A Systematic Review and Meta-analysis of the Impact of Mindfulness-Based Interventions on the Well-Being of Healthcare Professionals

Abstract

Efforts to improve the well-being of healthcare professionals include mindfulness-based interventions (MBIs). To understand the value of such initiatives, we conducted a systematic review and meta-analysis of empirical studies pertaining to the use of MBIs with healthcare professionals. Databases were reviewed from the start of records to January 2016 (PROSPERO registration number: CRD42016032899). Eligibility criteria included empirical analyses of well-being outcomes acquired in relation to MBIs. Forty-one papers met the eligibility criteria, consisting of a total of 2101 participants. Studies were examined for two broad classes of well-being outcomes: (a) “negative” mental health measures such as anxiety, depression, and stress; (b) “positive” indices of well-being, such as life satisfaction, together with outcomes associated with well-being, such as emotional intelligence. MBIs were generally associated with positive outcomes in relation to most measures (albeit with moderate effect sizes), and mindfulness does appear to improve the well-being of healthcare professionals. However, the quality of the studies was inconsistent, so further research is needed, particularly high-quality randomised control trials.

Full text

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
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Title
A systematic review and meta-analysis of the impact of mindfulness-based interventions on
the wellbeing of healthcare professionals
Mindfulness
Note: This article may not exactly replicate the final version published in Mindfulness. It is
not the copy of record.
Authors
Tim Lomas1, Juan Carlos Medina2, Itai Ivtzan1, Silke Rupprecht3, Francisco Eiroa-Orosa2†
1 School of Psychology, University of East London, Arthur Edwards Building, Water Lane,
London, E15 4LZ, United Kingdom
2 Section of Personality, Evaluation and Psychological Treatment, Departament of Clinical
Psychology and Psychobiology Faculty of Psychology, University of Barcelona, Passeig de la
Vall d'Hebron, 171, 08035 Barcelona, Spain
3 Leuphana University, Scharnhorststraße 1, 21335 Lüneburg, Germany
† Author responsible for correspondence:
Email: fjeiroa@gmail.com

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A systematic review and meta-analysis of the impact of mindfulness-based interventions
on the wellbeing of healthcare professionals.
Abstract
Efforts to improve the well-being of healthcare professionals include mindfulness-based
interventions (MBIs). To understand the value of such initiatives, we conducted a systematic
review and meta-analysis of empirical studies pertaining to the use of MBIs with healthcare
professionals. Databases were reviewed from the start of records to January 2016
(PROSPERO registration number: CRD42016032899). Eligibility criteria included empirical
analyses of well-being outcomes acquired in relation to MBIs. Forty-one papers met the
eligibility criteria, consisting of a total of 2101 participants. Studies were examined for two
broad classes of well-being outcomes: (a) “negative” mental health measures such as anxiety,
depression, and stress; (b) “positive” indices of well-being, such as life satisfaction, together
with outcomes associated with well-being, such as emotional intelligence. MBIs were
generally associated with positive outcomes in relation to most measures (albeit with
moderate effect sizes), and mindfulness does appear to improve the well-being of healthcare
professionals. However, the quality of the studies was inconsistent, so further research is
needed, particularly high-quality randomised control trials.
Keywords: mindfulness; meditation; healthcare professionals; meta-analysis.

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A wealth of research has accumulated indicating that healthcare professionals (HCPs) are
liable to a range of mental health issues, including anxiety (Gao et al., 2012), and depression
(Givens & Tjia, 2002). These problems may be particularly acute among HCPs relative to
other professions: a recent survey of over 3,700 public sector workers in the UK found that
staff working for the National Health Service were the most stressed, with 61% reporting
feeling stressed all or most of the time, and 59% stating that their stress is worse this year
than last year (Dudman, Isaac, & Johnson, 2015). These issues represent a significant
problem, obviously for the wellbeing of the HCPs themselves, but also for patients (e.g., the
ability of HCPs to treat them skilfully), and for the healthcare system (e.g., the economic cost
of staff burnout) (Toppinen-Tanner, Ojajärvi, Väänaänen, Kalimo, & Jäppinen, 2005). As
such, efforts are underway to protect against or ameliorate work-related mental health issues
in HCPs. Prominent among such initiatives are programmes based around mindfulness
meditation – mindfulness-based interventions (MBIs) – which is the focus of this review.
Originating in the context of Buddhism around the 5th millennium B.C.E. (Lomas,
2017), mindfulness came to prominence in the West through Kabat-Zinn’s (1982)
Mindfulness-Based Stress Reduction (MBSR) programme for chronic pain. “Mindfulness” is
frequently used to refer to both: (1) a state/quality of mind; and (2) a form of meditation that
enables one to cultivate this particular state/quality. (Meditation is a broad label for mental
activities which share a common focus on training the self-regulation of attention and
awareness, with the goal of enhancing voluntary control of mental processes, thereby
increasing wellbeing (Walsh & Shapiro, 2006).) The most prominent operationalisation of
mindfulness as a state/quality of mind is Kabat-Zinn’s (2003) definition, which constructs it
as “the awareness that arises through paying attention on purpose, in the present moment, and
nonjudgmentally to the unfolding of experience moment by moment” (p.145) The term

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mindfulness is then also deployed for meditation practices which can facilitate this mindful
state/quality of mind.
In theoretical terms, the main significance of mindfulness is that it is thought to
facilitate a meta-cognitive mechanism known as “decentring” – or alternatively
“reperceiving” (Shapiro, Carlson, Astin, & Freedman, 2006) – defined as “the ability to
observe one’s thoughts and feelings as temporary, objective events in the mind, as opposed to
reflections of the self that are necessarily true” (Fresco et al., 2007, p.234). For example, in
Mindfulness-Based Cognitive Therapy (MBCT) – designed to prevent depressive relapse
(Segal, Williams, & Teasdale, 2002) – participants are taught to decentre from their
cognitions, thus helping prevent a “downward spiral” of negative thoughts and worsening
negative affect which could otherwise precipitate relapse. Thus MBCT, and MBIs generally,
involve “retraining awareness” so that people have greater choice in how they relate and
respond to their subjective experience, rather than habitually responding in maladaptive ways
(Chambers, Gullone, & Allen, 2009, p.659). The value of this extends across diverse mental
health issues. For instance, the development of decentring capabilities can help people
tolerate otherwise distressing qualia, which is important given that inability to tolerate such
qualia is regarded as a transdiagnostic factor underlying diverse psychopathologies (Aldao,
Nolen-Hoeksema, & Schweizer, 2010).
MBIs were generally limited to clinical populations initially. However, there has been
increasing use of mindfulness in occupational contexts, not only for staff who may be
suffering with mental health issues, but for workers “in general” (e.g., as a prophylactic
against future issues). This emergent literature has been summarised in a raft of recent
reviews. These include systematic reviews focusing on specific occupations, including
educators (e.g., Emerson et al., 2017; Hwang, Bartlett, Greben, & Hand, 2017; Lomas,
Medina, Ivtzan, Rupprecht, & Eiroa-Orosa, 2017a), social workers (Trowbridge & Mische

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Lawson, 2016), and athletes (Bühlmayer, Birrer, Röthlin, Faude, & Donath, 2017; Noetel,
Ciarrochi, Van Zanden, & Lonsdale, 2017), as well as more all-encompassing reviews, such
as Lomas, Medina, Ivtzan, Rupprecht, Hart, et al. (2017), which included 153 papers across
all occupational spheres. These have been augmented by several meta-analyses of non-
clinical populations of working adults, such as Virgili (2015) and Khoury, Sharma, Rush, and
Fournier (2015). Amidst this general interest in the impact of mindfulness in occupational
settings, there is a burgeoning literature focusing on HCPs specifically. This literature has
already been summarised in a number of systematic reviews. These include reviews focused
on specific sectors and professions, including nurses (Guillaumie, Boiral, & Champagne,
2017), occupational therapists (Luken & Sammons, 2016), mental health professionals
(Rudaz, Twohig, Ong, & Levin, 2017), “hospital providers” (Luken & Sammons, 2016),
medical students (Daya & Hearn, 2017), and healthcare profession students (McConville,
McAleer, & Hahne, 2017), or on specific outcomes, such as empathy and emotional
competency (Lamothe, Rondeau, Malboeuf-Hurtubise, Duval, & Sultan, 2016). There have
also been more general reviews, such as Lomas, Medina, Ivtzan, Rupprecht, and Eiroa-Orosa
(2018), who located 81 studies across all HCP sectors and professions, as well as Eby et al.
(2017), who provided a qualitative review of 67 studies. Such reviews have already offered a
good indication of the value of mindfulness to HCPs, generally showing a beneficial impact
with respect to wellbeing outcomes. However, these reviews have perhaps not revealed the
full potential of mindfulness with regard to HCPs, nor have they necessarily provided a
robust analysis of its utility or of its limits.
With regard to its potential, many studies have limited their focus to mental health,
with a particular focus on specific common disorders such as anxiety and depression (e.g.,
Guillaumie et al., 2017), stress and distress (Daya & Hearn, 2017), as well as employment-
related conditions like burnout (Luken & Sammons, 2016). However, while such outcomes

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are of course important, they do not give the full picture of wellbeing. As a construct,
wellbeing is increasingly favoured in academia as a broad, overarching, multidimensional
term, incorporating all the ways in which a person might hope to do or be well (de Chavez,
Backett-Milburn, Parry, & Platt, 2005; Lomas, Hefferon, & Ivtzan, 2015). This not only
includes mental health (as per the outcomes alluded to above), but also physical health
(Larson, 1999), social relationships (Bourdieu, 1986), and cognitive performance (Tang et al.,
2007). For instance, Pollard and Davidson (2001, p.10) define wellbeing as “a state of
successful performance across the life course integrating physical, cognitive and social-
emotional function.” Furthermore, wellbeing can be appraised in either deficit-based
“negative” terms, or asset-based “positive” terms. With the former, wellbeing consists in the
relative absence of some undesirable phenomenon, such as mental health outcomes like
anxiety or depression. However, fields like positive psychology have shown that wellbeing
does not only mean the absence of outcomes like anxiety, but also the presence of desirable
outcomes (Diener, 2000), such as “flourishing” (Keyes, 2002) or “satisfaction with life”
(Diener, Emmons, Larsen, & Griffin, 1985). The reviews of the HCP literature cited above
generally restrict themselves to deficit-based mental health outcomes, as alluded to above, as
indeed do many of the individual studies included within these reviews. There are some
exceptions; for instance, both McConville et al. (2017) and Lamothe et al. (2016) included a
focus on empathy within their systematic reviews. On the whole though, apart from Lomas et
al. (2018), the reviews have not included an expansive look at all facets of wellbeing, which
is something the current paper aims to redress.
The second limitation with the HCP reviews above is that they have not necessarily
provided a robust analysis of the utility of mindfulness with respect to this population, nor of
its limits. This comment is not a criticism of the reviews per se, but rather a reflection of the
inherent analytical limits of reviews, even systematic ones. Even though reviews such as

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Lomas et al. (2018) have sought to calculate and report on effect sizes with respect to the
studies reviewed, it is still hard to gain an overall impression of the impact of mindfulness on
a particular outcome (other than, for instance, simply reporting on the number of studies that
have found a small, medium, or large effect size, or alternatively no effect). For that kind of
comparative statistical assessment, meta-analyses are required. Unfortunately, though, to date
there have been few meta-analyses focusing on HCPs, and these have been relatively limited
in scope. We were only able to locate one that focused on HCPs specifically, an analysis by
Burton, Burgess, Dean, Koutsopoulou, and Hugh‐Jones (2017) which looked just at stress,
and featured only seven studies. To this end, the present paper sought to provide a more
inclusive meta-analysis of mindfulness in a HCP context, one not limited to particular mental
health outcomes such as stress (as per Burton et al., 2017), but rather that takes an inclusive
look at the panoply of outcomes pertaining to wellbeing. The paper is a follow-up to the
general systematic review of HCPs provided by Lomas et al. (2018), who located 81 studies
across all HCP sectors; of these 81 studies, 37 were selected as being amenable to meta-
analysis, as outlined below.
Method
Eligibility Criteria
Our analysis considered any study examining the pre-post or controlled effects of MBIs in
HCP populations, for a wide range of wellbeing outcomes, including: (a) “negative” mental
health measures such as anxiety and depression; and (b) “positive” indices of wellbeing, such
as life satisfaction, including outcomes associated with wellbeing, such as emotional
intelligence. The literature search was conducted using the MEDLINE and Scopus electronic
databases; terms included in the review were: mindfulness AND work OR occupation OR
profession OR staff (in all fields in MEDLINE and limited to article title, abstract, and
keywords in Scopus).

