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Open Access
OBM Integrative and
Complementary Medicine
Original Research
Leveraging Mindfulness to Build Resilience and Professional Quality of Life
in Human Service Professionals
Andrew Hanna 1,*, Aileen M. Pidgeon 2
1. School of Health and Human Sciences, Southern Cross University, Coffs Harbour, NSW, Australia
2450; E-Mail: a.hanna.23@student.scu.edu.au
2. Faculty of Society and Design, Bond University, QLD, Australia 4229; Email: apidgeon@bond.edu.au
* Correspondence: Andrew Hanna; E-Mail: a.hanna.23@student.scu.edu.au
Academic Editor: Sok Cheon Pak
Special Issue: Health Benefits of Meditation
OBM Integrative and Complementary Medicine
2018, volume 3, issue 2
doi:10.21926/obm.icm.1802007
Received: April 4, 2018
Accepted: May 7, 2018
Published: May 16, 2018
Abstract
Objective: Mindfulness-based interventions (MBIs) have shown promise in cultivating resilience
and are widely accepted as efficacious in the treatment of a range of psychological disorders.
This paper explores the feasibility of a mindful-awareness and resilience skills training (MARST)
program to enhance mindfulness and resilience, as a means of increasing psychological
well-being and alleviating burnout and compassion fatigue in human service professionals.
Method: In this randomised control trial, 46 human service professionals were randomly
allocated to either a MARST group or to a no intervention, control group.
Results: Multivariate analysis of covariance (MANCOVA), with pre-test scores as the covariates,
revealed that the MARST intervention resulted in significant improvements in mindfulness,
resilience, compassion satisfaction, and psychological well-being, and significant reductions in
burnout and compassion fatigue; at post-intervention. These results were maintained at one
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month follow-up, with the exception of compassion satisfaction which was non-significant.
Mediation analysis using a bootstrap resampling method indicated that mindfulness fully
mediated changes in resilience and psychological well-being, as a result of the MARST
intervention. Self-reported reductions in burnout following the intervention were mediated by
mindfulness and resilience, and decreased compassion fatigue was mediated by resilience.
Conclusions: The results of this study suggest that the MARST program may assist in developing
resilience and reduce burnout and compassion fatigue in human service professionals. The
study also provides evidence for the potential of mindfulness-based approaches to enhance
resilience.
Keywords:
Resilience; mindfulness; compassion fatigue; burnout; psychological well-being
Key Points:
1. Human service professionals are at risk of compassion fatigue and burnout.
2. Strategies that cultivate resilience may ameliorate the development of these conditions.
3. Mindfulness-based interventions have been shown to build resilience.
4. MARST may assist in developing resilience and reduce burnout and compassion fatigue in
human service professionals.
5. The observed change in resilience was mediated by mindfulness.
6. The change in compassion fatigue was mediated by resilience and mindfulness.
1. Introduction
Over the past two decades, research has demonstrated that prolonged exposure to the pain and
suffering of others may have deleterious effects on psychological well-being and functioning [1, 2].
Evidence also suggests that those who work with individuals with mental illness, addiction, social
deprivation, and trauma may suffer similar and often debilitating consequences [3-5]. As an
occupational group, human service professionals are concerned with the intervention and
empowerment of clinical and otherwise vulnerable social populations. As a result, practitioners are
routinely confronted with the psychological distress, emotional pain and traumatic recollections of
the individuals with whom they work [6]. Indeed, researchers who have examined the occupational
hazards of the human services have stressed that the process of caring itself, may come at significant
personal and psychological costs [4, 7].
The “cost of caring” was first described by Figley [8] who identified compassion fatigue (or
secondary traumatic stress) as the potential consequence of bearing witness to the suffering of
others. Defined as a state of tension and preoccupation with the traumatised client, compassion
fatigue describes a syndrome which often parallels the symptoms of post-traumatic stress disorder
(PTSD[4]). Human service professionals who experience compassion fatigue are also at an increased
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risk of developing psychological conditions, such as mood and anxiety disorders [9]; substance
dependence [10]; eating disorders [11]; suicide [12]; and clinician burnout [4].
Burnout refers to a multifaceted work-related disorder which occurs when professionals have
insufficient resources to handle excessive occupational demands [13]. Those affected describe
feelings of being over-extended, fatigued, and depleted; attitudes of negativity and cynicism; and a
reduced sense of accomplishment [14]. Burnout among human service professionals is also
considered to contribute to a number of adverse organisational consequences including; increased
staff turnover and absenteeism, unproductive work behaviours, and reduced job-satisfaction [15,
16]. Therefore, practitioner-focused research has recognised the need to understand the factors
which safeguard clinician mental health and explain why some professionals develop these
conditions, while others do not.
