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The eye of the storm: a feasibility study of an adapted Mindfulness-based Cognitive Therapy (MBCT) group intervention to manage NHS staff stress

Published online by Cambridge University Press:  19 December 2014

Robert Marx ,
Clara Strauss ,
Cleo Williamson ,
Karunavira  and
Taravajra
Robert Marx*
Affiliation:
Sussex Partnership NHS Foundation Trust, Training Department, East Brighton Community Mental Health Centre, Brighton General Hospital, Brighton, UK
Clara Strauss
Affiliation:
Sussex Partnership NHS Foundation Trust, Research and Development Department, Sussex Education Centre, Hove, UK
Cleo Williamson
Affiliation:
Sussex Partnership NHS Foundation Trust, Training Department, East Brighton Community Mental Health Centre, Brighton General Hospital, Brighton, UK
Karunavira
Affiliation:
Mindful Health, 40 St Luke's Road, Brighton, UK
Taravajra
Affiliation:
Mindful Health, 40 St Luke's Road, Brighton, UK
*
*Author for correspondence: Dr R. Marx, Sussex Partnership NHS Foundation Trust, Training Department, East Brighton Community Mental Health centre, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, UK (email: robert.marx@sussexpartnership.nhs.uk).
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Abstract

A feasibility study evaluated five adapted Mindfulness-based Cognitive Therapy (MBCT) groups that were delivered to staff in a National Health Service (NHS) mental health Trust as part of a staff health and wellbeing initiative. Using an uncontrolled design typical of a feasibility study, recruitment, retention and acceptability of the groups were assessed. Effectiveness was also measured at pre- and post-therapy, and at 3-month follow-up, using quantitative methods. In addition, qualitative methods were used to explore staff experiences of the groups. Results demonstrated high levels of feasibility, and significant improvements in staff perceived stress and self-compassion at both post-therapy and follow-up. Qualitative data suggested many staff felt the groups had improved their physical and emotional health, their ability to manage stress at work and the quality of their work with patients and of their relationships with colleagues. Although Mindfulness-based Stress Reduction (MBSR) has typically been used to help manage staff stress, these results are promising for the use of an adapted MBCT with this population. Challenges and factors contributing to these outcomes are discussed.

Keywords

MBCTmental healthmindfulnessNHSstaffstress
Type
Original Research
Information
the Cognitive Behaviour Therapist , Volume 7 , December 2014 , e18
Copyright
Copyright © British Association for Behavioural and Cognitive Psychotherapies 2014 

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References

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De Zoysa, N, Hutton, J, Ruths, FA, Frearson, SJ, Williams, JMG, Walsh, J (2013). Mindfulness-based cognitive therapy for mental health professionals – a pilot study. Mindfulness 4, 289–295.Google Scholar
Segal, ZV, Williams, JMG, Teasdale, JD (2013). Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse, 2nd edn. New York: Guilford Press.Google Scholar
Shapiro, SL, Astin, JA, Bishop, SR, Cordova, M (2005). Mindfulness-based stress reduction for health care professionals: results from a randomised trial. International Journal of Stress Management 12, 164–176.Google Scholar
Bimbaum, L (2008). The use of mindfulness training to create an ‘accompanying place’ for social work students. Social Work Education 27, 837–852.Google Scholar
Braun, M, Schonfelt-Lecuona, C, Freudenmann, RW, Mehta, T, Hay, B, Kachele, H, Beschoner, P (2010). Depression, burnout and effort-reward imbalance among psychiatrists. Psychotherapy and Psychosomatics 79, 326–327.Google Scholar
Braun, V, Clarke, V (2006). Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101.Google Scholar
Butler, SK, Constantine, MG (2005). Collective self-esteem and burnout in professional school counsellors. Professional School Counseling 9, 55–62.Google Scholar
Chiesa, A, Serretti, A (2009). Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. Journal of Alternative and Complementary Medicine 15, 593–600.Google Scholar