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Search Strategies
The search was conducted as part of a broader ongoing systematic review on mindfulness in
all occupations (please see Lomas, Medina, Ivtzan, Rupprecht, Hart, et al., 2017). The dates
selected were from the start of the database records to 10th January 2016. We also looked
through the reference lists of studies selected for inclusion in the review for other articles that
may be relevant (but which did not appear in our database search). For the current review of
HCPs specifically, in terms of PICOS (participants, interventions, comparisons, outcomes
and study design), the key inclusion criteria were: participants – currently employed in a
healthcare context; outcomes – any pertaining to wellbeing (using this term in the broad,
inclusive way outlined above); and study design – any empirical study examining the
quantitative pre-post or controlled effects of MBIs in HCP populations.
Inclusion and Exclusion Criteria
Exclusion criteria were theoretical articles, commentaries without statistical analyses, and
studies that did not feature pre-post quantitative testing of an MBI. Studies were required to
be published (or in press) in English in a peer-reviewed academic journal. The review was
conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009). The review
protocol was registered with the International Prospective Register of Systematic Reviews
(PROSPERO) database on 5th January 2016 (registration number: CRD42016032899).
Data Extraction
The following variables were extracted from each paper: type of design (i.e., Randomised
Controlled Trial [RCT] versus pre-post and non-randomised intervention studies); occupation
of participants; number of experimental participants; number of control participants and
nature of the control condition (if applicable); type of MBI; length of MBI; wellbeing
outcomes; and the mean and standard deviations of principle outcomes.

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As discussed above, wellbeing serves as an all-encompassing, multidimensional
construct that includes all the ways a person might hope to do or be well (de Chavez et al.,
2005). In this review, two “classes” of wellbeing measures were extracted. First, the main
measures were psychometric scales pertaining to “deficit-based” mental health outcomes –
i.e., whose relative absence is regarded as indicative of wellbeing, as elucidated above – such
as anxiety and depression. Second, there were various positive “asset-based” psychological
outcomes – i.e., whose relative presence is regarded as indicative of wellbeing – such as
satisfaction with life. This second class included outcomes that, although not regarded as
indices of wellbeing per se, are closely associated with it, such as emotional intelligence
(Salovey & Mayer, 1990). Whenever a study met the inclusion criteria to be part of the meta-
analysis but did not report all the data needed to compute weighted parameters, trial authors
were contacted to request all the missing information.
Quality Assessment
The Quality Assessment Tool for Quantitative Studies (QATQS; National Collaborating
Centre for Methods and Tools, 2008) was used to assess the quality of the studies. QATQS
assesses methodological rigor in six areas: (a) selection bias; (b) design; (c) confounders; (d)
blinding; (e) data collection method; and (f) withdrawals and drop-outs. Each area is assessed
on a quality score of 1 to 3 (1 = strong; 2 = moderate; 3 = weak). Scores for each area were
collated, and a global score assigned to each study. If there are no weak ratings, the study is
scored 1 (strong); one weak rating leads to a 2 (moderate); and two or more weak ratings
generates a 3 (weak). QATQS scoring was conducted primarily by the third author, following
the guidelines outlined in the QATQS protocol. While not specifically in receipt of QATQS
training, the author is a senior lecturer in psychology with over fifteen years of active
research experience, including with respect to conducting systematic reviews, and with
respect to mindfulness specifically – see Lomas, Ivtzan, and Fu (2015) for an example of

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previous work in this regard) – of which he is also an experienced teacher and teacher trainer.
A sample of 15 papers was independently coded by the first author; while also not
specifically trained in QATQS coding, he is a senior lecturer in psychology with over eight
years of active research experience, including with respect to conducting systematic reviews
of mindfulness specifically (as per Lomas et al., 2015). There was a disagreement only with
respect to one paper, where the first author disagreed with the scores for three of the QATQS
criteria assigned by the third author. These discrepancies were resolved by discussion (with
an amended score accepted on one of the criteria). In light of that discussion, the third author
re-checked the rest of the papers, but this did not lead to any further revisions in coding.
Statistical Analyses
The meta package (Schwarzer, 2007) for the R software (R Core Team, 2017) was used to
compute the statistical analyses and create funnel and forest plots. As we were assessing
studies carried with different formats in different contexts, we chose random effects models
as we assumed that the estimates of treatment effect could vary across studies because of real
differences in the intervention effect (Riley, Higgins, & Deeks, 2011). Only outcomes
represented in three or more studies are included in the models and, therefore, forest plots,
although all outcomes for all studies were included in the analyses for publication bias. We
assessed publication bias using contour-enhanced funnel plots and Begg and Mazumdar
(1994) tests by outcome valence. In cases where a study reported a trial with two intervention
groups and at least one control group, separate analyses were conducted for each inter-group
comparison.
As most studies reported means and standard deviations, according to the
aforementioned variable grouping strategy, different scales were grouped under a common
outcome type. We calculated Hedges’ g standardized mean differences with 95% confidence
intervals (Sedgwick & Marston, 2013) for each outcome within each study design. When

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adding a negative valence scale to an asset-based outcome, means were recoded (multiplied
by minus one) so that the valences coincided. For studies with more than one scale in the
same outcome group, mean values for each of these metrics were converted to a single mean
value for the intervention and control groups respectively. The variance of the mean among
scales included within the same outcome grouping was calculated using Borenstein, Hedges,
Higgins, and Rothstein’s method (2009):
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 
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When the correlation between scales was unknown, r = .5 was assumed as a midpoint
between total independence and total dependence. This procedure was implemented to
estimate all outcomes’ overall effect size, confidence intervals, sample size, and
heterogeneity, and was needed to preserve the statistical independence of assumptions,
controlling for the risk of bias due to the inflation of the main effect size’s variance.
Heterogeneity was systematically assessed among the studies using the Cochran's Q,
I2 and the τ2 statistics. While Cochran's Q (a Chi-squared distributed measure of weighted
squared deviations that can be converted into a p value) is the usual test statistic, the principal
advantage of I2 (the ratio of true heterogeneity to total observed variation, i.e., the proportion
of the observed variance reflecting real differences in effect size) is that it can be calculated
and compared across meta-analyses of different sizes, of different types of study, and using
different types of outcome data (Higgins, Thompson, Deeks, & Altman, 2003). τ2 is the
variance of the true effect sizes (i.e., the actual standard deviation), calculated as part of
random effects meta-analyses.
Finally, to account for possible moderators, all covariates that can usually be found in
similar meta analyses (Khoury et al., 2013; Spielmans & Flückiger, 2018) and were possible
to gather within the studies analysed, were taken into account: study design type (non-

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randomised trials/quasi-experimental designs, pre-post studies, RCTs); publication year of
the study; gender; age; profession (students vs. professionals); type of intervention (MBSR
vs. others); treatment intensity (including a compound outcome made of treatment duration,
session length, homework, retreatments, and frequency); professional activity; and studies’
QATQS scores. These factors were all correlated with metanalytic models using tests for
subgroup differences and meta-regressions. These analyses were performed taking each
outcome as a unit, as doing it within each study design would mean lacking an adequate
sample for practically all calculations.
Results
Literature Search Results
For the broader systematic review – i.e., mindfulness across all occupations (Lomas, Medina,
Ivtzan, Rupprecht, Hart, et al., 2017) – following the removal of duplicate citations, 721
potentially relevant papers were identified. In the current systematic review, focusing
specifically on HCPs, from reviewing the abstract, 543 papers were excluded, while from the
full text reviews of 178 papers, 124 further papers were also excluded. From the 54 articles
within the scope of this review, 12 were not included in the analysis since they were
qualitative studies, therefore leaving 41 articles. However, since inclusion in the analyses
required that study designs with a specific outcome had to have been assessed by at least
three different studies (Higgins & Green, 2011), two studies (Grepmair, Mitterlehner, Loew,
& Nickel, 2007, and Poulin, Makenzie, Soloway, & Karayolas, 2008) were only included in
publication bias analyses. This process of winnowing is shown below as a PRISMA flow
diagram (see figure 1).
[Please insert figure 1 about here]
The studies comprised a total of 2,101 participants (discounting participants not
including in analyses due to attrition), including 1,415 undertaking MBIs, and 686 separate

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control participants. The studies covered a range of occupations, including healthcare
students (n=15), physicians (n = 5), nurses (n = 6), therapists, mental health (n = 5), and
mixed (non-specific) healthcare professionals (n = 11). As for study design, 24 were pre-post
studies of a single sample, 12 RCTs, and 6 non-randomised studies. Details of the particular
studies – which have also been previously described in Lomas, Medina, Ivtzan, Rupprecht,
Hart, et al. (2017) – are outlined below in table 1, and a summary of the overall outcomes is
shown in table 2. In table 2, studies have been grouped according to the specific wellbeing
outcomes they explicitly reported on. In most cases, particularly with respect to “deficit-
based” outcome measures, studies reported on well-established common constructs (e.g.,
anxiety, depression, distress, and stress). In some instances, though, outcomes which were
less-frequently reported on have been aggregated into larger categories. For instance, a
heterogenous range of “positive” measures were reported by a number of studies, such as
satisfaction with life and positive affect, and these have been aggregated into a category of
“positive wellbeing.” In addition, table 3 shows the outcomes of the QATQS quality
assessment.
[Please insert figure 1 and tables 1, 2 & 3 about here]
Reporting Bias
We constructed two contour-enhanced funnel plots by grouping positive (e.g., satisfaction)
and negative (e.g., distress) outcome measures (see figures 2 and 3). Singh, Singh, Sabaawi,
Myers, and Wahler (2006) and Singh et al. (2015) were excluded from the forest plots due to
extreme SMD values (28.98 and -3.89 respectively), and Begg and Mazumdar’s (1994) tests
were calculated both including and excluding them. Both funnel plots showed an apparently
symmetric distribution. When testing asymmetry with Begg and Mazumdar’s tests, both
positive (z = -0.623, p =.53; z = -0.238, p = .81, including Singh et al., 2006) and negative (z

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14
= -0.792, p = 0.43; z = -1.113, p = .27, including Singh et al., 2015) outcomes showed no
statistically significant asymmetry.
[Please insert figures 2 & 3 about here]
“Negative” Wellbeing Outcomes
Anxiety. Mindfulness appears to have a beneficial impact upon anxiety (which was
the only dependent variable with enough studies to perform calculations in all three design
types), as shown in figure 4 below. Effect sizes for non-randomised trials, pre-post studies
and RCTs were -1.01 (95% CI= -2.06, -0.04, p=.059), -0.31 (95% CI= -0.62, -0.01, p<0.05)
and --0.49 (95% CI= -0.81, -0.16, p<0.005) respectively, with most studies showing a
reduction in anxiety as a result of the intervention. High and statistically significant
heterogeneity was found just for non-randomised trials (I2 = 85%, τ2=.724,