This growing interest in resilience represents a shift from the traditional focus on
psychopathology, to an emphasis on the protective factors which promote a healthy response to
stress [17]. Although a universal definition does not exist, resilience is considered an individual’s
capacity to overcome adversities that would otherwise be expected to have negative consequences
[18]. The development of resilience may serve to ameliorate or buffer the impact of occupational
stressors and protect clinicians from instances of burnout, compassion fatigue, and mental illness
[19, 20]. Furthermore, contemporary research suggests that while some individuals may possess an
innate resilience, others have learned to develop and maintain a high degree of resilience through
experience and learning [21]. Therein presents the opportunity for clinicians to identify means to
cultivate and replenish resilience, in order to enhance psychological well-being.
Of the factors thought to contribute to resilience, mindfulness has increasingly gained attention in
recent years [22-24]. Conceptualised as an intentional state of awareness, mindfulness concerns the
process of bringing one’s attention to the present moment, in a non-judgmental and accepting
manner [25]. When contemplating the potential benefits of mindfulness, Richardson [26] argued that
a willingness to attend to unpleasant stimuli and events might encourage growth and adaptive
reintegration; elements considered fundamental to resilience [27, 28]. Contemporary research
appears to support this assertion with positive correlations found between mindfulness and
resilience [29]; distress tolerance [30], emotion regulation skills [31], and psychological flexibility [32].
Accordingly, various psychotherapeutic interventions incorporate a significant mindfulness
component and are widely accepted as effective in the treatment of a range of psychological
conditions [33, 34].
Mindfulness-based interventions (MBIs) have demonstrated some value in increasing resilience
[35, 36], preventing burnout and compassion fatigue [37], and fostering psychological well-being [34,
38]. Shapiro et al. [39] conducted one such study, using a randomised-controlled trial to assess an
eight week mindfulness-based stress reduction program (MBSR; [25]) in human service professionals.
Whilst the results demonstrated preliminary evidence for the potential of mindfulness interventions
to reduce work-related stress and burnout among human service professionals, a small sample size
limited the generalisability of these results. Additionally, this work did not consider resilience or
other factors that might mediate treatment outcomes.
Several authors have called for the appropriate analysis of the mechanisms of change within such
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programs, rather than simply reporting variations in symptomology [40, 41]. This issue is particularly
salient in studies of MBIs as mindfulness practices are seldom used as a stand-alone intervention. As
a result, it is often not possible to infer whether the beneficial outcomes of MBIs are in fact due to
increased levels of mindfulness or other simultaneous therapeutic elements [42]. Investigating the
mediators of interventions that target burnout and compassion fatigue may also allow an assessment
of how such interventions are effective, and how they may be improved.
1.1 Aims and Hypotheses
The primary aim of this study was to examine the efficacy of a mindful-awareness and resilience
skills training (MARST) program to enhance mindfulness and resilience, as a means of increasing
psychological well-being and compassion satisfaction, and alleviating burnout and compassion
fatigue in human service professionals. Furthermore, in response to calls for research of this nature
to address the factors which mediate experimental outcomes, the current research investigates the
indirect effect of the MARST intervention on burnout and compassion fatigue, through changes in
mindfulness and resilience.
On the basis of the presented research, the following hypotheses were formulated. Hypothesis
one, pertaining to short-term intervention effects, predicts that at post intervention the MARST
group will report significantly higher levels of mindfulness, resilience, compassion satisfaction and
psychological well-being, and significantly lower levels of burnout and compassion fatigue, compared
to the control group. Hypothesis two predicted that the intervention outcomes outlined in the first
hypothesis will be maintained at one month post-intervention. Hypothesis three, predicted that
increased levels of resilience and psychological well-being, as a result of participation in the MARST
group, will be mediated by increased mindfulness. Hypothesis four predicted that reductions in
compassion fatigue, as a result of participation in the MARST group, will be mediated by increased
mindfulness and resilience. Hypothesis five predicted that reductions in burnout, as a result of
participation in the MARST group, will be mediated by increased mindfulness and resilience. That is,
mindfulness and resilience will emerge as significant unique mediators, and together as a group of
mediators, of the impact of the MARST intervention on compassion fatigue and burnout.
2. Method
2.1 Participants
A sample of 50 human service professionals was recruited from a not-for-profit community and
family services organisation. The professionals provide a range of services for children, young people
and families including: counselling, family intervention and support, live-in home services for
mothers and babies, and community engagement and development programs. Of the initial sample,
46 participants returned baseline data and met inclusion criteria (i.e., >18 years of age, working with
clients directly and not engaged in professional psychological intervention at the time of
recruitment). Table 1 presents the participant demographics.