Cohen, S, Williamson, G (1988). Perceived stress in a probability sample of the United States. In: The Social Psychology of Health (ed. Spacapan, S. and Oskamp, S.), pp. 31–67. Newbury Park, CA: Sage.Google Scholar
Cohen-Katz, JE, Wiley, S, Capuano, T, Baker, DM, Dietrick, L, Shapiro, S (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout: a qualitative and quantitative study, part III. Holistic Nursing Practice 19, 78–86.Google Scholar
De Zoysa, N, Hutton, J, Ruths, FA, Frearson, SJ, Williams, JMG, Walsh, J (2013). Mindfulness-based cognitive therapy for mental health professionals – a pilot study. Mindfulness 4, 289–295.Google Scholar
Elliott, E, Harrap, E, Rothwell, H, Shepherd, M, Williams, G (2013). The impact of the economic downturn on health in Wales: a review and case study. Cardiff: Cardiff Institute of Society and Health.Google Scholar
Elliott, R, Slatick, E, Urmann, M (2001). Qualitative change process research on psychotherapy: alternative strategies. Psychologische Beitrage 43, 69–111.Google Scholar
Enochs, WK, Etzbach, CA. (2004). Impaired student counsellors: ethical and legal considerations for the family. The Family Journal 12, 396–400.Google Scholar
Flanagan, NA, Flanagan, TJ (2002). An analysis of the relationship between job satisfaction and job stress in correctional nurses. Research in Nursing and Health 25, 282–294.Google Scholar
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, 412–420.Google Scholar
Francis, R (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery OfficeGoogle Scholar
Galantino, ML, Baime, M, Maguire, M, Szapary, PO, Farrar, J (2005). Association of psychological and physiological measures of stress in health-care professionals during an 8 week mindfulness meditation program: mindfulness in practice. Stress and Health: Journal of the International Society for the Investigation of Stress 21, 255–261.Google Scholar
Garman, A, Corrigan, P, Morris, S (2002). Staff burnout and patient satisfaction: evidence of relationships at the care unit level. Journal of Occupational Health Psychology 7, 235–241.Google Scholar
Gilroy, PJ, Carroll, L, Murra, J (2002). A preliminary survey of counseling psychologists' personal experiences with depression and treatment. Professional Psychology: Research and Practice 33, 402–407.Google Scholar
Gokhan, N, Meehan, EF, Peters, K (2010). The value of mindfulness-based methods in teaching at a clinical field placement. Psychological Reports 106, 455–466.Google Scholar
Grepmair, L, Mitterlehner, F, Loew, T, Bachler, E, Rother, W, Nickel, M (2007). Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, double-blind, controlled study. Psychotherapy and Psychosomatics 76, 332–338.Google Scholar
Ham, C, Dixon, A, Brooke, B (2012). Transforming the Delivery of Health and Social Care: the Case for Fundamental Change. London: King's Fund.Google Scholar
Hewitt, PL, Flett, GL, Mosher, SW (1992). The perceived stress scale: factor structure and relation to depression symptoms in a psychiatric sample. Journal of Psychopathology and Behavioral Assessment 14, 247–257.Google Scholar
IBM Corp. (2010). IBM SPSS Statistics for Windows, version 19. Armonk, NY: IBM.Google Scholar
Irving, JA, Dobkin, PL, Park, J (2009). Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness-based stress reduction (MBSR). Complementary Therapies in Clinical Practice 15, 61–66.Google Scholar
Jacobson, NS, Truax, P (1991). Clinical significance: statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical psychology 59, 12–19.Google Scholar
Jain, S, Shapiro, SL, Swanick, S, Roesch, SC, Mills, PJ, Bell, I (2007). A randomized controlled trail of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination and distraction. Annals of Behavioural Medicine 33, 1–21.Google Scholar
Kieselbach, Th, Armgarth, E, Bagnara, S, Elo, A-L, Jeffreys, S. Joling, C, Kuhn, K, Nielsen, K, Popma, J, Rogovsky, N, Sahler, B, Thomson, G, Triomphe, CE, Wiederszal-Bazyl, M (2009). Health in Restructuring: Innovative Approaches and Policy Recommendations. University of Bremen and the Institute for Psychology of Work, Unemployment and Health.Google Scholar