2=13.19,
p<.001). No statistically significant results were found for any moderator (and calculations
could not be carried using MSBR or homework as independent variable, as only one study
did not use this intervention model in its implementation, and all studies included take-home
activities).
[Please insert figure 4 about here]
Burnout. Mindfulness appears to have a beneficial impact upon burnout, as shown in
figure 5 below, with effect sizes of -0.51 (95% CI= -0.70, -0.32, p<.0001) for pre-post studies
and -0.31 (95% CI= -0.57, -0.04, p=.024) for RCTs. Heterogeneity was not statistically
significant in both cases. In addition, one study (Mackenzie et al., 2006) had significant
differences between groups at pre-intervention time, which needs to be taken into account
when interpreting the results. No statistically significant results were found for any moderator
or between study designs.
[Please insert figure 5 about here]

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Depression. Mindfulness appears to have a beneficial impact upon depression, as
shown in figure 6 below, with effect sizes of -0.29 (95% CI= -0.55, -0.03, p<.05) for pre-post
designs and -0.55 (95% CI= -0.87, -0.22, p=.001) for RCTs. In these analyses, neither
heterogeneity nor subgroup differences showed statistical significance. No statistically
significant results were found for any moderator or between study designs.
[Please insert figure 6 about here]
Distress. Mindfulness appears to have a beneficial impact upon distress and anger, as
shown in figure 7 below, with effect sizes of -0.54 (95% CI= -0.75, -0.33, p<.0001) for pre-
post and -0.61 (95% CI= -0.79, -0.44, p<.0001) for RCTs. Neither heterogeneity nor the
design subgroup differences or any moderator showed statistically significant differences.
[Please insert figure 7 about here]
Stress. Mindfulness appears to have a beneficial impact upon stress, as shown in
figure 8 below, with effect sizes of -0.58 (95% CI= -0.81, -0.34, p<.0001) for pre-post and -
0.42 (95% CI= -0.67, -0.17, p=.0001) for RCTs. High and statistically significant
heterogeneity was found just for pre-post designs (I2 = 66%, τ2=.154,

2=50.5, p<.0001), but
the subgroup differences were not. Additionally, one study included here (Burnett &
Pettijohn, 2015) observed significant pre-intervention differences between the two groups,
hence its results must be interpreted with caution. No statistically significant results were
found for any moderator.
[Please insert figure 8 about here]
“Positive” Wellbeing Outcomes
Compassion. Mindfulness appears to have a beneficial impact upon compassion, as
shown in figure 9 below, with effect sizes of 0.52 (95% CI= 0.15, 0.90, p=.006) for pre-post
and 0.35 (95% CI= -0.08, 0.78, p=.109) for RCTs (although the latter was not statistically
significant). Both had high heterogeneity levels, but statistical significance was only reached

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16
with pre-post designs (I2 = 71%, τ2=.181,

2=20.93, p=.002). Hence, again, results should be
interpreted with caution. Statistically significant higher effect sizes were found in studies
carried using the original MSBR (Q= 4.53, p<.05) and including retreatments (Q= 5.22,
p<.05). Calculations could not be carried using homework as independent variable as all
studies included take-home activities.
[Please insert figure 9 about here]
Emotional intelligence and regulation. There was only enough information to
perform meta-analytic calculations for pre-post designs with this variable. In contrast to other
outcomes, the results showed no significant differences in emotional intelligence and
regulation after mindfulness practice. As figure 10 displays, although there was a mild
improvement, it did not reach statistical significance, with an overall effect size of 0.18 (95%
CI= -0.14, 0.51, p=0.26). The level of heterogeneity was non-significant. No statistically
significant results were found for any moderator.
[Please insert figure 10 about here]
Empathy. As in the case of emotional intelligence, only pre-post designs were
numerous enough to perform calculations. Mindfulness appears to have a beneficial impact
upon empathy, as shown in figure 11 below, with an effect size of 0.31 (95% CI= 0.02, 0.60,
p<.05). Heterogeneity and subgroup differences were non-significant, and no statistically
significant correlations were found with any moderator.
[Please insert figure 11 about here]
Positive wellbeing. Mindfulness appears to have a beneficial impact upon “positive
wellbeing” (e.g., life satisfaction), as shown in figure 12 below, with effect sizes of 0.49
(95% CI= 0.14, 0.83, p=.005) for pre-post and 0.27 (95% CI= 0.12, 0.43, p<.001) for RCTs.
With pre-post designs, the heterogeneity was statistically significant (I2 = 58%, τ2=.088,

2=9.59, p=.05). Subgroup differences were non-significant. Statistically significant

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17
correlations were found for intervention intensity (QM=4.718, p<.05) with higher gains for
more intense interventions and for profession (Q=4.18, p<.05) with higher gains for students.
[Please insert figure 12 about here]
Mindfulness. Mindfulness practice appears to have a beneficial impact upon
mindfulness, as shown in figure 13 below, with effect sizes of 0.52 (95% CI= 0.31, 0.73,
p<.0001) for pre-post, and 0.34 (95% CI= -0.06, 0.73, p=.09) for RCTs (although the latter
was not statistically significant). Heterogeneity was relatively high and statistically
significant in both cases (pre-post: I2 = 46%, τ2=.056,

2=20.29, p=.04, RCTs: I2 = 72%,
τ2=.136,

2=14.3, p<.01), but subgroup differences were not. Statistically significant
correlations were found for intervention intensity (QM=4.888, p<.05) with higher gains for
more intense interventions. Additionally, and contrarily to what we found for compassion,
higher effect sizes were found in studies not using the original MSBR (Q= 4.53, p<.05).
[Please insert figure 13 about here]
Discussion
Overall, MBIs appeared to have a positive impact upon most outcome measures, of which
there were a great range. As discussed above, one of the prerogatives of the current review
was to take an inclusive approach to wellbeing, viewing this as a multidimensional construct
encompassing the myriad ways a person might hope to do or be well (de Chavez et al., 2005).
Such an approach differentiates the current paper from previous analyses on the impact of
mindfulness in HCPs, which have tended to just focus on “deficit-based” mental health
outcomes such as anxiety and depression. For instance, the only meta-analysis we located
concentrating on HCPs specifically was just concerned with stress, featuring only seven
studies (Burton et al., 2017). By contrast, the current review looked at two broad classes of
wellbeing outcomes: (a) negative “deficit-based” mental health outcomes (e.g., depression;
(b) positive “asset-based” psychological outcomes (e.g., satisfaction with life), as well as

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
18
outcomes associated with wellbeing (e.g., emotional intelligence). Let’s consider these
classes in turn.
First, the analysis supports the contention that MBIs can be helpful in addressing the
mental health needs of HCPs. Effect sizes ranging from small to medium were observed in
the expected direction (i.e., reduced burden) for all measures, including anxiety (-1.01 for
non-randomised trials, -0.49 for RCTs, and -0.31 for pre-post studies), burnout (-0.31 RCTs
and -0.51 pre-post), depression (-0.55 and -0.29), distress (-0.61 and -0.54) and stress (-0.42
and -0.58). All random effects models performed on negative outcomes, except anxiety (non-
randomised trials), yielded statistically significant results of around half standardised average
difference. These findings somewhat align with previous meta-analyses looking at the impact
of mindfulness on such measures in non-clinical populations (but not HCPs specifically). For
instance, analysing 29 studies of MBSR, Khoury et al. (2015) observed a large effect size
with respect to stress, a medium effect in relation to anxiety, distress, and depression, and a
small effect for burnout. The findings here are promising, given the mental health burdens
faced by HCPs, with surveys suggested that mental health issues may be even higher among
HCPs than in the general population. For instance, a longitudinal study of 318 GPs by Firth-
Cozens (1998) found that 16.8% were above the threshold for depression on the depression
scale of the Symptom Checklist 90, with 9.9% having some suicidal ideation (4.6% more
than “occasionally”). These figures contrast with estimates that around 2.3% of the general
UK adult population experience a depressive episode at any one time (i.e., in the past week),
with 9% experiencing mixed anxiety and depressive disorder (The Health & Social Care
Information Centre, 2009). There are many hypothesised reasons for this greater liability to
depression among HCPs, including personality traits such as perfectionism, burdens of
clinical responsibility, and reluctance to seek treatment (Bright & Krahn, 2011). Whatever
the reasons, it is encouraging that MBIs appear to help in this regard, reflecting the more

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19
established efficacy of MBIs such as MBCT with respect to depression (Segal, Williams, &
Teasdale, 2002). In terms of moderator analyses, no statistically significant differences were
observed for any negative outcome.
Similarly, the relatively positive results regarding stress are welcome here, especially
given that stress appears to be generally higher among HCPs than in the general population.
For instance, Firth-Cozens (2003) reported that the proportion of HCPs being above threshold
levels of stress is around 28% in surveys, compared with about 18% in the general working
population. As with depression, a similar range of factors have been implicated in elevated
stress levels among HCPs, from long working hours to the burden of clinical responsibility
(Sochos, Bowers, & Kinman, 2012). Unfortunately, as highlighted above, these burdens have
only increased over recent years, due to factors such as curbs on healthcare spending meaning
that overwork has become even more acute. As noted above, a survey of National Health
Service staff found that 61% reporting feeling stressed all or most of the time, and 59%
stating that their stress is worse this year than last year (Dudman et al., 2015). Thus, the small
to medium effect size observed in relation to stress here is notable, although this was less
than the large effect size observed by Khoury et al.’s (2015) aforementioned meta-analysis of
MBSR in non-clinical populations (not HCPs specifically). Such findings show that
mindfulness may have a useful role to play in ameliorating work-based stress and burnout.
However, while these results are encouraging, concerns have been expressed about MBIs
being used in occupational contexts as a sticking plaster to merely treat the symptoms of a
“toxic” or otherwise challenging work environment, rather than undertaking the more
difficult task of creating environments more hospitable to employees (Van Gordon, Shonin,
Lomas, & Griffiths, 2016). Moreover, such interventions can potentially place the onus on
employees to “cope” with stress and burnout via MBIs, rather than on employers to render
the work itself less demanding. As such, while MBIs may well be helpful to HCPs in terms of

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20
alleviating mental health issues, it is vital that their underlying structural causes are also
addressed.
The second class of wellbeing outcomes are more positive “asset based” measures.
These include outcomes that have recently come to prominence via the burgeoning paradigm
of “positive psychology” (Seligman & Csikszentmihalyi, 2000), like satisfaction with life
(Diener et al., 1985) (even if such topics predate the emergence of positive psychology in the
late 1990s). The relative lack of attention to such outcomes in the HCP literature considered
here is somewhat reflective of the field of psychology more broadly. That is, one rationale
behind the emergence of the positive psychology movement was the charge that mainstream
psychology tended to be concerned with disorder, deficit and dysfunction, and paid relatively
little attention to “the brighter sides of human nature,” as Linley and Joseph (2004, p.4) put it,
to the ways in which humans excel and flourish. One of positive psychology’s foundational
metaphors of PP was of a continuum, stretching from a nominal minus 10, through zero and
up to plus 10 (Keyes, 2002). On that metaphor, ameliorating deficits such as mental disorder
constitutes bringing people up to “zero.” That is hugely beneficial, as far as it goes. But being
at “zero” does not necessarily mean people are flourishing (e.g., truly thriving, and fulfilling
their potential). Thus, positive psychology sought to draw attention to outcomes that might
represent the positive integers in this metaphor. The current review sought to capture this
aspect of wellbeing, including such outcomes as satisfaction with life (e.g., Cohen & Miller,
2009). Overall a small to medium effect size was observed (0.27 for RCTs and 0.49 for pre-
post), which is encouraging (with no significant results observed for any moderator).
However, this is a relatively understudied domain of wellbeing in the literature on
mindfulness in HCPs, and further research is needed.
Relatedly, the review also included “positive” outcomes measures that, although not
constitutive of wellbeing in themselves, are closely related to it. These include mindfulness