The majority of participants reported that they did not practice mindfulness meditation at the
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time of recruitment (n = 25; 54.3%) and had not previously attended training in mindfulness
meditation (n = 26; 56.5%). Based on random assignment, a total of 25 participants in the MARST
group and 21 participants in the control group completed baseline and post-intervention data. A
total of 41 human service professionals completed one month follow-up measurement, comprised of
23 and 18 participants from the MARST and control groups, respectively.
Table 1 Participant demographics.
Variables
N
%
Age
Gender
Education
Employment status
24 - 64
(M = 42, SD = 10.58)
Male
Female
Bachelor
Postgraduate
Other
Full-Time
Part-Time
46
9
37
22
14
10
36
10
100
19.6
80.4
47.8
30.4
21.7
78.3
21.7
2.2 Materials
Demographic Questions. Participants were asked to supply demographic information for the
purpose of describing the sample. Participants indicated their age, gender, education, employment
status, involvement in current meditative practices, and participation in past mindfulness-based
training programs or retreats.
Mindfulness. Self-reported mindfulness was assessed with the Five Facet Mindfulness
Questionnaire (FFMQ; [43]). The FFMQ is a 39-item measure of five distinct skill areas cultivated by
the practice of mindfulness: observing, describing, acting with awareness, non-reactivity, and
non-judging. Items are measured on 5-point Likert scales (1 = never or very rarely true to 5 = very
often or always true). The FFMQ identifies five subscale scores and a total FFMQ; with higher scores
reflecting greater mindfulness [43]. Research has shown the FFMQ to be a valid and reliable measure
of the skills cultivated by the practice of mindfulness, both in long-term meditators and in novices
[44]. The measure has shown adequate internal consistency, with Cronbach’s alpha coefficients
ranging from .73 for non-reactivity to .91 for describing [45]. In the present study, the Cronbach
alpha value for total FFMQ was .87.
Resilience. The Resilience Quotient Scale (RQS; [46]) is a 60-item measure of an individual’s level
of resilience, based on seven factors of resilience: emotion regulation, impulse control, causal
analysis, self-efficacy, realistic optimism, empathy, and reaching out. Participants respond on 6-point
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scales (1 = not at all true to 5 = very true or often true, and 6 = don’t know) yielding total scores across
each of the seven factors and an overall resilience quotient (RQ). Higher scores on each of the scales
indicate a higher endorsement of that factor of resilience and a higher RQ indicated a higher level of
resilience. The RQS is a valid and psychometrically sound instrument with established evidence of
criterion and predictive validity [46]. Adequate internal consistency of the RQS was demonstrated in
the present study with a Cronbach’s alpha of .83.
Compassion Fatigue, Burnout and Compassion Satisfaction. The Professional Quality of Life Scale
- Fifth Edition (ProQOL-V; [47]) is a 30-item measure of compassion fatigue, burn-out and compassion
satisfaction in those who work with traumatised populations. Compassion fatigue has been defined
as a psychological syndrome resulting from work-related secondary exposure to extremely stressful
events [48]. Items are measured on a 5-point scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often and
5 = very often) with the three distinct constructs yielding independent totals. Validity evidence for
the ProQOL is based on several studies indicating that practitioners with higher levels of compassion
fatigue or burnout perform in a manner consistent with the construct [16, 49]. The Cronbach’s alpha
values reported by Stamm [47] for the three scales were .82 for compassion satisfaction, .71 for
burnout, and .78 for compassion fatigue. The current study identified adequate internal consistency
with mean values for Cronbach’s alpha as .88 for compassion satisfaction, .83 for compassion fatigue,
and .89 for burnout.
Psychological Well-Being. The General Well-Being Schedule (GWS; [50]) is an 18-item
self-reported measure of psychological well-being and distress. The instrument addresses six
dimensions of subjective well-being including: depression, anxiety, positive well-being, self-control,
vitality and general health. As several items are reverse scored (i.e., items 1, 3, 6, 7, 9, 11, 15, and 16),
14 is subtracted from the total score, yielding a total range of scores from 0 to 110; lower scores
represent distress and higher scores representing greater well-being [50]. The GWB is a valid and
psychometrically sound instrument with evidence of test-rest reliability and high internal consistency
[47, 51]. The total GWB mean value of Cronbach’s alpha in the current study was .73.
2.3 Procedure
This research was approved by the affiliated university ethics committee and gatekeeper approval
was obtained from the relevant not-for-profit organisation. The recruitment process commenced
with an invitation to attend an information seminar delivered by the principal investigator. Following
the presentation, participants expressing interest in the study were provided with an explanatory
statement and requested to complete the battery of questionnaires.
Participants were assigned to the MARST or control groups on the basis of an unpredictable,
chance (random) process, using simple (unrestricted) randomisation. This process involved the
generation of a table of random numbers and the authors assigned participants to the trial groups.
