionals. levels of the staff of a pain clinic in a tertiary public hospital. Front. Psychol. 13:1009266. doi: 10.3389/fpsyg.2022.1009266 Materials and methods: A longitudinal study with a within subject pre/post- COPYRIGHT intervention design, consisting of daily face-to-face 10-min sessions and the © 2022 Server, Suso-Ribera, creation of a virtual group using a social media platform. Variables measured: Pérez-Carrasco, Medel, Mesas, Ayora and Gracia. This is an open-access article burnout, mindfulness, empathy, self-compassion, and demographic distributed under the terms of the Creative characteristics. Commons Attribution License (CC BY). The use, distribution or reproduction in other Results: Program feasibility (i.e., reach, adherence, acceptability, and forums is permitted, provided the original preliminary effectiveness) was evaluated in 10 participants (6 physicians, author(s) and the copyright owner(s) are credited and that the original publication in 2 nurse practitioners, 1 nursing assistant, and 1 administrative). The results this journal is cited, in accordance with revealed a high reach (i.e., participation rate of 90%), excellent adherence to accepted academic practice. No use, the program (daily practice 95% of times), and very good acceptability of the distribution or reproduction is permitted which does not comply with these terms. group format and satisfaction with most treatment components. Regarding potential effectiveness, we report the results of the Wilcoxon signed-rank tests and its associated effect size (r). We observed improvements in mindfulness and all its subscales (−2.077≤Z≤−2.703, 0.69≤r≤0.90, all p<0.05) except for non-reactivity and all subcomponents of self-compassion (−2.501≤Z≤−2.611, 0.83≤r≤0.87, all p<0.05) but not on its global self-compassion score. Empathy and burnout did not change. In an exploratory manner, however, we found significant reductions in the burnout component of emotional exhaustion, but only in physicians (Z=−2.201, p=0.028, r=0.73). Discussion: We believe that the 8-week mindfulness-based program described in the present investigation might be a feasible and potentially Frontiers in Psychology 01 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 effective method that can be easily implemented to reduce burnout and promote mindfulness in specialized pain clinics. KEYWORDS mindfulness, burnout, stress, health professionals, pain clinic Introduction 2017). Meditation techniques have been found of great value by Buddhists, Hindus, Muslims, or Christians for thousands of years It is widely known that the stress inherent in health care is and it has gained wide acceptance amongst non-religious public associated with unfavorable health and work outcomes in the over the past few years. However, it should be mentioned that the healthcare professional, including lowered mood and decreased contemporary understanding of mindfulness has been quality of life, unwillingness to work, job dissatisfaction, and substantially simplified and divorced from its origins to fit current suboptimal patient care practices (Suñer-Soler et al., 2014; Kumar, society requirements. In such contemporary understandings, 2016; Salyers et al., 2017). In an attempt to summarize all these mindfulness is seen as a state of mind in which one is highly aware variables that can be affected by occupational stress in a single of the present moment, observing what happens in a moment-to- construct, the literature has converged towards the concept of moment manner, including one’s inner experiences, without burnout (Paris and Hoge, 2010). evaluating or judging one’s experiences, and being highly Burnout is a complex syndrome characterized by compassionate with oneself (Bishop et al., 2004). The fact that this depersonalization, emotional exhaustion, and a sense of low skill can be successfully trained improving inner peace and personal accomplishment (Maslach, 1993). Burnout impacts coupled with modern psychology approaches has enabled the negatively both on the healthcare professional, as well as on the development of specific stress management programs, such as quality of patient care (Paris and Hoge, 2010). Burnout increases Mindfulness-Based Stress Reduction (MBSR), originally the risk of sick-leave absences, future systemic diseases, and developed by Kabat-Zinn (1982). mental and behavioural disorders. Consequently, calls have been So far, the effectiveness of MBSR to reduce stress has been repeatedly made to search for initiatives to enhance the healthcare proven in different populations, including patients with professional’s well-being and to reduce this syndrome in this emotional disorders (López-del-Hoyo et al., 2022) or chronic population (Toppinen-Tanner et al., 2005; Moss et al., 2016). pain (Sanabria-Mazo et al., 2020), as well as in physicians from Burnout appears to be a very frequent syndrome in medical several specialties, psychologists, and nurses, among others disciplines, including family physicians and surgeons, among (Franco et al., 2010; Aranda Auserón et al., 2017; Gracia Gozalo others (Kumar, 2016). Only recently, there has been a growing et al., 2018; Villarreal et al., 2021). Encouragingly, recent awareness about the problem of occupational stress and burnout systematic reviews suggests that this intervention has the among anesthesiologists