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21
itself, for which an effect size of 0.52 was observed for pre-post studies, although only 0.34
for RCTs (which moreover was non-significant). The latter result is somewhat surprising and
suggests that whatever benefits participants may be gaining from MBIs, it is unclear the
extent to which this is attributable to increases in mindfulness itself (since, after all, this did
not increase significantly in RCTs), as opposed to accruing from other rewarding components
of the programme (e.g., a supportive social environment). Mindfulness also yielded some
interesting results in terms of subgroup and meta-regression analyses, with variability with
respect to the type of intervention (with greater effect sizes in mindfulness among studies that
did not use the MBSR programme).
Other positive outcomes of note included empathy and compassion. In this respect
though, while significant effect sizes were observed in pre-post studies for both empathy
(0.31) and compassion (0.52), the compassion effect size (0.35) in RCTs was non-significant
(while RCT calculations were not possible for empathy due to insufficient studies). Also of
note here is the moderating factor of MBI, where – contrary to the mindfulness outcomes
reported above – higher effect sizes were observed in studies that did use the original MBSR
protocol. These conflicting findings regarding moderator variables precludes us from making
any simple generalisations about which type of MBI is most effective. More generally,
qualities of empathy and compassion are not only relevant in a HCP context because of their
close association with wellbeing, such as the possibility that they provide a buffer against
stress (Cosley, McCoy, Saslow, & Epel, 2010). There is a significant literature though on the
risks of “compassion fatigue” among HCPs (Coetzee & Klopper, 2010), which emphasises
the importance, among other things, of HCPs developing self-compassion (Boellinghaus,
Jones, & Hutton, 2014).) Empathy and compassion are further interesting here, since in a
healthcare context, these qualities are regarded as important occupational skills, for instance
being linked to better outcomes for patients (Mannion, 2014). This finding aligns with

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22
reviews which have reported on job performance metrics in HCPs, such as Guillaumie et al.
(2017), who observed – in relation to mindfulness – improved communication with
colleagues, greater sensitivity to patients’ experiences, clearer analyses of complex situations,
and emotional regulation in stressful contexts, and likewis McConville et al. (2017), who
observed better learning and clinical performance among health professional students.
This class of positive wellbeing-related outcomes here also included emotional
intelligence and regulation. The interest in such outcomes lies, in part, with the possibility
that they may play mediating roles with respect to the outcomes considered above. For
instance, emotional intelligence and regulation have been studied as coping resources that can
mitigate the deleterious impact of work demands for HCPs (Weng et al., 2011). These
outcomes are also relevant, since theoretically they represent one of the strongest candidates
for the way in which mindfulness might exert its beneficial effects upon all the outcomes
considered in this review. As outlined in the introduction, theorists such as Shapiro et al.
(2006) have proposed that a key way in which mindfulness operates beneficially is through a
process of “reperceiving,” whereby people are empowered to “decentre” from distressing
qualia that might otherwise generate distress etc. And, reperceiving could be regarded as one
facet of a more general capacity of emotion regulation. For instance, Walsh and Shapiro
(2006) define meditation as “a family of self-regulation practices that focus on training
attention and awareness in order to bring mental processes under greater voluntary control
and thereby foster general mental well-being” (pp.228-229). However, although
improvements were noted here with respect to emotional intelligence/regulation, surprisingly
(given the above-mentioned theoretical background), the effects did not reach statistical
significance. Clearly, this makes one wary here about definitively granting these outcomes a
pivotal role in mediating the effects of MBIs on the outcomes above, and highlights the need

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for further research on the relevance of these psychological processes to whatever benefits
may be conferred by mindfulness practice.
Overall, though, the results are fairly encouraging in terms of the value of MBIs for
HCPs. However, there are various issues with the research base which must temper one’s
enthusiasm here, and which limit the conclusions that can be drawn. The quality assessment
revealed considerable variation among studies, with several prominent issues. The first is that
older studies tended not to use an RCT design, and more generally had a poorer quality of
design compared to more recent studies. A second issue is that studies overwhelmingly
featured a majority of female participants; this raises doubts concerning the ecological
validity of these studies when it comes to their relevance for both males and females (and see
Lomas, Cartwright, Edginton, and Ridge (2015) for potential gendered differences in the way
men may respond to meditation practice). A third issue was blinding, i.e., whether or not
participants were aware of the research question and whether assessors were aware of the
intervention, which was rarely addressed by studies.
Furthermore, there are other issues beyond those around quality. First, there is
considerable heterogeneity in the design of the studies – including type of MBI, and outcome
measures – which makes it difficult to conduct comparative assessments, and hence to draw
robust conclusions about the research as a whole. A further issue is that the research is biased
towards “negative” psychiatric outcomes (e.g., anxiety, stress, depression), with relatively
little attention to “positive” outcomes that are specifically relevant to the work arena, such as
work engagement or creativity. Finally, despite not having obtained statistically significant
results in our calculations, our appraisal of the literature base is likely to have been hindered
by publication bias, i.e., the “file-drawer problem,” in that studies with less conclusive or
even negative results are less likely to be published (Smith, 1980). It was not feasible to
collect data from unpublished trials of MBIs with HCPs, which means that the studies

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reviewed must inevitably be regarded as a somewhat selective survey of the studies that have
been conducted in this arena. As an additional point, it should also be noted that it was
necessary to perform the calculations with moderating variables using all study designs
together (rather than separately according to specific designs, i.e., randomised vs non-
randomised). The reason is that separating such analyses by specific designs would generate
an unwieldy proliferation of subgroups, many of which would have had just one or even no
studies within them. Future meta-analyses, with a greater pool of studies to draw on, may
well be able to perform calculations separated by study designs, which would be ideal.
Based on the critiques above, the following recommendations can be made vis-à-vis
future work in this area, including in relation to the (a) outcomes, (b) study design, (c) type of
MBI, and (d) cost-benefit analyses. First, it would be good to see a diversification of outcome
measures. Currently, most studies focus on deficit-based wellbeing measures, such as anxiety
and stress. While those outcomes are important, and the focus on them understandable given
the clinical context in which MBIs were developed, they do not provide the “whole picture”
with regard to wellbeing. As fields like positive psychology have emphasised, wellbeing is
also a question of asset-based outcomes (whose presence is indicative of wellbeing), such as
life satisfaction or positive affect. As such, we recommend that all studies consider including
at least one such asset-based outcome in their assessment. Relatedly, when researching MBIs
in occupational contexts specifically, we also recommend the inclusion of asset-based
outcomes that are particularly germane to this arena, but which have so far received hardly
attention at all (and none in the studies reviewed here). These could include, for instance,
creativity and leadership (see Kudesia (2015) and George (2012) for reflections on links in
the workplace between mindfulness and creativity and leadership respectively).
Second, our QATQS review of the general quality of studies leads us to several
recommendations regarding the design of the research. Most importantly, where possible,

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25
studies should implement an RCT design, ideally with large numbers of participants
(determined by a priori power calculations drawing on estimated effect size). Moreover, in
addition to a wait-list control protocol, the design of studies would be improved if trials
included an “active” control group. A good example of this in an occupational context is
Wolever et al. (2012), who included yoga as an active control. Such designs will better enable
any positive effects to be ascribed to mindfulness per se (i.e., rather than simply being
involved in an absorbing group activity). Relatedly, studies should pay more attention to the
extent to which participants are actually practising mindfulness (e.g., in terms of adherence to
homework activities). As Vettese, Toneatto, Stea, Nguyen, and Wang (2009) noted, failure to
track such participation is a perennial issue in MBI research, and this trend was observed in
the studies analysed here. Additionally, beyond people simply participating in an MBI, much
more knowledge is needed about the extent and quality of their involvement with meditation.
In that respect, besides quantitatively tracking participation, studies could incorporate a
qualitative element to their assessment (see Lomas, Cartwright, Edginton, and Ridge (2013,
2014a, 2014b, 2015, 2016) on the value of qualitative analyses in relation to mindfulness
practice).
Third, where possible, trials should involve well-established MBIs (i.e., rather than
bespoke adaptations), to better enable comparison and aggregation across studies. Of the 81
studies analysed in Lomas et al.’s (2018) general systematic review of HCPs – of which the
current paper provides a meta-analysis of 41 – the 56 intervention studies used a range of
different MBIs. These included MBSR (n = 9), MBSR adaptations (15), and MBCT (5),
together with a range of other less-well-established programmes (16), as well as bespoke
interventions seemingly created for that particular study (21). For the purposes of assessing
the value of MBIs in occupational contexts it would be helpful – at least in this point in our
early understanding of this particular context – for studies to use established MBIs such as

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26
MBSR and MBCT, rather that creating bespoke programmes or adaptations. Having said that
though, we also recognise the value of moving beyond MBIs developed primarily for clinical
contexts (e.g., MBSR), and creating MBIs specifically for the workplace, including for
particular types of occupation (e.g., HCPs). For instance, Goodman and Schorling (2012)
created and used a bespoke MBSR adaptation called “Mindfulness for Healthcare Providers,”
which was specifically tailored for a HCP context. As such, we would not want to discourage
that kind of innovation. Thus, as the research moves forward, it will be helpful to see a
balance between the implementation and assessment of established MBIs on the one hand,
and innovation and adaption of these into occupational contexts on the other.
Finally, the case for implementing mindfulness in occupational contexts will be
enhanced considerably – certainly from the perspective of employers – through cost-benefit
analyses. If MBIs can be seen to generate an overall net gain, there are strong incentives for
these to be introduced in the workplace. Unfortunately though, few such analyses currently
exist (Edwards, Bryning, & Crane, 2015). There are some valuable and instructive exceptions
though. For instance, analysing the impact of “mindful organising” across three large
hospitals, Vogus, Cooil, Sitterding, and Everett (2014) calculated that this generated a 13.6%
decrease in turnover, representing an average hospital saving of between $169,000 and
$1,014,560. Such analyses will be very valuable in terms of generating organisational buy-in
to the potential of mindfulness, thus helping facilitate research going forward that can enable
the promise of the research reviewed here to be substantiated (see Edwards et al. (2015) for
recommendations on conducting such analyses). Nevertheless, despite the limitations and
issues with the current research base, the evidence of the value of mindfulness for HCPs is
strong, and one might speculate that this will only strengthen over the years ahead.
Compliance with Ethical Standards
Funding

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27
This study was unfunded.
Compliance with Ethical Standards
This article does not contain any studies with human participants or animals performed by
any of the authors.
References
(All meta-analysis papers are indicated by *)
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies
across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2),
217-237. doi: 10.1016/j.cpr.2009.11.004
*Barbosa, P., Raymond, G., Zlotnick, C., Wilk, J., Toomey, I. R., & Mitchell, I. J. (2013).
Mindfulness-based stress reduction training is associated with greater empathy and
reduced anxiety for graduate healthcare students. Education for Health, 26(1), 9-14.
doi: 10.4103/1357-6283.112794
*Bazarko, D., Cate, R. A., Azocar, F., & Kreitzer, M. J. (2013). The impact of an innovative
mindfulness-based stress reduction program on the health and well-being of nurses
employed in a corporate setting. Journal of Workplace Behavioral Health, 28(2), 107-
133.
Begg, C.B., & Mazumdar, M. (1994). Operating characteristics of a rank correlation test for
publication bias. Biometrics 50(4), 1088-1101. http://dx.doi.org/10.2307/2533446.
Boellinghaus, I., Jones, F. W., & Hutton, J. (2014). The role of mindfulness and loving-
kindness meditation in cultivating self-compassion and other-focused concern in
health care professionals. Mindfulness, 5(2), 129-138.
*Bond, A. R., Mason, H. F., Lemaster, C. M., Shaw, S. W., Mullin, C. S., Holick, E. A., &
Saper, R. B. (2013). Embodied health: The effects of a mind-body course for medical
students. Medical Education Online, 18(1). doi: 10.3402/meo.v18i0.20699