The table of random numbers was generated using the random number generator from
http://stattrek.com/statistics/random-number-generator.aspx. Prior to disbursement, 50
pre-intervention questionnaire packages were assigned a number based on the table of random
numbers to allocate prospective participants to either the MARST group or the control group. Of the
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50 participants who volunteered for the study, a total of 25 MARST group, and 21 control group
participants returned completed pre-intervention questionnaires. Repeat data were obtained from
the intervention and control groups at post-intervention and at one month follow-up. Minimal
attrition was realised at one month follow-up in both groups, due to absences as a result of sick and
annual leave, time pressures and conflicting organisational commitments. As a result, 41 human
service professionals completed one month follow-up measurement, comprised of 23 MARST group
and 18 control group participants. The schedule of the research design and measurement of the
MARST and control groups is depicted in Figure 1.
Figure 1 Schedule of research design and measurement for the mindful-awareness and
resilience skills training group and the control group.
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Mindful-Awareness and Resilience Skills Training (MARST). The MARST intervention involved
three days (approximately eight hours) of training over three consecutive weeks. The program was
facilitated by a clinical psychologist with some 20 years of experience utilising mindfulness-based
approaches and training in mindfulness. The two co-facilitators had received training in
mindfulness-based interventions as part of a Master’s Degree in Clinical Psychology and also regularly
practiced formal meditation.
The MARST intervention teaches a set of core skills and strategies derived from the principles
theoretically underpinning mindfulness-based cognitive therapy (MBCT; [52]) , mindfulness-based
stress reduction (MBSR; [25]) and mindful self-compassion (MSC; [53]), and integrates some of the
basic principles of cognitive behavioural therapy (CBT).
The mindfulness component of the program included training in formal (i.e., mindfulness of the
breathe meditation, body-scan meditation and compassion meditation) and informal mindfulness
practice (i.e., mindful walking, eating and posture exercises) with periods of extended silence.
Approximately one hour of the program was devoted to teaching the basic cognitive behavioural ABC
model however MARST aims to assist individuals to make changes in a different way to CBT. While
CBT attempts to change unhelpful behaviour by modifying people's non-resilient thinking, MARST
aims to assist individuals to learn to develop control over the processes that maintain the
non-resilient thoughts through mindfulness training. Essentially, MARST aims to change the process
of thinking, not just the content of the thoughts. Table 2 presents an overview of the structure and
content of the MARST program.
Table 2 Overview of content of mindful-awareness and resilience skills training program.
Training Day
Content
Week 1 - Day One
The MARST course objectives, content and structure.
Psychoeducation on resilience and the cognitive-behavioural
model.
Introduction to the ABC model, strategies to develop resilient
thinking.
Introduction and practice of mindfulness and
mindful-awareness skills.
Home activities
Week 2 - Day Two
Review of home activities
Introduction to mindfulness compassion meditation and
mindful-awareness integration tool.
Practice of formal and informal mindfulness meditation and
exercises.
Practice applying the mindful-awareness integration tool.
Home activities
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Week 3 - Day Three
Review of home activities
Introduction to situational awareness and the map of
mindful-awareness.
Experiential exercises to develop resilient thinking.
Practice of formal and informal mindfulness meditation and
exercises.
Practice applying the mindful-awareness integration tool.
2.4 Design
A randomisation process was employed with one independent variable of two levels; the
mindful-awareness and resilience skills training group (MARST) and no intervention (Control). The
dependent variables for the study were resilience, mindfulness, compassion fatigue, burn-out and
compassion satisfaction, and psychological well-being.
To determine group differences, multivariate analysis of covariance (MANCOVAs) were used to
compare short-term (i.e., baseline to post intervention) and follow-up (i.e., baseline to one month
follow-up) differences on each of the dependent variables; in combination with subsequent
univariate analysis of variance (ANOVAs). In accordance with relevant research, baseline data and age
were incorporated as covariates [54, 55]. Next, the study incorporated a bootstrapping resampling
procedure to explore the role of mindfulness in mediating the impact of participation in the MARST
program on resilience and psychological well-being. Finally, multiple mediation analysis was
conducted to consider the role of mindfulness and resilience, in mediating changes in compassion
fatigue and burnout as a function of the MARST intervention.
3. Results
3.1 Multivariate Analysis of Covariance
Short Term Treatment Effects. A one-way between-groups MANCOVA was performed to
investigate group differences for the six aforementioned dependent variables, immediately following
the MARST intervention (i.e., post-intervention). The analysis included one independent variable of
two levels; the MARST group and control (no intervention) group. Baseline scores on the dependent
variables and participant age were used as covariates, to control for individual differences and reduce
unexplained variance.
Preliminary checks were conducted to test assumptions of multivariate normality, linearity,
univariate and multivariate outliers, and multicollinearity, with no violations noted. Covariates were
judged to be adequately reliable for covariance analysis. A non-significant Box’s M indicated that the
homogeneity of variance-covariance matrix assumption had not been violated. After adjusting for
baseline scores and age, a significant multivariate main effect was found for group, F (6, 32) = 2.94, p
<.05, Pillai’s Trace = .36;
2 = .36, power = .83.