worldwide and research has highlighted potential to significantly reduce stress in healthcare professionals the risk of different manifestations and consequences of burnout, (Burton et al., 2017; Lomas et al., 2019; Fendel et al., 2021). In which range from medical errors to suicide (De Hert, 2018). particular, MBSR has been argued to be a program of choice for As a result of the above, several initiatives have been developed the reduction of burnout in healthcare professionals because in to reduce burnout in healthcare professionals, including structural taps into key mechanisms involved in daily practice, such as interventions (e.g., shortened attending rotation length and attentional processes, decision making, and emotional various modifications to clinical work processes) and individual- competencies (Braun et al., 2019; Hanson et al., 2020; Weisbaum focused interventions (e.g., stress management and self-care and Chadi, 2022). The goal of the present investigation is to training or communication skills training), with encouraging explore whether these promising findings can be generalized to results (Luberto et al., 2017). Among the wide range of strategies healthcare professionals attending an arguably different available, brief mindfulness-based programs have gained ground population, namely patients with chronic pain. Compared to in the past years due to their relatively reduced costs, moderate other hospital units, pain clinics were more recently created and efficacy, healthcare acceptability, and their ability to enhance job owe their existence to a conceptual change in the understanding performance (Gracia Gozalo et al., 2018; Pérez-Aranda et al., of pain as a clinical entity, as opposed to only accompanying 2019; Xie et al., 2021). different pathologies (Bonica, 1953). Because of this The term mindfulness corresponds to the Pali term “sati,” reconceptualization of pain, specialized, multidisciplinary pain which is a significant element of Buddhist traditions. In its original units have been created, where anesthesiologists collaborate with context, mindfulness is the ability to systematically understand other healthcare specialists (e.g., nurses, psychologists, one’s moment-to-moment experience and to develop self- psychotherapists, and occupational therapists, among others) for knowledge through practice (Karunamuni and Weerasekera, a comprehensive management of pain. Frontiers in Psychology 02 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 Like other countries, pain clinics in Spain are often assessment and treatment of complex patients with chronic pain. The heterogeneous with respect to structure and equipment, including demand for care is therefore very high and involves 1,450 new a variable number of staff members across units and different medical appointments, 4,500 follow-up consultations, and 4,000 levels of multidisciplinarity, but they are often characterized by a interventional procedures yearly. The sample included the whole staff, majority of anesthesiologists. Work overload is frequent, as well as which comprises 6 anesthesiologists, 2 nurse practitioners, 1 nursing shortage of specialized pain staff, although this has not been assistant, and 1 administrative staff. Except for a few anesthesiologists properly documented. In addition to these potentially stressful who develop part of their activities outside the clinic (operating factors, the personality and behavioral characteristics of persons theatres, preoperative consultation, or medical wards), the rest of the with chronic pain, as well as the unrealistic expectations that they workforce (55%) have exclusive dedication to the pain clinic. often hold about the efficacy of pain treatments, have also been argued to represent a major challenge for pain professionals (Strous et al., 2006). This adds up to the potential stress of care in Measures this population. In fact, there is recent evidence to suggest that physicians working in pain clinics show particularly high levels of As recommended in recent guidelines (Pearson et al., 2020), burnout compared with other specialties, which are characterized feasibility calculations will include several areas of research, such by high emotional exhaustion and depersonalization, together as reach (i.e., the percent of individuals willing to participate, with reduced personal accomplishment (Riquelme et al., 2018). which will be calculated as program participation rates), Also importantly, the repeated exposure of the healthcare adherence (i.e., the degree to which the program is implemented professionals to the pain of others has been argued to decrease as expected in terms of content or frequency, which will their empathy (an important component of burnout), ultimately be assessed in the present study as the frequency of participant leading to underestimate the patient’s pain (Grégoire et al., 2016), involvement in the virtual group during the program), which is likely to have negative consequences on patient care. acceptability (i.e., the perception that the program is agreeable, As noted in recent systematic reviews about mindfulness which will be evaluated with a measure of satisfaction with the programs for healthcare professionals, these programs are program), and calculations of preliminary effectiveness (with a potentially useful for this population (Burton et al., 2017; Lomas special emphasis on burnout, in line with the literature overview et al., 2019; Fendel et al., 2021). However, these investigations also presented at the beginning of the work). reveal that the number of published studies on the application of To evaluate the effectiveness of the program, the same mindfulness programs for healthcare professionals is still scarce, assessment protocol was administered twice at the beginning and especially in a particularly stressed population like healthcare the end of the program. This consisted of the following professionals working in pain clinic. Also importantly, review questionnaires: studies have shown that most research on the topic has focused on the effectiveness of mindfulness programs, while research has - The Maslach Burnout Inventory – Human Service Survey generally ignored feasibility components (e.g., reach, adherence, (Seisdedos, 1997) was administered to evaluate three and acceptability), which are crucial if a program is to components of burnout: be implemented in daily practice (King et al., 2019). Consequently, the present study will assess the feasibility of an 8-week o Emotional exhaustion addresses feelings of being mindfulness-based program to reduce the burnout levels of the emotionally overwhelmed and exhausted by work (e.g., “I staff of a pain clinic in Spain. We expect that the training will feel emotionally drained from my work”). Higher scores be feasible (i.e., a large percentage of potential participants will correspond to greater experienced burnout, with scores join the program, they will actively participate in it, and will ranging from 0 to 54. be satisfied with the program). We also expect that preliminary o Depersonalization measures a tendency to be unfeeling and analyses of effectiveness will show a reduction of burnout and to have an impersonal response toward recipients of one’s increases mindfulness skills, self-compassion, and empathy levels. service, care treatment, or instruction (e.g., “I feel I treat some patients as if they were impersonal objects”). Higher scores correspond to greater experienced burnout, with Materials and methods scores ranging from 0 to 30. o Personal accomplishment evaluates feelings of competence A longitudinal study with a within subject pre/post design was and successful achievement in one’s work (e.g., “I deal very conducted in a tertiary hospital pain clinic between April and effectively with the problems of my patients”). Lower scores May 2018. correspond to greater experienced burnout, with scores The pain clinic is categorized as a third level health institution ranging from 0 to 48. according to the standards and quality recommendations of the Spanish Government. Its area of influence covers a population of Response scales in the Maslach Burnout Inventory consist of almost 450.000 residents and it is a center of reference for the a 7-point Likert scale ranging from 0 = “never” to 6 = “every day.” Frontiers in Psychology 03 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 Each scale measures its own unique dimension of burnout inadequate (e.g., “I’m kind to myself when I’m and they should not be combined to form a single burnout scale. experiencing suffering”). Burnout syndrome usually presents with a high score in emotional o Common humanity is a component of self-compassion exhaustion and depersonalization and a low score in that involves recognizing that suffering and personal personal accomplishment. inadequacy are part of the shared human experience - Mindfulness abilities were measured by means of the Five (e.g., “When I feel inadequate in some way, I try to Facets of Mindfulness Questionnaire (FFMQ; Cebolla et al., remind myself that feelings of inadequacy are shared by 2012). The scale differentiates five dimensions of most people”). mindfulness, namely: oMindfulness evaluates the ability to take a balanced approach to our negative emotions so that feelings are o Observing: ability to observe and attend one’s inner and neither suppressed nor exaggerated (e.g., “When something outer experiences, such as thoughts, emotions, or painful happens, I try to make a balanced view of sensations (e.g., “I pay attention to sensations, such as the the situation”). wind in my hair or sun on my face”). o Describing: ability to represent or give an account of Response scales in the SCS use a 5-point Likert scale with experiences in words (e.g., “Even when I’m feeling terribly labels 1 = “almost never” to 7 = “almost always.” Scores in the scale upset, I can find a way to put it into words”). can range from 12 to 60, with higher scores reflecting greater self- o Acting with awareness: ability to engage fully in activities compassion. Both the subscales and a total self-compassion score in the present moment (e.g., “I rush through activities have been used in past research (Garcia-Campayo et al., 2014). without being really attentive to them”). Other variables collected in the study were the following: o Non-judging of inner experience: ability to adopt a non-evaluative position towards experiences (e.g., “I tell - Socio-demographic data. This included age (age 35 or myself that I should not be thinking the way I’m thinking”). under/36-50/over 50), sex, marital status (single/in a o Non-reactivity to inner experience: ability to let the feelings