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
28
*Bonifas, R. P., & Napoli, M. (2014). Mindfully increasing quality of life: A promising
curriculum for MSW students. Social Work Education, 33(4), 469-484. doi:
10.1080/02615479.2013.838215
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009). Multiple
outcomes or time-points within a study. In Introduction to meta-analysis (pp. 225–
238). Chichester, UK: John Wiley & Sons, Ltd.
Bourdieu, P. (1986). The forms of capital. In J. G. Richardson (Ed.), Handbook of theory and
research for the sociology of education (pp. 241-258). New York: Greenwood.
*Brady, S., O'Connor, N., Burgermeister, D., & Hanson, P. (2012). The impact of
mindfulness meditation in promoting a culture of safety on an acute psychiatric unit.
Perspectives in Psychiatric Care, 48(3), 129-137. doi: 10.1111/j.1744-
6163.2011.00315.x
Bright, R. P., & Krahn, L. (2011). Depression and suicide among physicians. Current
Psychiatry, 10(4), 16.
Bühlmayer, L., Birrer, D., Röthlin, P., Faude, O., & Donath, L. (2017). Effects of
mindfulness practice on performance-relevant parameters and performance outcomes
in sports: A meta-analytical review. Sports Medicine, 47(11), 2309-2321.
*Burnett, M., & Pettijohn, C. (2015). Investigating the efficacy of mind-body therapies and
emotional intelligence on worker stress in an organizational setting: An experimental
approach. Journal of Organizational Culture, Communications and Conflict, 19(1),
146-158.
Burton, A., Burgess, C., Dean, S., Koutsopoulou, G. Z., & Hugh‐Jones, S. (2017). How
effective are mindfulness‐based interventions for reducing stress among healthcare
professionals? A systematic review and meta‐analysis. Stress and Health, 33(1), 3-13,
doi: 10.1002/smi.2673

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
29
Chambers, R., Gullone, E., & Allen, N. B. (2009). Mindful emotion regulation: An
integrative review. Clinical Psychology Review, 29(6), 560-572. doi:
10.1016/j.cpr.2009.06.005
Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A
concept analysis. Nursing & health sciences, 12(2), 235-243.
*Cohen, J. S., & Miller, L. J. (2009). Interpersonal mindfulness training for well-being: A
pilot study with psychology graduate students. Teachers College Record, 111(12),
2760-2774.
Cosley, B. J., McCoy, S. K., Saslow, L. R., & Epel, E. S. (2010). Is compassion for others
stress buffering? Consequences of compassion and social support for physiological
reactivity to stress. Journal of Experimental Social Psychology, 46(5), 816-823. doi:
https://doi.org/10.1016/j.jesp.2010.04.008
Daya, Z., & Hearn, J. H. (2017). Mindfulness interventions in medical education: A
systematic review of their impact on medical student stress, depression, fatigue and
burnout. Medical Teacher, 1-8. doi: 10.1080/0142159X.2017.1394999
de Chavez, A. C., Backett-Milburn, K., Parry, O., & Platt, S. (2005). Understanding and
researching wellbeing: Its usage in different disciplines and potential for health
research and health promotion. Health Education Journal, 64(1), 70-87. doi:
10.1177/001789690506400108
Diener, E. (2000). Subjective well-being: The science of happiness and a proposal for a
national index. American Psychologist, 55(1), 34-43. doi: 10.1037/0003-066X.55.1.34
Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The satisfaction with life
scale. Journal of Personality Assessment, 49(1), 71-75. doi:
10.1207/s15327752jpa4901_13

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
30
*De Vibe, M., Solhaug, I., Tyssen, R., Friborg, O., Rosenvinge, J. H., Sørlie, T., & Bjørndal,
A. (2013). Mindfulness training for stress management: A randomised controlled
study of medical and psychology students. BMC Medical Education, 13(1). doi:
10.1186/1472-6920-13-107
*Dobie, A., Tucker, A., Ferrari, M., & Rogers, J. M. (2016). Preliminary evaluation of a brief
mindfulness-based stress reduction intervention for mental health professionals.
Australasian Psychiatry, 24(1), 42-45. doi: 10.1177/1039856215618524
Dudman, J., Isaac, A., & Johnson, S. (2015, 10 June 2015). Revealed: How the stress of
working in public services is taking its toll on staff, The Guardian. Retrieved from
http://www.theguardian.com/society/2015/jun/10/stress-working-public-services-
survey
Eby, L. T., Allen, T. D., Conley, K. M., Williamson, R. L., Henderson, T. G., & Mancini, V.
S. (2017). Mindfulness-based training interventions for employees: A qualitative
review of the literature. Human Resource Management Review. doi:
https://doi.org/10.1016/j.hrmr.2017.03.004
Edwards, R. T., Bryning, L., & Crane, R. (2015). Design of economic evaluations of
mindfulness-based interventions: Ten methodological questions of which to be
mindful. Mindfulness, 6(3), 490-500.
Emerson, L.-M., Leyland, A., Hudson, K., Rowse, G., Hanley, P., & Hugh-Jones, S. (2017).
Teaching mindfulness to teachers: A systematic review and narrative synthesis.
Mindfulness, 8(5), 1136-1149. doi: 10.1007/s12671-017-0691-4
*Erogul, M., Singer, G., McIntyre, T., & Stefanov, D. G. (2014). Abridged mindfulness
intervention to support wellness in first-year medical students. Teaching and Learning
in Medicine, 26(4), 350-356. doi: 10.1080/10401334.2014.945025

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
31
Firth-Cozens, J. (1998). Individual and organizational predictors of depression in general
practitioners. British Journal of General Practice, 48(435), 1647-1651.
Firth-Cozens, J. (2003). Doctors, their wellbeing, and their stress: It's time to be proactive
about stress—and prevent it. BMJ : British Medical Journal, 326(7391), 670-671.
*Fortney, L., Luchterhand, C., Zakletskaia, L., Zgierska, A., & Rakel, D. (2013). Abbreviated
mindfulness intervention for job satisfaction, quality of life, and compassion in
primary care clinicians: A pilot study. Annals of Family Medicine, 11(5), 412-420.
doi: 10.1370/afm.1511
*Foureur, M., Besley, K., Burton, G., Yu, N., & Crisp, J. (2013). Enhancing the resilience of
nurses and midwives: Pilot of a mindfulness-based program for increased health,
sense of coherence and decreased depression, anxiety and stress. Contemporary
nurse, 45(1), 114-125.
Fresco, D. M., Moore, M. T., van Dulmen, M. H. M., Segal, Z. V., Ma, S. H., Teasdale, J. D.,
& Williams, J. M. G. (2007). Initial psychometric properties of the experiences
questionnaire: Validation of a self-report measure of decentering. Behavior Therapy,
38(3), 234-246. doi: 10.1016/j.beth.2006.08.003
Gao, Y.-Q., Pan, B.-C., Sun, W., Wu, H., Wang, J.-N., & Wang, L. (2012). Anxiety
symptoms among Chinese nurses and the associated factors: A cross sectional study.
BMC Psychiatry, 12(1), 141.
*Gauthier, T., Meyer, R. M. L., Grefe, D., & Gold, J. I. (2015). An on-the-job mindfulness-
based intervention for pediatric ICU nurses: A pilot. Journal of Pediatric Nursing,
30(2), 402-409. doi: 10.1016/j.pedn.2014.10.005
George, B. (2012). Mindfulness helps you become a better leader. Harvard Business Review,
26, 21-32.

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
32
Givens, J. L., & Tjia, J. (2002). Depressed medical students' use of mental health services and
barriers to use. Academic Medicine, 77(9), 918-921.
*Goodman, M. J., & Schorling, J. B. (2012). A mindfulness course decreases burnout and
improves well-being among healthcare providers. International Journal of Psychiatry
in Medicine, 43(2), 119-128. doi: 10.2190/PM.43.2.b
*Grepmair, L., Mitterlehner, F., Loew, T., & Nickel, M. (2007). Promotion of mindfulness in
psychotherapists in training: Preliminary study. European Psychiatry, 22(8), 485-489.
doi: 10.1016/j.eurpsy.2007.02.004
Guillaumie, L., Boiral, O., & Champagne, J. (2017). A mixed-methods systematic review of
the effects of mindfulness on nurses. Journal of Advanced Nursing, 73(5), 1017-1034.
doi: 10.1111/jan.13176
*Hallman, I. S., O'Connor, N., Hasenau, S., & Brady, S. (2014). Improving the culture of
safety on a high-acuity inpatient child/adolescent psychiatric unit by mindfulness-
based stress reduction training of staff. Journal of Child and Adolescent Psychiatric
Nursing, 27(4), 183-189. doi: 10.1111/jcap.12091
Higgins, J. P. T., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring
inconsistency in meta-analyses. BMJ, 327(7414), 557–560. doi:
0.1136/bmj.327.7414.557
Higgins, J. P., & Green, S. (Eds.). (2011). Cochrane handbook for systematic reviews of
interventions (Vol. 5). Chichester, UK: Wiley-Blackwell.
*Hopkins, A., & Proeve, M. (2013). Teaching mindfulness-based cognitive therapy to trainee
psychologists: Qualitative and quantitative effects. Counselling Psychology
Quarterly, 26(2), 115-130. doi: 10.1080/09515070.2013.792998
Hwang, Y.-S., Bartlett, B., Greben, M., & Hand, K. (2017). A systematic review of
mindfulness interventions for in-service teachers: A tool to enhance teacher wellbeing

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
33
and performance. Teaching and Teacher Education, 64(Supplement C), 26-42. doi:
https://doi.org/10.1016/j.tate.2017.01.015
*Johnson, J. R., Emmons, H. C., Rivard, R. L., Griffin, K. H., & Dusek, J. A. (2015).
Resilience training: A pilot study of a mindfulness-based program with depressed
healthcare professionals. EXPLORE: The Journal of Science and Healing, 11(6), 433-
444. doi: 10.1016/j.explore.2015.08.002
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain
patients based on the practice of mindfulness meditation: Theoretical considerations
and preliminary results. General Hospital Psychiatry, 4(1), 33-47. doi: 10.1016/0163-
8343(82)90026-3
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future.
Clinical Psychology: Science and Practice, 10(2), 144-156. doi:
10.1093/clipsy.bpg016
*Kemper, K. J., & Khirallah, M. (2015). Acute effects of online mind–body skills training on
resilience, mindfulness, and empathy. Journal of Evidence-Based Complementary and
Alternative Medicine, 20(4), 247-253. doi: 10.1177/2156587215575816
Keyes, C. L. M. (2002). The mental health continuum: From languishing to flourishing in
life. Journal of Health and Social Behavior, 43(2), 207-222. doi: 10.2307/3090197
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., … Hofmann, S.
G. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical
Psychology Review, 33(6), 763–771. doi: 10.1016/j.cpr.2013.05.005
Khoury, B., Sharma, M., Rush, S. E., & Fournier, C. (2015). Mindfulness-based stress
reduction for healthy individuals: A meta-analysis. Journal of Psychosomatic
Research, 78(6), 519-528. doi: https://doi.org/10.1016/j.jpsychores.2015.03.009