Given the significant multivariate main effect, univariate analysis of variance (ANOVAs) for each
dependent variable was assessed. Levene’s test of homogeneity was non-significant across all
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dependent variables, indicating the data set had equal variance across the sample. The results
revealed significant univariate effects for group across the dependent variables; mindfulness, F(1, 44)
= 5.92, p <.05,
2 =.14 ; resilience, F(1, 44) = 7.66, p <.01,
2 =.17; psychological well-being, F(1, 44) =
7.88, p <.01,
2 =.18; compassion satisfaction, F(1, 44) = 6.86, p <.05,
2 =.16; burnout, F(1, 44) =
12.19, p = .001,
2 =.25; and compassion fatigue, F(1, 44) = 12.46, p =.001,
2 = .25.
Table 3 displays the means and standard deviations for the dependent variables between groups,
at baseline, post-intervention and one month follow-up. As noted in Table 3, the MARST group
reported significantly higher levels of mindfulness, resilience, psychological well-being, and
compassion satisfaction post-intervention, compared to the control group. Furthermore, the MARST
group reported significantly lower levels of burnout and compassion fatigue, when compared with
the control group immediately following the intervention. Thus, the results suggest that hypothesis
one was supported.
Follow-up Treatment Effects. A one-way between-groups MANCOVA was performed to
investigate group differences for the dependent variables, one month following the MARST
intervention (i.e., follow up effects). The analysis included group allocation as the independent
variable and the six dependent variables. Baseline scores on the dependent variables and participant
age were used as covariates as per previous research [54, 55].
Results of evaluation of assumptions of normality, linearity, univariate and multivariate outliers,
reliability of covariates, and multicollinearity were considered satisfactory. Results showed a
significant multivariate main effect was found for group, F (6, 27) = 2.92, p <.05, Pillai’s Trace = .39;
2
= .39, power = .81.
Given the significant multivariate main effect, univariate analyses of variance (ANOVAs) for each
dependent variable were examined. Levene’s test was non-significant across all dependent variables,
indicating homogeneity of variance. The results revealed significant univariate effects for group
across the following dependent variables; mindfulness, F(1, 39) = 6.84, p <.05,
2 =.18; resilience, F(1,
39) = 16.75, p <.001,
2 =.34; psychological well-being, F(1, 39) = 5.19, p <.05,
2 =.14; burnout, F(1,
39) = 8.55, p <.01,
2 =.21; and compassion fatigue, F(1, 39) = 5.87, p <.05,
2 = .16. No significant
difference was found between groups on measures of compassion satisfaction at one month
follow-up, F(1, 39) = 18.73, p >.05,
2 =.02.
As shown in Table 3, the MARST group reported significantly higher levels of mindfulness,
resilience and psychological well-being and significantly lower levels of burnout and compassion
fatigue at one month follow-up compared to the control group. As differences in compassion
satisfaction between groups were not statistically significant, hypothesis two was partially supported.
Table 3 Means and Standard Deviations of the Dependent Variables between Groups at
Pre, Post and Follow-up.
MARST (n = 23)
Control (n = 18)
Variable
Pre
Post
Follow-Up
Pre
Post
Follow-Up
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
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Mindfulness
138.60
(28.44)
149.44
(20.12)
154.04*
(21.82)
135.14
(20.69)
136.19
(22.53)
139.28
(21.25)
Resilience
67.15
(9.32)
70.17
(6.87)
74.30***
(7.01)
66.11
(9.76)
64.37
(12.21)
64.72
(11.19)
Psychological
Well-being
70.96
(16.69)
80.92
(11.20)
80.22*
(12.66)
76.14
(14.84)
73.62
(13.72)
73.83
(15.39)
Compassion
Satisfaction
41.04
(6.24)
42.12
(4.72)
42.35
(5.60)
40.38
(5.94)
38.52
(7.25)
39.61
(7.78)
Burnout
20.20
(5.45)
18.20
(3.42)
18.09**
(4.34)
20.00
(6.12)
21.62
(6.38)
21.67
(6.49)
Compassion
Fatigue
18.56
(4.45)
17.68
(3.59)
17.17*
(3.71)
18.90
(5.21)
21.76
(6.36)
20.00
(7.57)
Note. * p<.05, ** p<.01, ***p<.001. MARST = mindful-awareness and resilience skills training
(treatment group).
3.2 Simple Mediation Analysis: Bootstrap Resampling
Mediation analysis was conducted using a bootstrap resampling method which provides a formal
significance test of the indirect effect (ab product; [56]).This procedure is a non-parametric
multivariate extension of the Sobel test, recommended with studies of smaller sample sizes (i.e., n <
80) as it is considered to have higher power with reasonably controlled Type I error rate [57].