Krasner, MS, Epstein, RM, Beckman, H, Suchman, AL, Chapman, B, Mooney, CJ, Quille, TE (2009). Association of an educational program in mindful communication with burnout, empathy and attitudes among primary care physicians. Journal of the American Medical Association 302, 1284–1293.Google Scholar
Kuyken, W, Watkins, E, Holden, E, White, K, Taylor, R, Byford, S, Evans, A, Radford, S, Teasdale, JD, Dalgleish, T (2010). How does mindfulness-based cognitive therapy work? Behaviour Research and Therapy 48, 1105–1112.Google Scholar
Ma, SH, Teasdale, JD (2004). Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology 72, 31–40.Google Scholar
Mackenzie, CS, Smith, MC, Hasher, L, Leach, L, Behl, P (2007). Cognitive functioning under stress: evidence from informal caregivers of palliative patients. Journal of Palliative Medicine 10, 749–758.Google Scholar
McCollum, EE, Gehart, DR (2010). Using mindfulness meditation to teach beginning therapists therapeutic presence: a qualitative study. Journal of Marital and family Therapy 36, 347–360.Google Scholar
National Institute for Health Research (NIHR) (2013). Evaluation, Trials and Studies Coordinating Centre: Glossary (http://www.netscc.ac.uk/glossary/).Google Scholar
Neff, KD (2003). Development and validation of a scale to measure self-compassion. Self and Identity 2, 223–250.Google Scholar
Neff, KD, Rude, SS, Kirkpatrick, K (2007). An examination of self-compassion in relation to positive psychological functioning and personality traits. Journal of Research in Personality 41, 908–916.Google Scholar
Newsome, S, Christopher, JC, Dahlen, P, Christopher, S (2006). Teaching counsellors self-care through mindfulness practices. Teachers College Record 108, 1881–1990.CrossRefGoogle Scholar
PPMA (Sector Public People Managers’ Association) (2012). Leading culture change: employee engagement and public service transformation. Policy into Practice. London: Chartered Institute of Personnel and Development.Google Scholar
Rosenzweig, S, Reibel, DK, Gresson, JM, Brainard, GC, Hojat, M (2003). Mindfulness-based stress reduction lowers psychological distress in medical students. Teaching and Learning in Medicine 15, 88–92.CrossRefGoogle ScholarPubMed
Ryback, CJ, Russell-Chaplin, LA (1998). The teaching well: experience, education and counselling. International Journal for the Advancement of Counseling 20, 131–139.Google Scholar
Schenström, A, Rönnberg, S, Bodlund, O (2006). Mindfulness-based cognitive attitude training for primary care staff: a pilot study. Complemenatry Health Practices Review 11, 144–152.Google Scholar
Schure, MB, Christopher, J, Christopher, S (2008). Mind-body medicine and the art of self-care: teaching mindfulness to counseling students through yoga, meditation and qigong. Journal of Counseling and Development 86, 47–54.CrossRefGoogle Scholar
Segal, ZV, Williams, JMG, Teasdale, JD (2002). Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York: Guilford Press.Google Scholar
Shanefelt, TD, Bradley, KA, Wipf, JE, Back, AL (2002). Burnout and self-reported patient care in an internal medicine residency program. Annals of Internal Medicine 136, 358–367.Google Scholar
Shapiro, SL, Astin, JA, Bishop, SR, Cordova, M (2005). Mindfulness-based stress reduction for health care professionals: results from a randomised trial. International Journal of Stress Management 12, 164–176.Google Scholar
Shapiro, SL, Brown, KW, Biegel, GM (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, 105–115.Google Scholar
Shapiro, SL, Burnham, CL (2011). Mindfulness and healthcare professionals. In: The Art and Science of health Care (ed. Kirkcaldy, B. D.), pp. 243–262. Cambridge, MA: Hogrefe.Google Scholar
Shapiro, SL, Carlson, LE (2009). The Art and Science of Mindfulness: Integrating Mindfulness into Psychology and the Helping Professions. Washington DC: American Psychological Association.Google Scholar
Shapiro, SL, Carlson, LE, Astin, JA, Freedman, B (2006). Mechanisms of mindfulness. Journal of Clinical psychology 62, 373–386.CrossRefGoogle ScholarPubMed
Spickard, A, Gabbe, S, Christensen, J (2002). Mid-career burnout in generalist and specialist physicians. Journal of the American Medical Association 288, 1447–1450.Google Scholar