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
34
*Krasner, M. S., Epstein, R. M., Beckman, H., Suchman, A. L., Chapman, B., Mooney, C. J.,
& Quill, T. E. (2009). Association of an educational program in mindful
communication with burnout, empathy, and attitudes among primary care physicians.
JAMA - Journal of the American Medical Association, 302(12), 1284-1293. doi:
10.1001/jama.2009.1384
Kudesia, R. S. (2015). Mindfulness and creativity in the workplace. In J. Reb & P. W. B.
Atkins (Eds.), Mindfulness in organizations: Foundations, research, and applications
(pp. 190-212). Cambridge: Cambridge University Press.
Lamothe, M., Rondeau, É., Malboeuf-Hurtubise, C., Duval, M., & Sultan, S. (2016).
Outcomes of MBSR or MBSR-based interventions in health care providers: A
systematic review with a focus on empathy and emotional competencies.
Complementary Therapies in Medicine, 24, 19-28.
Larson, J. S. (1999). The conceptualization of health. Medical Care Research and Review,
56(2), 123-136. doi: 10.1177/107755879905600201
Linley, P. A., & Joseph, S. (2004). Applied positive psychology: A new perspective for
professional practice. In P. A. Linley & S. Joseph (Eds.), Positive psychology in
practice (pp. 3-12). Hoboken, New Jersey: John Wiley and Sons.
Lomas, T. (2017). Recontextualising mindfulness: Theravada Buddhist perspectives on the
ethical and spiritual dimensions of awareness. Psychology of Religion and
Spirituality, Vol 9(2), 209-219. doi: 10.1037/rel0000080
Lomas, T., Cartwright, T., Edginton, T., & Ridge, D. (2013). ‘I was so done in that I just
recognized it very plainly, “You need to do something”’: Men’s narratives of struggle,
distress and turning to meditation. Health:, 17(2), 191-208. doi:
10.1177/1363459312451178

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
35
Lomas, T., Cartwright, T., Edginton, T., & Ridge, D. (2014a). A religion of wellbeing?: The
appeal of Buddhism to men in London, UK. Psychology of Religion and Spirituality,
6(3), 198-207. doi: 10.1037/a0036420
Lomas, T., Cartwright, T., Edginton, T., & Ridge, D. (2014b). Engagement with meditation
as a positive health trajectory: Divergent narratives of progress in male meditators.
Psychology and Health, 29(2), 218-236. doi: 10.1080/08870446.2013.843684
Lomas, T., Cartwright, T., Edginton, T., & Ridge, D. (2015). A qualitative analysis of
experiential challenges associated with meditation practice. Mindfulness, 6(4), 848-
860. doi: 10.1007/s12671-014-0329-8
Lomas, T., Cartwright, T., Edginton, T., & Ridge, D. (2016). New ways of being a man:
‘Positive’ hegemonic masculinity in meditation-based communities of practice. Men
and Masculinities, 19(3), 289-310. doi: 10.1177/1097184X15578531
Lomas, T., Hefferon, K., & Ivtzan, I. (2015). The LIFE model: A meta-theoretical conceptual
map for applied positive psychology. Journal of Happiness Studies, 16(5), 1347-1364.
doi: 10.1007/s10902-014-9563-y
Lomas, T., Ivtzan, I., & Fu, C. (2015). A systematic review of the neurophysiology of
mindfulness on EEG oscillations. Neuroscience & Biobehavioral Reviews, 57, 401-
410. doi: 10.1016/j.neubiorev.2015.09.018
Lomas, T., Medina, J. C., Ivtzan, I., Rupprecht, S., & Eiroa-Orosa, F. J. (2017a). The impact
of mindfulness on the wellbeing and performance of educators: A systematic review
of the empirical literature. Teaching and Teacher Education, 61, 132-141. doi:
10.1016/j.tate.2016.10.008
Lomas, T., Medina, J. C., Ivtzan, I., Rupprecht, S., & Eiroa-Orosa, F. J. (2018). A systematic
review of the impact of mindfulness on the wellbeing of healthcare professionals.
Journal of Clinical Psychology, 7(3), 319–355. doi: 10.1002/jclp.22515

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
36
Lomas, T., Medina, J. C., Ivtzan, I., Rupprecht, S., Hart, R., & Eiroa-Orosa, F. J. (2017). The
impact of mindfulness on wellbeing and performance in the workplace: An inclusive
systematic review of the empirical literature. European Journal of Work and
Organizational Psychology, 26(4), 492-513. doi: 10.1080/1359432X.2017.1308924
Luken, M., & Sammons, A. (2016). Systematic review of mindfulness practice for reducing
job burnout. American Journal of Occupational Therapy, 70(2). doi:
10.5014/ajot.2016.016956
*Mackenzie, C. S., Poulin, P. A., & Seidman-Carlson, R. (2006). A brief mindfulness-based
stress reduction intervention for nurses and nurse aides. Applied Nursing Research,
19(2), 105-109. doi: 10.1016/j.apnr.2005.08.002
Mannion, R. (2014). Enabling compassionate healthcare: Perils, prospects and perspectives.
International Journal of Health Policy and Management, 2(3), 115-117. doi:
10.15171/ijhpm.2014.34
*Manotas, M., Segura, C., Eraso, M., Oggins, J., & McGovern, K. (2014). Association of
brief mindfulness training with reductions in perceived stress and distress in
Colombian health care professionals. International Journal of Stress Management,
21(2), 207-225. doi: 10.1037/a0035150
*Martín-Asuero, A., & García-Banda, G. (2010). The mindfulness-based stress reduction
program (MBSR) reduces stress-related psychological distress in healthcare
professionals. Spanish Journal of Psychology, 13(2), 897-905.
*Martín-Asuero, A., Queraltó, J. M., Pujol-Ribera, E., Berenguera, A., Rodriguez-Blanco, T.,
& Epstein, R. M. (2014). Effectiveness of a mindfulness education program in
primary health care professionals: A pragmatic controlled trial. Journal of Continuing
Education in the Health Professions, 34(1), 4-12. doi: 10.1002/chp.21211

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
37
*McConachie, D. A. J., McKenzie, K., Morris, P. G., & Walley, R. M. (2014). Acceptance
and mindfulness-based stress management for support staff caring for individuals with
intellectual disabilities. Research in Developmental Disabilities, 35(6), 1216-1227.
doi: 10.1016/j.ridd.2014.03.005
McConville, J., McAleer, R., & Hahne, A. (2017). Mindfulness training for health profession
students—The effect of mindfulness training on psychological well-being, learning
and clinical performance of health professional students: A systematic review of
randomized and non-randomized controlled trials. EXPLORE: The Journal of Science
and Healing, 13(1), 26-45. doi: https://doi.org/10.1016/j.explore.2016.10.002
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for
systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7),
e1000097. doi: doi:10.1371/journal.pmed.1000097
National Collaborating Centre for Methods and Tools (2008). Quality assessment tool for
quantiative studies (QATQS). Hamilton, ON: McMaster University.
*Newsome, S., Waldo, M., & Gruszka, C. (2012). Mindfulness group work: Preventing stress
and increasing self-compassion among helping professionals in training. Journal for
Specialists in Group Work, 37(4), 297-311. doi: 10.1080/01933922.2012.690832
Noetel, M., Ciarrochi, J., Van Zanden, B., & Lonsdale, C. (2017). Mindfulness and
acceptance approaches to sporting performance enhancement: A systematic review.
International Review of Sport and Exercise Psychology, 1-37.
*Noone, S. J., & Hastings, R. P. (2010). Using acceptance and mindfulness-based workshops
with support staff caring for adults with intellectual disabilities. Mindfulness, 1(2), 67-
73. doi: 10.1007/s12671-010-0007-4

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
38
*Pflugeisen, B. M., Drummond, D., Ebersole, D., Mundell, K., & Chen, D. (2016). Brief
video-module administered mindfulness program for physicians: A plot study.
Explore, 12(1), 50-54. doi: 10.1016/j.explore.2015.10.005
*Pipe, T. B., Bortz, J. J., Dueck, A., Pendergast, D., Buchda, V., & Summers, J. (2009).
Nurse leader mindfulness meditation program for stress management: A randomized
controlled trial. Journal of Nursing Administration, 39(3), 130-137.
Pollard, E. L., & Davidson, L. (2001). Foundations of child wellbeing. Paris: UNESCO.
*Poulin, P. A., Mackenzie, C. S., Soloway, G., & Karayolas, E. (2008). Mindfulness training
as an evidenced-based approach to reducing stress and promoting well-being among
human services professionals. International Journal of Health Promotion and
Education, 46(2), 72-80. doi: 10.1080/14635240.2008.10708132
*Raab, K., Sogge, K., Parker, N., & Flament, M. F. (2015). Mindfulness-based stress
reduction and self-compassion among mental healthcare professionals: A pilot study.
Mental Health, Religion and Culture, 18(6), 503-512. doi:
10.1080/13674676.2015.1081588
R Core Team (2017). R: A language and environment for statistical computing. Vienna,
Austria: R Foundation for Statistical Computing. Retrieved from https://www.R-
project.org/.
Riley, R. D., Higgins, J. P. T., & Deeks, J. J. (2011). Interpretation of random effects meta-
analyses. BMJ, 342(feb10 2), d549–d549. doi: 10.1136/bmj.d549
*Rimes, K. A., & Wingrove, J. (2011). Pilot study of mindfulness-based cognitive therapy for
trainee clinical psychologists. Behavioural and Cognitive Psychotherapy, 39(2), 235-
241. doi: 10.1017/S1352465810000731
Rudaz, M., Twohig, M. P., Ong, C. W., & Levin, M. E. (2017). Mindfulness and acceptance-
based trainings for fostering self-care and reducing stress in mental health

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
39
professionals: A systematic review. Journal of Contextual Behavioral Science, 6(4),
380-390. doi: https://doi.org/10.1016/j.jcbs.2017.10.001
Salovey, P., & Mayer, J. D. (1990). Emotional intelligence. Imagination, Cognition, and
Personality, 9(3), 185-211.
Schwarzer, G. (2007). Meta: An R package for meta-analysis. R News, 7(3), 40-45.
Sedgwick, P., & Marston, L. (2013). Meta-analyses: Standardised mean differences. BMJ,
347(dec06 1), f7257–f7257. doi: 10.1136/bmj.f7257
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive
therapy for depression: A new approach to preventing relapse. New York: Guilford
Press.
Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction.
American Psychologist, 55, 5-14.
*Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress
reduction for health care professionals: Results from a randomized trial. International
Journal of Stress Management, 12(2), 164-176. doi: 10.1037/1072-5245.12.2.164
*Shapiro, S. L., Brown, K. W., & Biegel, G. M. (2007). Teaching self-care to caregivers:
Effects of mindfulness-based stress reduction on the mental health of therapists in
training. Training and Education in Professional Psychology, 1(2), 105-115. doi:
10.1037/1931-3918.1.2.105
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of
mindfulness. Journal of Clinical Psychology, 62(3), 373-386. doi: 10.1002/jclp.20237
*Shapiro, S. L., Schwartz, G. E., & Bonner, G. (1998). Effects of mindfulness-based stress
reduction on medical and premedical students. Journal of Behavioral Medicine, 21(6),
581-599. doi: 10.1023/A:1018700829825

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
40
Singh, N. N., Lancioni, G. E., Karazsia, B. T., Myers, R. E., Winton, A. S. W., Latham, L. L.,
& Nugent, K. (2015). Effects of training staff in MBPBS on the use of physical
restraints, staff stress and turnover, staff and peer injuries, and cost effectiveness in
developmental disabilities. Mindfulness, 6(4), 926-937. doi: 10.1007/s12671-014-
0369-0
Singh, N. N., Singh, S. D., Sabaawi, M., Myers, R. E., & Wahler, R. G. (2006). Enhancing
treatment team process through mindfulness-based mentoring in an inpatient
psychiatric hospital. Behavior Modification, 30(4), 423–441. doi:
10.1177/0145445504272971
Smith, M. L. (1980). Publication bias and meta-analysis. Evaluation in Education,
4(Supplement C), 22-24. doi: https://doi.org/10.1016/0191-765X(80)90004-X
Sochos, A., Bowers, A., & Kinman, G. (2012). Work stressors, social support, and burnout in
junior doctors: Exploring direct and indirect pathways. Journal of Employment
Counseling, 49(2), 62-73. doi: 10.1002/j.2161-1920.2012.00007.x
*Song, Y., & Lindquist, R. (2015). Effects of mindfulness-based stress reduction on
depression, anxiety, stress and mindfulness in Korean nursing students. Nurse
Education Today, 35(1), 86-90. doi: 10.1016/j.nedt.2014.06.010
Tang, Y.-Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q., . . . Posner, M. I. (2007). Short-term
meditation training improves attention and self-regulation. Proceedings of the
National Academy of Sciences, 104(43), 17152-17156. doi: 10.1073/pnas.0707678104
The Health & Social Care Information Centre (2009). Adult psychiatric morbidity in
England: Results of a household survey. London: The Health & Social Care
Information Centre.