Within the current study, bootstrapping was accomplished by taking 5000 samples of the original
sample size at post-intervention (n = 46) and computing the ab product for the mediator in each
sample [56]. The point estimate of the indirect effect is the mean of the ab product over 5000
samples and the procedure yields a 95% confidence interval [56, 57]. If the upper and lower limits of
the confidence interval do not contain zero, the null hypothesis may be rejected and the indirect
effect is significant [56].
The Indirect Effect of the MARST Intervention on Resilience, through Mindfulness. Mediation
analysis was conducted to assess mindfulness as a potential mediator of improvements in resilience
as a result of participation in the MARST intervention. The analysis included a dichotomous
independent (predictor) variable; participation in the MARST group and no intervention (control)
group, post-intervention mindfulness as the mediator, and post-intervention resilience as the
dependent variable. As per previous research, baseline covariates where included in the analysis to
increase the efficacy of estimating the direct and indirect effects [54, 58]. Furthermore, due to the
dichotomous nature of the independent variable, regression coefficients were reported in
unstandardised form [59]. The analysis was conducted using SPSS macros for mediation analysis
provided online at http://www.afhayes.com/spss-sas-and-mplus-macros-and-code.html#indirect.
Results indicated that participation in the MARST group (as opposed to the control group) was
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positively related to resilience (B = 5.00, SEB = 1.66, t(44) = 3.00, p <.01). It was also found that
participation in the MARST group was positively related to increased mindfulness (B = 11.16, SEB =
4.35, t(44) = 2.56, p <.05). Lastly, results indicated that the mediator, mindfulness, was positively
associated with resilience (B = .24, SEB = .05, t (44) = 5.11, p <.001). Figure 2 displays the mediation
results and unstandardised regression coefficients.
Figure 2 Indirect effect of MARST intervention on resilience, through mindfulness. Note. *
p<.05, ** p<.01, ***p<.001. a = independent variable to mediator, b = mediator to
dependent variable, c = total effect, c’ = direct (partial) effect.
As both the a-path and b-path were significant, mediation analysis based on 5000 bootstrapped
samples using bias-corrected 95% confidence estimates was conducted [56, 57]. Results confirmed
the significant mediating role of mindfulness in the relationship between participation in the MARST
group and resilience (B = 2.70, CI = .69 to 5.91). In addition, the results indicated that the direct effect
of the MARST program on resilience became non-significant when controlling for the effects of
mindfulness (B = 2.34, SEB = 1.41, t(44) = 6.39, p >.05), thus suggesting full mediation and support of
hypothesis three.
The Indirect Effect of the MARST Intervention on Psychological Well-Being, through Mindfulness.
Mediation analysis was conducted to assess whether improvements in psychological well-being as a
result of participation in the MARST group, were mediated by increased mindfulness. Thus, the
analysis included the independent variable of two levels; participation in the MARST group and no
intervention (control) group, post-intervention mindfulness as the mediator, post-intervention
psychological well-being as the dependent variable, and baseline scores as the covariates. First it was
found that participation in the MARST group (as opposed to the control group) was positively related
to psychological well-being (B = 8.76, SEB = 3.56, t(44) = 2.46, p <.05). It was then found that
participation in the MARST group was positively related to increased mindfulness (B = 10.75, SEB =
4.61, t(44) = 2.33, p <.05). Next, results indicated that the mediator, mindfulness, was positively
associated with psychological well-being (B = .38, SEB = .10, t(44) = 3.64, p <.001).
Mediation analysis using the bootstrapping method with bias-corrected confidence estimates was
conducted and a 95% confidence interval of the indirect effect was obtained (5000 samples; [56, 57]).
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Results of the mediation analysis confirmed the significant mediating role of mindfulness in the
relationship between participation in the MARST group and psychological well-being (B = 4.07, CI =
.61 to 8.43). The results also found that the direct effect of the MARST program on psychological
well-being became non-significant when controlling for the effects of mindfulness (B = 4.66, SEB =
3.33, t(44) = 1.40, p >.05); indicating full mediation and support of hypothesis three. Figure 3 displays
the results of the mediation analysis and unstandardised regression coefficients.
Figure 3 Indirect effect of MARST intervention on psychological well-being, through
mindfulness. Note. * p<.05, ** p<.01, ***p<.001. a = independent variable to mediator, b
= mediator to dependent variable, c = total effect, c’ = direct (partial) effect.