Teasdale, JD, Segal, ZV, Williams, JMG, Ridgeway, VA, Soulsby, JM, Lau, MA (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology 68, 615–623.Google Scholar
Thomas, MR, Dyrbye, LN, Huntington, JL, Lawson, KL, Novotny, PJ, Sloan, JA, Shanafelt, TD (2007). How do distress and well-being relate to medical student empathy? A multicenter study. Journal of General Medicine 22, 1497–1525.Google Scholar
Tyssen, R, Vaglum, P, Gronvold, NT, Ekeberg, O (2001). Suicidal ideation among medical students and young physician: a nationwide and prospective study of prevalence and predictors. Journal of Affective Disorders 64, 69–79.Google Scholar
UK Network for Mindfulness-based Teacher training Organisations (2012). Good Practice Guidelines for teaching mindfulness-based courses (http://mindfulnessteachersuk.org.uk/pdf/teacher-guidelines.pdf).Google Scholar
UNISON (2014). Running on Empty: NHS Staff Stretched to the Limit. London: UNISON.Google Scholar
Vahey, DC, Aitken, M, Sloane, DM, Clarke, SP, Vargs, D (2004). Nurse burnout and patient satisfaction. Medical Care 42, 57–66.Google Scholar
Van Dam, NT, Sheppard, SC, Forsyth, JP, Earleywine, M (2011). Self-compassion is a better predictor than mindfulness of symptom severity and quality of life in mixed anxiety and depression. Journal of Anxiety Disorders 25, 123–130.Google Scholar
Wong, J (2008). Doctors and stress. The Hong Kong Medical Diary 13, 4–7.Google Scholar
Bimbaum, L (2008). The use of mindfulness training to create an ‘accompanying place’ for social work students. Social Work Education 27, 837–852.Google Scholar
Braun, M, Schonfelt-Lecuona, C, Freudenmann, RW, Mehta, T, Hay, B, Kachele, H, Beschoner, P (2010). Depression, burnout and effort-reward imbalance among psychiatrists. Psychotherapy and Psychosomatics 79, 326–327.Google Scholar
Braun, V, Clarke, V (2006). Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101.Google Scholar
Butler, SK, Constantine, MG (2005). Collective self-esteem and burnout in professional school counsellors. Professional School Counseling 9, 55–62.Google Scholar
Chiesa, A, Serretti, A (2009). Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. Journal of Alternative and Complementary Medicine 15, 593–600.Google Scholar
Cohen, S, Williamson, G (1988). Perceived stress in a probability sample of the United States. In: The Social Psychology of Health (ed. Spacapan, S. and Oskamp, S.), pp. 31–67. Newbury Park, CA: Sage.Google Scholar
Cohen-Katz, JE, Wiley, S, Capuano, T, Baker, DM, Dietrick, L, Shapiro, S (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout: a qualitative and quantitative study, part III. Holistic Nursing Practice 19, 78–86.Google Scholar
De Zoysa, N, Hutton, J, Ruths, FA, Frearson, SJ, Williams, JMG, Walsh, J (2013). Mindfulness-based cognitive therapy for mental health professionals – a pilot study. Mindfulness 4, 289–295.Google Scholar
Elliott, E, Harrap, E, Rothwell, H, Shepherd, M, Williams, G (2013). The impact of the economic downturn on health in Wales: a review and case study. Cardiff: Cardiff Institute of Society and Health.Google Scholar
Elliott, R, Slatick, E, Urmann, M (2001). Qualitative change process research on psychotherapy: alternative strategies. Psychologische Beitrage 43, 69–111.Google Scholar
Enochs, WK, Etzbach, CA. (2004). Impaired student counsellors: ethical and legal considerations for the family. The Family Journal 12, 396–400.Google Scholar
Flanagan, NA, Flanagan, TJ (2002). An analysis of the relationship between job satisfaction and job stress in correctional nurses. Research in Nursing and Health 25, 282–294.Google Scholar
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, 412–420.Google Scholar
Francis, R (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery OfficeGoogle Scholar
Galantino, ML, Baime, M, Maguire, M, Szapary, PO, Farrar, J (2005). Association of psychological and physiological measures of stress in health-care professionals during an 8 week mindfulness meditation program: mindfulness in practice. Stress and Health: Journal of the International Society for the Investigation of Stress 21, 255–261.Google Scholar