relationship), and occupation (doctor/nurse/assistant flow avoiding overreaction or refusal (e.g., “In difficult nurse/administrative staff). situations, I can pause without immediately reacting”). - Previous experience in mindfulness/meditation (1 = “yes”/0 = “no”). Response scales in the FFMQ use a 5-point Likert scale ranging from 1 = “never” to 5 = “very often or always.” Scores in the subscales range from 8 to 40 except for “non-reactivity to inner Procedure experience,” where scores have a 7–35 range. Scores in the global FFMQ range from 39 to 195. Higher The first phase of the study consisted of an introductory session, scores should be interpreted as representing greater awareness which was conducted by one of the present study authors, who has or mindfulness. been accredited with a master’s degree in mindfulness (University of Barcelona). Basic concepts and fundamentals, as well as a short- - The Jefferson Scale of Empathy (Alcorta-Garza et al., 2016) guided practice, were provided. The purpose of this session was both was used to measure the ability to understand the other to disseminate information and to inspire and raise awareness about person’s pain, suffering, and perspective, combined with an mindfulness practices amongst the participants. ability to communicate this understanding and an intention All staff members were then offered the opportunity to to help (e.g., “Empathy is a therapeutic skill without which participate in an 8-week program that consisted in guided a healthcare providers’ success is limited”). Response scales practical sessions held in the pain clinic before the start of the in the questionnaire consist of a 7-point Likert scale ranging working day. All the staff voluntarily agreed to participate. from 1 = “totally disagree” to 7 = “totally agree.” Scores in the Right after the introductory session, the previously described scale can range from 20 to 140, with higher scores questionnaires (pre-program) were completed. Next, a virtual corresponding to greater empathy. group was created using a social media platform on the - A 12-item, short version of the Self-Compassion Scale smartphone (i.e., WhatsApp). This virtual group using technology, (SCS) was administered to evaluate the ability to show which is a novel practice compared to past research (Lomas et al., self-compassion without judging (Garcia-Campayo et al., 2019; Fendel et al., 2021), allowed full access to all the 2014). Three subscales can be obtained from psychoeducational content and audiovisual material daily used the questionnaire: during practices. This allowed great flexibility in repeating sessions individually according to one’s availability. All the participants o Self-kindness evaluates the tendency to be warm and agreed to participate in this virtual group. Examples of the digital understanding toward ourselves when we suffer, fail, or feel content used can be found in Appendix I. Frontiers in Psychology 04 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 FIGURE 1 Contents of the training programme. The program consisted of daily face-to-face 10-min sessions the study was to conduct group on-site sessions. This for 8 weeks. condition was possible thanks to the specific features of the At the beginning of each week, early on Monday morning, the pain clinic and the similarity of the working hours between participants were sent a pre-session text with information on their most professionals. The participants arrived an hour earlier to smartphones so that they could prepare for the week’s topic. In the work to avoid disrupting the flow of activity. During the group sessions, depending on the weekly topic, the study weekends, the practice was carried out individually, based on coordinator selected audiovisual material from specialized web personal circumstances. sites lasting between 5 and 8 min. These materials changed daily The program took place in a meeting room at the pain clinic. and were also sent to the participants via the virtual group after The room was selected to provide a relaxed, low sensory each session. The reason for doing this was to offer the participants environment that would facilitate a warm and intimate different practical tools (varying tones and cadences of voice, atmosphere. The sessions began with the use of a singing bowl silences or ambient sounds, etcetera) to be used for practice. because of its ability to produce harmonic sounds that lead to Session topics were based on the MBSR program designed by serenity, mental balance, and reduced feelings of tension, which Jon Kabat-Zinn and used at the Medical Center of the University facilitates a meditative state (Goldsby et al., 2017). Except for the of Massachusetts (Kabat-Zinn, 1982) and included: origins and week when the body motion practices were performed, the rest of theoretical basis, attention to breathing, attention to body position, the sessions were carried out with the participants seated around attention to thoughts, daily life activities, and conscious a round meeting table. movements. The last two weeks were focused on generative The participants received at least one face-to-face session practices (emotional regulation and introduction to compassion). from Monday to Friday and were encouraged to do extra The concepts and practices addressed are detailed in Figure 1. practicing using