3.3 Multiple Mediation Analysis: Bootstrap Resampling
The Indirect Effect of the MARST Intervention on Compassion Fatigue, through Mindfulness and
Resilience. To explore hypothesis four, that changes in mindfulness and resilience will mediate the
impact of the MARST intervention on compassion fatigue, a bootstrapping resampling procedure that
allows the simultaneous examination of multiple mediators was conducted [41]. In the current
analysis, changes in mindfulness and resilience were entered as candidate mediators of the effects of
participation in the MARST group (as opposed to the control group) on changes in compassion
fatigue.
The results indicated that participation in the MARST group was negatively related to compassion
fatigue, (B = -3.97, SEB = 1.50, t(44) = -2.65, p <.05). It was also found that participation in the MARST
group was positively related to increased mindfulness (B = 11.16, SEB = 4.35, t(44) = 2.56, p <.05) and
resilience (B = 5.00, SEB = 1.66, t(44) = 3.00, p <.01). Lastly, it was found that resilience was negatively
associated with compassion fatigue (B = -.46, SEB = .15, t(44) = -3.13, p <.01), however changes in
mindfulness were non-significant (B = -.04, SEB = .06, t(44) = -.63, p >.05). Figure 4 displays the results
and unstandardised regression coefficients.
As the a-path and b-path were significant for the mediator, resilience, bootstrapping with
bias-corrected confidence estimates was subsequently conducted with a 95% confidence interval of
the indirect effect (5000 samples; [41]). Results of the mediation analysis confirmed the role of
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resilience in mediating the relationship between participation in the MARST group and reductions in
compassion fatigue (B = -2.26, CI = -4.65 to -.83). Furthermore, the results indicated that the direct
effect of the MARST group on compassion fatigue became non-significant when controlling for the
effects of the mediators (B = -1.26, SEB = 1.38, t(44) = -.91, p = .37). However, as only resilience
emerged as a unique individual mediator (specific indirect effect), hypothesis four was partially
supported.
Figure 4 Mediation analysis of mindfulness and resilience as candidate mediators of the
MARST intervention’s effects on changes in compassion fatigue. Note. * p<.05, ** p<.01,
***p<.001.
The Indirect Effect of the MARST Intervention on Burnout, through Mindfulness and Resilience.
Changes in mindfulness and resilience were entered as candidate mediators of the effects of group
participation (MARST intervention vs. control) on changes in burnout. The results indicated that
participation in the MARST group was negatively related to burnout, (B = -3.16, SEB = 1.35, t(44) =
-2.35, p <.05). It was also found that participation in the MARST group was positively related to
increased mindfulness (B = 11.16, SEB = 4.35, t(44) = 2.56, p <.05) and resilience (B = 5.00, SEB = 1.66,
t(44) = 3.00, p <.01). Next, it was found that the mediators, mindfulness (B = -.14, SEB = .05, t(44) =
-3.05, p <.01) and resilience (B = -.26, SEB = .12, t(44) = -2.24, p <.05), were negatively associated with
burnout.
Bootstrapping with bias-corrected confidence estimates was therefore conducted with a 95%
confidence interval of the indirect effect (with 5000 samples; [41]). Results of the mediation analysis
confirmed the independent mediating roles (specific indirect effects) of mindfulness (B = -1.48, CI =
-3.82 to -.21) and resilience (B = -1.32, CI = -2.80 to -.25) in the relationship between MARST
participation and reductions in burnout. Additionally, the results indicated that the direct effect of
the MARST program on burnout became non-significant when controlling for the effects of the
mediators as a group (B = -.31, SEB = 1.10, t(44) = -.28, p >.05), subsequently demonstrating full
mediation and support of hypothesis five. Figure 5 displays the results of the mediation analysis and
unstandardised regression coefficients.
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Figure 5 Mediation analysis of mindfulness and resilience as candidate mediators of the
MARST intervention’s effects on changes in burnout. Note. * p<.05, ** p<.01, ***p<.001.
4. Discussion
To the authors’ knowledge, this was the first study to implement and evaluate a brief intensive
mindfulness based program to cultivate resilience and mindfulness, as a means of increasing
psychological well-being and reducing burnout and compassion fatigue, in human service
professionals. To achieve this, the study examined the efficacy of a mindful-awareness and resilience
skills training (MARST) program and sought to determine if treatment outcomes were mediated by
increased levels of mindfulness and/or resilience.
The first and second hypotheses predicted that compared to the control group, MARST
participants would report significantly higher levels of mindfulness, resilience, compassion
satisfaction and psychological well-being, and significantly lower levels of burnout and compassion
fatigue; immediately after and one month following the intervention. These effects were found
across each of the variables, at both time intervals, with the exception of compassion satisfaction
which failed to sustain self-reported improvements.
In agreement with authors that describe resilience as a dynamic and modifiable construct [20] this
finding suggests that clinician resilience is indeed amenable to change and responsive to educational
and cognitive transformational processes. The results also corroborate findings which suggest that
mindfulness-based interventions (MBIs) may effectively replenish resilience [36, 60] reduce states of
burnout and traumatic stress [37, 39], and improve psychological well-being [34, 38].