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
41
Toppinen-Tanner, S., Ojajärvi, A., Väänaänen, A., Kalimo, R., & Jäppinen, P. (2005).
Burnout as a predictor of medically certified sick-leave absences and their diagnosed
causes. Behavioral Medicine, 31(1), 18-32. doi: 10.3200/BMED.31.1.18-32
Trowbridge, K., & Mische Lawson, L. (2016). Mindfulness-based interventions with social
workers and the potential for enhanced patient-centered care: A systematic review of
the literature. Social Work in Health Care, 55(2), 101-124. doi:
10.1080/00981389.2015.1094165
Van Gordon, W., Shonin, E., Lomas, T., & Griffiths, M. D. (2016). Corporate use of
mindfulness and authentic spiritual transmission: Competing or compatible ideals? .
Mindfulness and Compassion, 1(2), 75-83. doi: 10.1016/j.mincom.2016.10.005
Vettese, L. C., Toneatto, T., Stea, J. N., Nguyen, L., & Wang, J. J. (2009). Do mindfulness
meditation participants do their homework? And does it make a difference? A review
of the empirical evidence. Journal of Cognitive Psychotherapy, 23(3), 198-225. doi:
10.1891/0889-8391.23.3.198
Virgili, M. (2015). Mindfulness-based interventions reduce psychological distress in working
adults: A meta-analysis of intervention studies. Mindfulness, 6(2), 326-337. doi:
10.1007/s12671-013-0264-0
Vogus, T. J., Cooil, B., Sitterding, M., & Everett, L. Q. (2014). Safety organizing, emotional
exhaustion, and turnover in hospital nursing units. Medical Care Research and
Review, 52(10), 870-876.
Walsh, R., & Shapiro, S. L. (2006). The meeting of meditative disciplines and western
psychology: A mutually enriching dialogue. American Psychologist, 61(3), 227-239.
doi: 10.1037/0003-066X.61.3.227
Weng, H.-C., Hung, C.-M., Liu, Y.-T., Cheng, Y.-J., Yen, C.-Y., Chang, C.-C., & Huang, C.-
K. (2011). Associations between emotional intelligence and doctor burnout, job

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
42
satisfaction and patient satisfaction. Medical Education, 45(8), 835-842. doi:
10.1111/j.1365-2923.2011.03985.x
*West, C. P., Dyrbye, L. N., Rabatin, J. T., Call, T. G., Davidson, J. H., Multari, A., . . .
Shanafelt, T. D. (2014). Intervention to promote physician well-being, job
satisfaction, and professionalism a randomized clinical trial. JAMA Internal Medicine,
174(4), 527-533. doi: 10.1001/jamainternmed.2013.14387
Wolever, R. Q., Bobinet, K. J., McCabe, K., Mackenzie, E. R., Fekete, E., Kusnick, C. A., &
Baime, M. (2012). Effective and viable mind-body stress reduction in the workplace:
A randomized controlled trial. Journal of Occupational Health Psychology, 17(2),
246-258. doi: 10.1037/a0027278

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Figure 1. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) Flow Diagram
Records identified through
database search
(n = 1,158)
Records identified through
additional searches of reference lists
(n = 9)
Records after duplicates removed
(n = 721)
Records screened
(n = 721)
Records excluded
(n = 543)
Reasons:
- Not about mindfulness (n = 98)
- Not empirical (n = 207)
- Not pertaining to work (172)
- Not pertaining to healthcare (n = 64)
- Not in English (n = 2)
Full-text articles
assessed for eligibility
(n = 178)
Full-text articles excluded
(n = 125)
Reasons:
- Not about mindfulness (n = 7)
- Not empirical (n = 48)
- Not pertaining to healthcare (n = 40)
- Not in English (n = 2)
- Not pre-post intervention (n = 27)
Papers included
(n = 41)

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Table 1. Overview of studies
Authors
Occupation
Design
Expt.
group
Control
group
Intervention
Length
Control
Primary outcome(s)
Barbosa et al.
(2013)
Healthcare
graduates
Nonrandomised,
Convenience
sample
13 (16)
15
MBSR
8 weeks
Nothing
Anxiety (-.09), burnout (emotional exhaustion, -.41; personal
accomplishment, .29; and depersonalisation, -.26), and
compassion & empathy (physician empathy, -.77).
Bazarko, Cate,
Azocar, and
Kreitzer (2013)
Nurses
(corporate)
Pre-Post,
Convenience
sample
36 (41)
-
MBSR adaptation
(6 sessions by
telephone)
8 weeks
N/A
Burnout (personal burnout, -.97; work-related burnout, -.67;
client-related burnout, -.30; and serenity, 1.48), compassion &
empathy (physician empathy, .76; and self-compassion, 1.25),
health (mental health, 1.40; and physical health, -.38), and
stress & strain (perceived stress, -1.21).
Bond et al. (2013)
Trainee doctors
Pre-Post,
Convenience
sample
24 (27)
-
Mind-body
course**
11 weeks
N/A
Compassion & empathy (self-compassion, .17; and physician
empathy, .09), emotional intelligence & regulation (self-
regulation, .01), and stress & strain (perceived stress, -.03).
Bonifas and Napoli
(2014)
Trainee social
workers
Pre-Post,
Convenience
sample
77
-
Mindfulness
curriculum
(specific to study)
16 weeks
N/A
Wellbeing, satisfaction & flourishing (quality of life, .88), and
stress & strain (perceived stress, .06).
Brady, O’Connor,
Burgermeister, and
Hanson (2012)
Psychiatric ward
professionals
Pre-Post,
Convenience
sample
16 (23)
-
MBSR adaptation
4 weeks
N/A
Burnout (emotional exhaustion, -.50; depersonalisation, -.23;
and personal accomplishment, .29), mindfulness & awareness
(mindfulness, .64; and intrapersonal presence, .54), and stress
& strain (stress, -.70).
Burnett and
Pettijohn (2015)
Healthcare
employees
RCT
20 active
18 & 17
MBST
5 weeks
Passive
intervention:
abstention from
work activity.
Control: nothing.
Passive intervention group: stress & strain (perceived stress, -
.09).
No intervention group: stress & strain (perceived stress, -.70).
Cohen and Miller
(2009)
Trainee clinical
psychologists
Pre-Post,
Convenience
sample
21 (28)
-
Interpersonal
mindfulness
training
6 weeks
N/A
Anxiety (-.46), depression (-.11), emotional intelligence &
regulation (emotional intelligence, .39), mindfulness &
awareness (mindful attention awareness, .48), relationships
(social connectedness, 57), stress & strain (perceived stress, -
.53), and wellbeing, satisfaction & flourishing (life satisfaction,
.43; presence of meaning in life, .12; and searching of meaning
in life, -.35).
de Vibe et al.
(2013)
Trainee doctors
RCT
144
144
MBSR adaptation
6 weeks
Nothing
Burnout (burnout, -1.5), distress & anger (distress, -.77),
mindfulness & awareness (non reacting, .31; non judging, -.23;
act aware, -.04; Describe, -.06; and Observe, .18), stress &
strain (stress, -.27), and wellbeing, satisfaction & flourishing
(subjective wellbeing, .43).
Dobie, Tucker,
Ferrari, and Rogers
(2015)
Mental health
professionals
Pre-Post,
Convenience
sample
9
-
MBSR adaptation
8 weeks
N/A
Anxiety (-.86), depression (-.44), mindfulness & awareness
(mindfulness, -.41), and stress & strain (stress, -.96).

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Erogul, Singer,
McIntyre, and
Stefanov (2014)
Trainee doctors
RCT
28
30
MBCT
8 weeks
Nothing
Compassion & empathy (self-compassion, .88), resilience
(resilience, .27), and stress & strain (perceived stress, -.60).
Fortney,
Luchterhand,
Zakletskaia,
Zgierska, and Rakel
(2013)
Primary care
clinicians
Pre-Post,
Convenience
sample
28 (30)
-
MBSR adaptation
18 hours
(over 5
sessions)
N/A
Anxiety (-.47), burnout (emotional exhaustion, -.31;
depersonalisation, -22; and personal accomplishment, .50),
depression (depression, -.54), compassion & empathy
(compassion, -.04), resilience (resilience, .17), and stress &
strain (perceived stress, -.54; and stress, -.31).
Foureur, Besley,
Burton, Yu, and
Crisp (2013)
Nurses &
midwives
Pre-Post,
Convenience
sample
28 (40)
MBSR adaptation
1 day (& 8
weeks
practice)
Anxiety (-.28), depression (-.33), distress & anger (distress, -
.59), stress & strain (stress, -.65), and wellbeing, satisfaction &
flourishing (sense of coherence, .73).
Gauthier, Meyer,
Grefe, and Gold
(2015)
Paediatric ICU
nurses
Pre-Post,
Convenience
sample
42 (45)
-
Mindfulness
program (specific
to study)
30 days
N/A
Burnout (emotional exhaustion, -.18; depersonalisation, -.13;
and personal accomplishment, .12), compassion & empathy
(self-compassion, .23), mindfulness & awareness (mindful
attention awareness, .07), and stress & strain (stress, -.40).
Goodman and
Schorling (2012)
Healthcare
professionals
Pre-Post,
Convenience
sample
73 (93)
-
Mindfulness for
healthcare
providers
8 weeks
N/A
Physicians sample: Burnout (emotional exhaustion, -.72;
depersonalisation, -.44; and personal accomplishment, .60),
health (physical health, -.16; and mental health, 1.00).
Other healthcare providers sample: Burnout (emotional
exhaustion, -.29; depersonalisation, -.27; and personal
accomplishment, .44), and health (physical health, -.02; and
mental health, .78).
Grepmair,
Mitterlehner, Loew,
and Nickel (2007)
Trainee
psychotherapists
Nonrandomised,
Convenience
sample
58
55
Mindfulness
program (specific
to study)
9 weeks
Pre-training
Job performance (patients’ distress, -.93).
Hallman,
O’Connor,
Hasenau, and Brady
(2014)
Psychiatric
service
professionals
Pre-Post,
Convenience
sample
12 (13)
-
MBSR
8 days
N/A
Mindfulness & awareness (mindfulness, .68), and stress &
strain (perceived stress, -.20).
Hopkins and Proeve
(2013)
Trainee
psychologists
Pre-Post,
Convenience
sample
11 (12)
-
MBCT
8 weeks
N/A
Compassion & empathy (emotional concern, -.40; perspective
taking, -.37; personal distress, -.23; and fantasy, -.30),
mindfulness & awareness (non reacting, .77; observe, .43; non
judging, 1.27; act aware, .11; and describe, .18), and stress &
strain, (perceived stress, -.67).
Johnson, Emmons,
Rivard, Griffin, and
Dusek (2015)
Healthcare
professionals
Nonrandomised,
Convenience
sample
18 (20)
19 (20)
Resilience
training
8 weeks
Wait-list
Anxiety (state, -1.02; and trait, -1.41), depression (depression
with the CESD-10, -1.50; and depression with the PHQ-9, -
1.56), health (health responsibility, .96; interpersonal relations,
1.40; nutrition, .34; physical activity, .81; spiritual growth, .99;
stress management, 1.17; abseentism, -.50; activity impairment,
-1.23; presenteeism, -1.28; and work productivity loss, -1.38),
and stress & strain (perceived stress, -1.30).
Kemper and
Khirallah (2015)
Health
professionals
Pre-Post,
Convenience
sample
112 one
module
and 102
the other
-
Introduction to
Mindfulness, and
Mindfulness in
daily life
1 hour
N/A
Mindfulness & awareness (cognitive and affective mindfulness,
.24; and mindful attention awareness, .20), and resilience
(resilience, .21).
Krasner et al.
(2009)
Primary care
physicians
Pre-Post,
Convenience
sample
59 (70)
-
Mindfulness
program (specific
to study)
8 weeks
N/A
Burnout (emotional exhaustion, -.37; depersonalisation, -.19;
and personal accomplishment, .15), compassion & empathy