the audiovisual material that best suited their Although the program was conducted in a hospital needs from the repertoire shared in the social media group. environment with an intense health care activity, the aim of Frequent reminders were sent via smartphone to promote Frontiers in Psychology 05 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 TABLE 1 Sociodemographic and professional characteristics. (60%), women (80%), and over 35 years of age (90%). None of them had previous experience with mindfulness practice. N° participants 10 Overall, the results suggested good feasibility of the program. Age Mean (SD) 46.5 (8.91) Regarding reach, which was calculated as the healthcare <= 35 years 1 (10%) professionals’ participation in the daily sessions from Monday to 36–50 years 5 (50%) Friday, 90% of the potential participants (9 out of 10) agreed to >50 years 4 (40%) participate in the program. Only one physician reported being too Gender Female 8 (80%) busy to participate. Taking adherence, the analysis of the Professional category Medical doctor 6 (60%) interaction in the virtual group indicated that there was a high Nurse 2 (20%) participation rate during the program (95% of the participants Assistant nurse 1 (10%) accessed the platform daily from Monday to Friday to check the Administrative staff 1 (10%) messages promoting practice). Marital status In a relationship 8 (80%) Finally, at the end of every practice and at the end of the study, N° of children None 4 (40%) participants were asked to rate each session informally on a scale 1 child 4 (40%) ranging from “0 = completely dissatisfied” to “5 = completely 2 children 2 (20%) satisfied” to evaluate satisfaction with the program components. All values reflect frequencies and percentages, except for the first line in age. It became evident that the last two components, that is, generative practices, proved less comfortable. The remaining components were rated by all the participants as either completely satisfactory practice based on the week session. At the end of the program, or mostly satisfactory. They were also asked to rate whether the the participants completed the assessment protocol again group format suited their needs, which also received high (post-program). satisfaction rates (from 4 to 5 on the aforementioned Likert-scale response rate from 0 to 5). Regarding preliminary effectiveness, results of the pre/post- Data analysis program measures for the whole sample are shown in Table 2. Burnout scores remained unaltered across the whole sample (all Description of the sample was performed using demographic p > 0.05). The same finding applied to empathy. Changes at the end and professional categorical and quantitative variables. The of the program, however, were revealed for the secondary analyses included frequency and proportion for categorical outcomes of mindfulness and self-compassion components (all variables, and median and inter-quartile range for quantitative p < 0.05). To explore whether burnout, but also mindfulness and variables due to the reduced sample size. The values of these related variables, differed across professionals (physicians vs. variables and the results of the questionnaires were both as a non-physicians), baseline scores were compared (Table 3). The whole and, in an exploratory manner, segmented by professional analyses only showed a trend for burnout (emotional exhaustion), categories (physicians vs. non-physicians). This was done because in the direction of physicians being more exhausted [24.5(8.25– the burnout associated with care provision was expected to 28.5) vs. 7(3.5–9.75); p = 0.069]. Medical professionals showed be different across employees, as reported in previous research lesser non-reactivity [14(17.5–18.5) vs. 21.5 (19.5–26.75); (Chou et al., 2014). p = 0.024] and common humanity [5.5 (4.25–5.75) vs. 6.75(5.75– Given the sample size, preliminary calculations of effectiveness 8.13); p = 0.047]. were made using a Mann–Whitney U test for continuous variables. Our next and final step included an exploratory analysis of Wilcoxon signed-rank test was used to compare pre/post-program the differential program effect across professionals (Table 4). results. Statistically significant differences were considered at Significant reductions in burnout, namely emotional p < 0.05. Wilcoxon effect sizes will be provided. Interpretations tend exhaustion (which was slightly higher in physicians), were only to be: 0.10–0.3 (small effect), 0.30–0.5 (moderate effect), and ≥ 0.5 revealed in physicians [24.5 (8.25–28.5) vs. 11 (4.75–18.75); (large effect; Tomczak and Tomczak, 2014). Due to the small sample p = 0.028]. Similarly, changes in mindfulness and self- size and the uncontrolled design of the study, the results of the compassion were only reported by physicians. Specifically, an statistical tests should be interpreted with caution. increase in observation [18.5(14.75–21.5) vs. 30.5(28–34); Statistical analyses were performed using the IBM SPSS p = 0.028], non-reactivity [17.5(14–18.5) vs. 21.5(20.75–22.25); Statistics program v. 22. (IBM Corp, 2013). p = 0.028], common humanity [5.5(3.75–7.25) vs. 7.5(5.88– 8.25); p = 0.043], and mindfulness [5(3.13–8.25) vs. 6.75(5.88– 8.5); p = 0.046] was revealed. On the contrary, a reduction in Results acting with awareness [28(15–34) vs. 18(11.25–22); p = 0.028] and non-judging was observed [23.5(20.75–29.75) vs. Socio-demographic and professional characteristics of the 10 17(14.25–23.5); p = 0.028]. No changes were observed in the participants are described in Table 1. Most of them were physicians sample of non-physicians. Frontiers in Psychology 06 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 TABLE 2 Results of pre/post-intervention questionnaires. Results Pre-intervention Post-intervention p Z r Burnout 9.5 (5.8–26.5) 9.5 (4.8–16.5) 0.110 −1.599 Emotional exhaustion 0.53 Depersonalization 5.5 (0.75–8.5) 4 (2.75–6) 0.590 −0.538 0.18 Personal accomplishment 40 (36.25–44.25) 42 (38–47) 0.550 −0.598 0.20 Mindfulness Global 106.5 (97.25–117.25) 116 (109.5–122) 0.037 −2.090 0.70 Observation 21 (16–25.25) 32 (28.75–34) 0.007 −2.703 0.90 Description 24 (23.3–24.25) 26.5 (24–27.25) 0.012 −2.512 0.84 Acting with awareness 18 (15–31.75) 18 (11.75–2.5) 0.038 −2.077 0.69 Non-judging 22 (19.25–25.25) 17.5 (14.25–23) 0.038 −2.077 0.69 Non-reactivity 18.5 (16.75–2.75) 22 (2.75–23.5) 0.028 −2.201 0.73 Empathy 82 (77.75–92.5) 82.5 (8.75–84.5) 0.798 −0.256 0.09 Self-compassion Global 37.5 (35.75–38.5) 37 (33.75–4.5) 0.678 −0.416 0.14 Self-kindness 6 (4.75–7.5) 7.8 (6–8.63) 0.012 −2.501 0.83 Common humanity 5.5 (5.25–6.6) 7 (5.9–8.5) 0.011 −2.536 0.85 Mindfulness 5.5 (4.25–8.25) 7 (6.5–8.75) 0.009 −2.611 0.87 Data represented as median (inter-quartile range). “Z” corresponds to Wilcoxon statistic; “r” corresponds to Wilcoxon effect size, where interpretations tend to be: 0.10–0.3 (small effect), 0.30–0.5 (moderate effect), and ≥0.5 (large effect). TABLE 3 Results of baseline questionnaires segmented by professional category. Physicians Non-physicians p Z r N 6 (60%) 4 (40%) Burnout 0.069 −1.818 Emotional exhaustion 24.5 (8.25–28.5) 7 (3.5–9.75) 0.61 Depersonalization 7 (3–1.75) 3 (0.25–7.75) 0.198 −1.287 0.43 Personal accomplishment 41.5 (36.75–45) 39.5 (32.75–43.25) 0.451 −0.753 0.25 Mindfulness Global 108.5 (96.25–119.25) 102.5 (96–117.25) 0.670 −0.426 0.14 Observation 18.5 (14.75–21.5) 25.5 (21.25–31.25) 0.054 −1.913 0.64 Description 24 (23.25–25) 24 (21–24) 0.278 −1.287 0.43 Acting with awareness 28 (15–34) 16.5 (13–18.5) 0.198 −0.753 0.25 Non-judging 23.5 (2.75–29.75) 19 (11–23.25) 0.133 −1.931 0.64 Non-reactivity 14 (17.5–18.5) 21.5 (19.5–26.75) 0.024 −1.0 0.33 Empathy 79.5 (73.25–84.25) 89.5 (82–99.25) 0.052 −1.942 0.65 Self-compassion Global 38 (35.75–38.5) 36.5 (32.25–39.25) 0.515 −0.652 0.22 Self-kindness 5.5 (3.75–7.25) 6.5 (6–8.5) 0.281 −1.079 0.36 Common humanity 5.5 (4.25–5.75) 6.75 (5.75–8.13) 0.047 −1.986 0.66 Mindfulness 5 (3.13–8.25) 6.5 (5.125–9) 0.336 −0.962 0.32 Data represented as median (inter-quartile range). “Z” corresponds to Wilcoxon. “r” corresponds to Wilcoxon effect size, where interpretations tend to be: 0.10–0.3 (small effect), 0.30– 0.5 (moderate effect), and ≥ 0.5 (large effect). Discussion change, dissatisfaction and distress have continued to increase. Given the inherent difficulties to influence personally in those Over a decade ago some authors started advocating that variables related to work overload or administrative burden, special attention should be paid to health care providers this study aimed to implement and explore the feasibility of a (Butterfield, 1988) and this remains relevant to the present date mindfulness training program for healthcare professionals in a (Martín-Brufau et al., 2020; Liu et al., 2021). Despite this call for high complexity pain clinic. To the best of our knowledge, this Frontiers in Psychology 07 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 TABLE 4 Results of pre/post-intervention questionnaires segmented by professional category. Physicians Non-physicians N° Subjects 6 (60%) 4 (40%) Questionnaires Pre- Post- p Z r Pre- Post- p Z r Burnout Emotional exhaustion 24.5 (8.25–28.5) 11 (4.75–18.75) 0.028 −2.201 0.73 7 (3.5–9.75) 9 (4.25–13.75) 0.109 −1.604 0.73 Depersonalization 7 (3–1.75) 4.5 (3–6) 0.225 −1.214 0.40 3 (0.25–5.75) 2 (2.25–9) 0.257 −1.134 0.40 Personal 41.5 (36.75–45) 45 (41–47) 0.084 −1.725 0.58 39.5 (32.75–43.25) 28 (26.75–42.2) 0.285 −1.069 0.58 accomplishment Mindfulness Global 108.5 (96.25– 116.5 (104.75– 0.249 −1.153 0.38 102.5 (96–117.25) 116 (118.5– 0.068 −1.826 0.38 119.25) 122) 127.75) Observation 18.5 (14.75– 3.5 (28–34) 0.028 −2.201 0.73 25.5 (21.25–31.25) 33 (29.75–34) 0.141 −1.473 0.73 21.5) Description 24 (23.25–25) 26.5 (23–27.25) 0.098 −1.656 0.55 24 (21–24) 26.5 (24.5–28.5) 0.068 −1.826 0.55 Acting with awareness 28 (15–34) 18 (11.25–22) 0.028 −2.201 0.73 16.5 (13–18.5) 18 (12.25–20) 0.414 −0.816 0.73 Non-judging 23.5 (2.75– 17 (14.25–23.5) 0.028 −2.201 0.73 19 (11–23.25) 20 (11.25–22.75) 0.785 −0.272 0.73 29.75) Non-reactivity 17.5 (14–18.5) 21.5 (2.75–22.25) 0.028 −2.201 0.73 21.5 (19.25–26.75) 23.5 (19.75–26.5) 1 <0.001 0.73 Empathy 79.5 (73.25– 82 (79.5–84.75) 0.527 −0.632 0.21 89.5 (82–99.25) 83.5 (81.5–85.5) 0.273 −1.095 0.21 84.25) Self-compassion Global 38 (35.75–38.5) 38 (36.5–4.5) 0.414 −0.816 0.27 36.5 (32.25–39.25) 33.5 (3.75–4.75) 0.854 −0.184 0.27 Self-kindness 5.5 (3.75–7.25) 7.5 (5.88–8.25) 0.058 −1.897 0.63 6.5 (6–8.5) 8.25 (6.5–9.63) 0.109 −1.604 0.63 Common humanity 5.5 (4.25–5.75) 6.5 (5.88–8.5) 0.043 −2.023 0.67 6.75 (5.75–8.13) 7.75 (5.875–8.88) 0.102 −1.633 0.67 Mindfulness 5 (3.13–8.25) 6.75 (6.13–8.75) 