Notwithstanding the non-significant finding of compassion satisfaction at follow up, the MARST
program was effective in producing sustainable outcomes over time.
Although practitioners may require additional or supplementary intervention to ensure
compassion satisfaction is maintained, improvements in mindfulness and resilience seemed to
accumulate and develop with time. This result was indicated by larger proportions of variance
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attributable to the MARST group at one-month follow up; resilience (post = 17%; one month follow
up = 34%) and mindfulness (post = 14%; one month follow up = 18%). In a similar observation,
Pidgeon et al. [60] predicted that the development of mindfulness and resilience may mature with
time, following an opportunity to practice the skills learnt. Should this assertion be justified, one
might conceptualise growth in these areas as following a ‘snowball effect’, based on the maintenance
of skills triggered by this brief intensive intervention.
Hypothesis three was supported and indicated that self-reported gains in resilience and
psychological well-being, following participation in MARST, were fully mediated by increased
mindfulness. This finding exemplifies the ability of human service professionals to build resilience and
enhance their psychological well-being through interventions and practices which increase
mindfulness. The mediating effect of mindfulness in influencing change in resiliency and
psychological well-being is also consistent with previous studies which suggest that mindfulness is
related to the development of skills that form the fundamental elements of resilience [27, 28].
Hypothesis four and five predicted that reductions in compassion fatigue and burnout, as a result
of MARST participation, would be mediated by increased mindfulness and resilience. Although
resilience was found to mediate the relation between MARST and compassion fatigue, mindfulness
was not a significant mediator of this effect. Both mindfulness and resilience were however found to
mediate the relationship between MARST and self-reported burnout.
Interestingly, this result may add to the assumed path by which MARST influenced its outcomes.
While mindfulness did not directly mediate MARST’s impact on compassion fatigue, increased
mindfulness was found to mediate the relationship between the intervention and resilience, which in
turn mediated change in compassion fatigue. This may suggest that participation in MARST led to
increased levels of mindfulness, which resulted in increased resilience, which subsequently impacted
upon reductions in compassion fatigue. Conversely, when considering clinical interventions for
burnout among professionals, both mindfulness and resilience appear to be important unique
therapeutic targets.
The noted mediation effect supports research which highlights the importance of personal
qualities and characteristics in safeguarding against compassion fatigue and burnout [48]. According
to third wave resilience research, increased mindfulness may provide the positive growth and
cognitive transformational processes required to replenish resiliency factors [26]. The development
of resilience would in turn safeguard professionals against the repeated exposure to traumatic
material inherent to the human service professions [19]. Further to this, developing skills to cultivate
mindfulness and replenish resilience may serve to protect clinicians from mental exhaustion and
workplace disengagement, by providing additional resources and restoring the balance with
occupational demands [13].
Nevertheless, a number of limitations must be considered when examining these results. First,
attrition contributed to the small sample size which limits the generalisability of the findings. The
sample was predominantly female, well-educated and recruited from the same not-for-profit
organisation. A large percentage of participants also reported prior experience with mindfulness.
Whilst exposure to mindfulness training among human service professionals is to be expected, the
research may have appealed more so to those individuals that are open to this intervention. Future
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studies should include a larger sample recruited from more diverse educational and socioeconomic
backgrounds, and multiple human service employers. The current study also involved a no
intervention control and future studies would benefit from the use of an alternative intervention or
waitlist control. In light of findings that mindfulness and resiliency skills may develop with time,
additional longitudinal measurement may also assist researchers to examine this phenomenon
further.
There are several implications of this work for future research. The findings contribute to an
understanding of the factors which influence the development and maintenance of resilience, in
addition to means of alleviating burnout and compassion fatigue among human service professionals.
The study provides preliminary evidence for MARST as a brief, intensive intervention that may bolster
psychological resources and safeguard against known job-related risk factors, prevalent among this
occupational group. Results suggest that interventions which effectively increase mindfulness among
human service professionals may result in the added benefits of increased resilience and subsequent
reductions in instances of burnout and compassion fatigue. Although the findings are to be
interpreted with some caution given the limitations of the study, they highlight the value of
simultaneously examining multiple variables as mediators of the effects of mindfulness-based
interventions.
Acknowledgments
The authors gratefully acknowledge the participation and support of Francis Klaassen and the staff
at Mercy Family Services, without which the present study could not have been completed. The
authors would also like to thank Breeana Souter for her assistance in co-facilitating the MARST
program.
Author Contributions
Both authors contributed to the design and implementation of the research, to the analysis of the
results and to the writing of the manuscript.
Funding
This research was financially supported by Mercy Family Services.
Competing Interests
The authors have declared that no competing interests exist.
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