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
46
(physician empathy, .36), distress & anger (distress, -.47),
mindfulness & awareness (mindfulness, .86).
Mackenzie, Poulin,
and Seidman-
Carlson (2006)
Nurses
RCT
16
14
MBSR adaptation
4 weeks
Wait-list
Burnout (emotional exhaustion, 3.44; depersonalisation, -.20;
and personal accomplishment, 8.27), wellbeing, satisfaction &
flourishing (relaxation dispositions, .24; intrinsic job
satisfaction, .17; satisfaction with life, -.13; and sense of
coherence, .16).
Manotas, Segura,
Eraso, Oggins, and
McGovern (2014)
Healthcare
professionals
RCT
40 (66)
43 (65)
MBSR adaptation
4 weeks
NR
Distress & anger (distress, -.61), mindfulness & awareness
(non reacting, .03; non judging, .32; act aware, -.29; Describe, -
.28; Observe, .23; and Total mindfulness, .07), and stress &
strain (perceived stress, -.68).
Martín-Asuero and
García-Banda
(2010)
Healthcare
professionals
Pre-Post, Selected
sample
29
-
MBSR adaptation
8 weeks
N/A
Distress & anger (psychological distress, -.59), emotional
intelligence & regulation (rumination, -.19), stress & strain
(daily stress, -.39), and wellbeing, satisfaction & flourishing,
(negative affect, -.26).
Martín-Asuero et al.
(2014)
Healthcare
professionals
RCT
43
25
MBSR adaptation
8 weeks
Wait-list
Burnout (emotional exhaustion, -7.20; depersonalisation, -1.80;
and personal accomplishment, 1.40), compassion & empathy
(physician empathy, .40), distress & anger (distress, -.83), and
mindfulness & awareness (non reacting, 1.21; non judging, .49;
act aware, .84; Describe, .44; and Observe, 1.27).
McConachie,
McKenzie, Morris,
and Walley (2014)
Support staff
RCT
66
54
Acceptance and
mindfulness
workshop
1.5 days
Wait-list
Distress & anger (distress, -.35), and wellbeing, satisfaction &
flourishing (mental wellbeing, .17).
Newsome, Waldo,
and Gruszka (2012)
Trainee helping
professionals
Pre-Post,
Convenience
sample
31
-
Mindfulness
program (specific
to study)
6 weeks
N/A
Compassion & empathy (self-compassion, 1.13), mindfulness
& awareness (mindful attention awareness, .91), and stress &
strain (perceived stress, -1.01).
Noone and Hastings
(2010)
Disability support
workers
Pre-Post,
Convenience
sample
34
-
Promotion of
acceptance in
carers and
teachers
1.5 days
N/A
Distress & anger (distress, -.54), and stress & strain (stress, -
.13).
Pflugeisen,
Drummond,
Ebersole, Mundell,
and Chen (2016)
Physicians
Pre-Post,
Convenience
sample
19 (23)
-
MBSR adaptation
8 weeks
N/A
Burnout (emotional exhaustion, -.46; depersonalisation, -.32;
and personal accomplishment, .56), mindfulness & awareness
(mindfulness skills, .84), and stress & strain (perceived stress, -
.87).
Pipe et al. (2009)
Nurses
RCT
15
17
MBSR adaptation
4 weeks
Wait-list
Anxiety (-.21), depression (-.54), distress & anger
(psychological distress, -.39), job performance (caring efficacy,
.48), and relationships (interpersonal sensitivity, -.38).
Poulin, Makenzie,
Soloway, and
Karayolas (2008)
Nurses
Nonrandomised,
Convenience
Sample
16
10 & 14
MBSR adaptation
4 weeks
Imagery &
progressive
muscle
relaxation, &
wait-list
Mindfulness vs. Imagery & progressive muscle relaxation:
burnout (emotional exhaustion, -.07; depersonalisation, -.16;
and personal accomplishment, .73), and wellbeing, satisfaction
& flourishing (relaxation, -.63; and satisfaction with life, .15).
Mindfulness vs. wait-list: burnout (emotional exhaustion, .22;
depersonalisation, .00; and personal accomplishment, 1.32),
and wellbeing, satisfaction & flourishing (relaxation, .24; and
satisfaction with life, -.07).

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
47
Raab, Sogge,
Parker, and Flament
(2015)
Mental health
professionals
Pre-Post,
Convenience
sample
22
-
MBSR
8 weeks
N/A
Burnout (emotional exhaustion, -.20; depersonalisation, -.11;
and personal accomplishment, .20), compassion & empathy
(self-compassion, .48), and wellbeing, satisfaction &
flourishing (quality of life, .02).
Rimes and
Wingrove (2011)
Trainee clinical
psychologists
Pre-Post,
Convenience
sample
20
-
MBCT
8 weeks
N/A
Anxiety (.26), compassion & empathy (empathic concern, .00;
fantasy, .52; personal distress, -.06; perspective taking, -.03;
and self-compassion, .48), depression (depression, .00; and
rumination, -.57), mindfulness & awareness (non reacting, .59;
non judging, .52; act aware, .10; Describe, .31; and Observe,
.38), and stress & strain (perceived stress, -.23).
Shapiro, Astin,
Bishop, and
Cordova (2005)
Healthcare
professionals
RCT
10 (18)
18 (20)
MBSR
8 weeks
Wait-list
Burnout (emotional exhaustion, -2.10; depersonalisation, -3.38;
and personal accomplishment, 3.38), compassion & empathy
(self-compassion, .02), distress & anger (distress, -.07), stress
& strain (perceived stress, -.15), and wellbeing, satisfaction &
flourishing (satisfaction with life, .15).
Shapiro, Brown,
and Biegel (2007)
Trainee
psychotherapists
Nonrandomised,
Convenience
sample
22
32 (42)
MBSR
8 weeks
Psychology
courses
Anxiety (state, -.55; and trait, -.91), compassion & empathy
(self-compassion, .42), depression (rumination, -.41),
mindfulness & awareness (mindful attention awareness, .36),
stress & strain (perceived stress, -.67), and wellbeing,
satisfaction & flourishing (positive affect, .57; and negative
affect, -.46).
Shapiro, Schwartz,
and Bonner (1998)
Trainee doctors
RCT
37
36
Stress reduction
and relaxation
7 weeks
Wait-list
Anxiety (state, -.46; and trait, -.59), compassion & empathy
(empathy, .47), depression (depression, -.46), distress & anger
(psychological distress, -.69), and wellbeing, satisfaction &
flourishing (spirituality, .32).
Song and Lindquist
(2015)
Trainee nurses
RCT
21 (25)
23 (25)
MBSR
8 weeks
Wait-list
Anxiety (-.50), depression (-.70), mindfulness & awareness
(mindful attention awareness, .13), and stress & strain (stress, -
.85).
West et al. (2014)
Physicians
RCT
35 (37)
37
Small group
curriculum*
9 months
Nothing
Compassion & empathy (physician empathy, -.05), stress &
strain (perceived stress, .13); and wellbeing, satisfaction &
flourishing (job satisfaction, -.14).
Note. expt = experimental group; cnt = control group; PI = post-intervention; NR = not-reported; MBCT = mindfulness-based cognitive therapy; MBSR = mindfulness-based stress reduction; MBST = mindfulness-
based stress reduction therapy. MM = mindfulness meditation; NCC = neural correlates of consciousness; NR = not recorded; N/A = not applicable; NA = not available; RCT = randomized controlled trial;.* =
number in parenthesis is the initial sample size (if different from sample size featured in analysis); ** = mindfulness just one component of broader intervention.

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
48
Table 2. Summary of common outcomes across all studies
Outcome
Number of studies
assessing
Improvement related to
mindfulness intervention
No change in relation to
mindfulness intervention*
Anxiety
11
10
1
Burnout
14
7
7
Compassion
12
9
3
Depression
9
4
5
Distress
13
11
2
Emotional regulation
3
0
3
Health
3
3
0
Empathy
7
6
1
Job performance
4
3
1
Mindfulness
19
15
4
Stress
27
19
8
Positive wellbeing
14
7
7
* The studies included in this category showed no significant improvements in the given outcome. None of the studies showed statistically significant deteriorations.

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
49
Table 3. QATQS Scoring Assessment of Studies
Authors
Selection bias
Design
Cofounders
blinding
Data collection
Attrition
Global
Barbosa et al. (2013)
3
3
2
3
2
2
3
Bazarko et al. (2013)
2
3
3
3
2
1
3
Bond et al. (2013)
3
3
3
3
2
2
3
Bonifas and Napoli
(2014)
3
3
3
3
1
1
3
Brady et al. (2012)
3
3
3
3
2
2
3
Burnett and Pettijohn
(2015)
3
2
2
3
1
2
3
Cohen and Miller
(2009)
3
3
3
3
1
2
3
de Vibe et al. (2013)
2
1
1
1
1
1
1
Dobie et al. (2015)
3
3
3
3
1
1
3
Erogul et al (2014)
1
1
1
1
1
2
1
Fortney et al. (2013)
3
3
3
3
1
1
3
Foureur et al. (2013)
3
3
3
3
1
2
3
Gauthier et al. (2015)
3
3
3
3
1
2
3
Goodman and
Schorling (2012)
2
3
3
3
1
3
3
Grepmair et al. (2007)
2
2
1
2
1
1
2
Hallman et al. (2014)
2
3
3
2
1
1
3
Hopkins and Proeve
(2013)
3
3
3
3
1
2
3
Johnson et al. (2015)
3
3
1
3
1
2
3
Kemper and Khirallah
(2015)
3
3
3
3
1
2
3
Krasner et al. (2009)
2
3
3
3
1
2
3
Mackenzie et al. (2006)
3
2
2
3
1
2
3
Manotas et al. (2014)
2
2
1
3
1
2
2
Martín-Asuero and
García-Banda (2010)
2
3
3
3
1
1
3
Martín-Asuero et al.
(2014)
2
2
2
3
1
1
2
McConachie et al.
(2014)
2
1
1
3
1
2
2
Newsome et al. (2012)
1
3
3
2
1
2
3
Noone and Hastings
(2010)
1
3
3
1
1
3
3
Pflugeisen et al. (2015)
1
3
3
2
2
1
3
Pipe et al. (2009)
2
1
2
1
1
1
1
Poulin et al. (2008)
1
2
1
1
1
3
2
Raab et al. (2015)
1
3
3
2
1
2
3
Rimes and Wingrove
(2011)
1
3
3
1
1
3
3
Shapiro et al. (1998)
1
1
2
1
1
1
1
Shapiro et al. (2005)
1
1
2
2
1
3
2

Running title: MINDFULNESS IN HEALTHCARE PROFESSIONALS
50
Shapiro et al. (2007)
1
2
1
2
1
1
1
Song and Lindquist
(2015)
1
1
2
1
1
1
1
West et al. (2014)
1
1
1
1
1
2
1