0.046 −1.997 0.67 6.5 (5.13–9) 7.5 (6.63–9.5) 0.066 −1.841 0.67 Data represented as median (inter-quartile range). “Z” corresponds to Wilcoxon statistic; “r” corresponds to Wilcoxon effect size, where interpretations tend to be: 0.10–0.3 (small effect), 0.30–0.5 (moderate effect), and ≥0.5 (large effect). is the very first study of this type in this population (e.g., experience. However, not all the participants reported the same healthcare professionals working at a pain clinic) and using satisfaction with all the practices conducted. This variability relied technology to facilitate, support, and encourage daily practice, both on the week proposal and the nature of the audiovisual which opens avenues for new research and might help inspire material. It was apparent that participants reported more future investigations and expands past similar research (Lebares discomfort with the last sessions of the program (difficult et al., 2018; Fendel et al., 2020). Even though the reduced emotions and self-compassion), as evidenced in previous studies sample size limits the generalizability and robustness of (Gracia Gozalo et al., 2018). These components are fundamental findings, our study suggests that the implementation of a MBSR in mindfulness programs, so their exclusion does not seem in real-life settings in a pain clinic might be feasible (e.g., it can appropriate. However, strategies like addressing the content be implemented with high satisfaction and participation rates differently (e.g., more progressively or including extra sessions to and leads to an acceptable interference on the daily routine of facilitate practice) could be considered in future research. care). We also obtained preliminary confirmatory evidence that Regarding the secondary outcomes of the study, which are the program might promote mindfulness and self-compassion related to the effectiveness of the program, the study evidenced skills and exploratory evidence on benefits for burnout, but only group changes in self-compassion and mindfulness skills, but in physicians. not in empathy and burnout. Regarding empathy, the result Regarding feasibility, reach, adherence, and acceptability might be attributable to a ceiling effect, which has been also results were excellent. It is important for implementation purposes reported in past research with health care professionals that almost all the healthcare professionals at the Pain Clinic were (Boellinghaus et al., 2014). While it is possible that this was not willing to participate in the program and those who participated as specifically addressed as mindfulness components in the were highly adherent and manifested a high degree of satisfaction program, it is also possible that baseline empathy (which was with the study design and found the format suitable for their high) might explain this. These results are consistent with those needs. They also expressed an eager willingness to repeat the obtained in earlier studies (Amutio Kareaga et al., 2008; Frontiers in Psychology 08 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 Gracia Gozalo et al., 2018), but at this stage it is impossible to might lead to a vicious cycle of patient dissatisfaction-physician conclude whether the program was ineffective or if baseline burnout. Provision of resources to the professionals to manage scores were already high in this construct and a ceiling effect levels of stress, feelings, attention span or empathy becomes a was responsible for the lack of change. necessity to provide a comprehensive care of this complex kind of An interesting finding was obtained for burnout in our patients. Therefore, it appears obvious to us that strategies directed exploratory analyses. In particular, our study revealed that a at preventing burnout development, lack of empathy, or self- brief mindfulness program reduced burnout, particularly compassion are needed. Although this study is done prior to the emotional exhaustion, in physicians working at our pain covid-19 pandemic, its results could support the use of this clinic. Even though this change did not occur in strategy at a time when burnout is so widespread in health care non-physicians, this might be attributable to the lower levels personnel globally (Gualano et al., 2021) and psychological of burnout in this population, as indicated in our results. support for this population is more necessary than ever (Önen Therefore, our findings are in line with research suggesting Sertöz et al., 2021). that physicians are a population at particular risk for burnout The methodological limitations of the study include a (Grover et al., 2018). Also consistent with past research, the reduced sample size and the absence of a control group. It fact that changes only occurred in the subgroup with higher should also be noted that participants may present a positive burnout might be interpreted as showing that there might bias towards the program, as they all accepted to participate be more room for improvement in persons with higher in the study because they were interested in mindfulness. suffering (Osma et al., 2021). This might be important for While acknowledging this, it is important to note that none implementation purposes and personalization of programs to of them had previous experience with mindfulness or the specific needs of individuals, as in stepped-care models meditation, which could have represented an additional bias where more intensive programs are offered to individuals in the sample. A final concern is the inability to monitor according to their baseline severity (Bailey et al., 2022). everyone’s practice between sessions. With the availability of In the case of pain clinics, it must be emphasized that pain smartphones, future studies could evaluate daily practice is a complex personal experience and, especially in chronic using an app for ecological momentary assessment (Colombo pain, it is deeply influenced by psychological mechanisms. et al., 2020). There is a shortage of psychology experts in our pain clinic, In conclusion, the 8-week mindfulness-based program entailing that non-expert professionals must deal with described in the present investigation might be a feasible and patients’ affective components. Without the adequate potentially effective method that can be easily implemented to resources to cope with these challenges, this could also play a promote mindfulness and self-compassion in healthcare role in burnout and needs to be addressed. In fact, as noted professionals of specialized pain clinics. Also importantly, earlier, in our study burnout in the physicians was slightly potential benefits in burnout were found for physicians. It is higher than in the rest of the staff, which would be in line with obvious that healthcare professionals need support in addressing the previous. The positive benefits of this mindfulness the wide range of potential stressors inherent to their work program on the pain clinic’s physicians’ burnout extends environment. Efforts to reduce burnout and promote previous evidence on the effectiveness of mindfulness-based satisfaction in healthcare professionals should be encouraged programs on other health care providers (Morgan et al., 2015; and we believe this kind of mindfulness strategies may lead to Gracia Gozalo et al., 2018). The effect sizes found in the healthier behaviors in our professionals and, therefore, to a present study, which generally ranged from moderate to large, better patient care. are also consistent with past similar research as noted in recent reviews (Burton et al., 2017; Lomas et al., 2019). A recent review, however, indicated only small effect sizes for burnout Data availability statement in physicians (Fendel et al., 2021). While the present study results should be taken with caution due to the reduced sample The raw data supporting the conclusions of this article will size, it is possible that the social media component included be made available by the authors, without undue reservation. in the present study helped incorporate some of the concepts more successfully, which might explain the good results obtained for burnout levels in physicians. Ethics statement The stress inherent to health care is known to have a negative impact on health care providers, both personally and The studies involving human participants were reviewed and professionally (Shanafelt et al., 2002). Considering the deleterious approved by Comité de Ética de Investigación con Medicamentos effects of a health care system weakened by stress and burnout, it y Comisión de Proyectos de Investigación del Hospital Universitari is imperative to focus on promoting good mental health amongst Vall D'Hebron (reference PR(ATR)441/2018). The patients/ professionals. Moreover, stress and burnout are associated with participants provided their written informed consent to participate low level of satisfaction from patients (Garman et al., 2002), which in this study. Frontiers in Psychology 09 frontiersin.org Server et al. 10.3389/fpsyg.2022.1009266 Author contributions Conflict of interest AS designed the study, conducted the study, collected the data, The authors declare that the research was conducted in the analyzed the data, and prepared the manuscript. CS-R designed absence of any commercial or financial relationships that could the study, analyzed the data, and prepared the manuscript. MP-C be construed as a potential conflict of interest. collected the data and analyzed the data. JM and ÁM conducted the study and prepared the manuscript. AA and RG designed the study and prepared the manuscript. All authors have read and Publisher’s note approved the final version of the manuscript. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated Funding organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or This research was funded by Universitat Jaume I, grant claim that may be made by its manufacturer, is not guaranteed or number UJI-A2020-03. endorsed by the publisher. Acknowledgments Supplementary material Our most sincere gratitude to the staff of the Pain Clinic of Vall The Supplementary material for this article can be found online d’Hebron University Hospital for their collaboration and precious at: https://www.frontiersin.org/articles/10.3389/fpsyg.2022.1009266/ support, without which this project would have not taken place. full#supplementary-material References Alcorta-Garza, A., San-Mart, M., Delgado-Bolton, R., Soler-Gonz, J., Roig, H., Colombo, D., Suso-Ribera, C., Fernández-Álvarez, J., Cipresso, P., and Vivanco, L. (2016). Cross-validation of the Spanish hp-version of the Jefferson García-Palacios, A., Riva, G., et al. 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