Garman, A, Corrigan, P, Morris, S (2002). Staff burnout and patient satisfaction: evidence of relationships at the care unit level. Journal of Occupational Health Psychology 7, 235–241.Google Scholar
Gilroy, PJ, Carroll, L, Murra, J (2002). A preliminary survey of counseling psychologists' personal experiences with depression and treatment. Professional Psychology: Research and Practice 33, 402–407.Google Scholar
Gokhan, N, Meehan, EF, Peters, K (2010). The value of mindfulness-based methods in teaching at a clinical field placement. Psychological Reports 106, 455–466.Google Scholar
Grepmair, L, Mitterlehner, F, Loew, T, Bachler, E, Rother, W, Nickel, M (2007). Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, double-blind, controlled study. Psychotherapy and Psychosomatics 76, 332–338.Google Scholar
Ham, C, Dixon, A, Brooke, B (2012). Transforming the Delivery of Health and Social Care: the Case for Fundamental Change. London: King's Fund.Google Scholar
Hewitt, PL, Flett, GL, Mosher, SW (1992). The perceived stress scale: factor structure and relation to depression symptoms in a psychiatric sample. Journal of Psychopathology and Behavioral Assessment 14, 247–257.Google Scholar
IBM Corp. (2010). IBM SPSS Statistics for Windows, version 19. Armonk, NY: IBM.Google Scholar
Irving, JA, Dobkin, PL, Park, J (2009). Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness-based stress reduction (MBSR). Complementary Therapies in Clinical Practice 15, 61–66.Google Scholar
Jacobson, NS, Truax, P (1991). Clinical significance: statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical psychology 59, 12–19.Google Scholar
Jain, S, Shapiro, SL, Swanick, S, Roesch, SC, Mills, PJ, Bell, I (2007). A randomized controlled trail of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination and distraction. Annals of Behavioural Medicine 33, 1–21.Google Scholar
Kieselbach, Th, Armgarth, E, Bagnara, S, Elo, A-L, Jeffreys, S. Joling, C, Kuhn, K, Nielsen, K, Popma, J, Rogovsky, N, Sahler, B, Thomson, G, Triomphe, CE, Wiederszal-Bazyl, M (2009). Health in Restructuring: Innovative Approaches and Policy Recommendations. University of Bremen and the Institute for Psychology of Work, Unemployment and Health.Google Scholar
Krasner, MS, Epstein, RM, Beckman, H, Suchman, AL, Chapman, B, Mooney, CJ, Quille, TE (2009). Association of an educational program in mindful communication with burnout, empathy and attitudes among primary care physicians. Journal of the American Medical Association 302, 1284–1293.Google Scholar
Kuyken, W, Watkins, E, Holden, E, White, K, Taylor, R, Byford, S, Evans, A, Radford, S, Teasdale, JD, Dalgleish, T (2010). How does mindfulness-based cognitive therapy work? Behaviour Research and Therapy 48, 1105–1112.Google Scholar
Ma, SH, Teasdale, JD (2004). Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology 72, 31–40.Google Scholar
Mackenzie, CS, Smith, MC, Hasher, L, Leach, L, Behl, P (2007). Cognitive functioning under stress: evidence from informal caregivers of palliative patients. Journal of Palliative Medicine 10, 749–758.Google Scholar
McCollum, EE, Gehart, DR (2010). Using mindfulness meditation to teach beginning therapists therapeutic presence: a qualitative study. Journal of Marital and family Therapy 36, 347–360.Google Scholar
National Institute for Health Research (NIHR) (2013). Evaluation, Trials and Studies Coordinating Centre: Glossary (http://www.netscc.ac.uk/glossary/).Google Scholar
Neff, KD (2003). Development and validation of a scale to measure self-compassion. Self and Identity 2, 223–250.Google Scholar
Neff, KD, Rude, SS, Kirkpatrick, K (2007). An examination of self-compassion in relation to positive psychological functioning and personality traits. Journal of Research in Personality 41, 908–916.Google Scholar
Newsome, S, Christopher, JC, Dahlen, P, Christopher, S (2006). Teaching counsellors self-care through mindfulness practices. Teachers College Record 108, 1881–1990.CrossRefGoogle Scholar
PPMA (Sector Public People Managers’ Association) (2012). Leading culture change: employee engagement and public service transformation. Policy into Practice. London: Chartered Institute of Personnel and Development.Google Scholar
Rosenzweig, S, Reibel, DK, Gresson, JM, Brainard, GC, Hojat, M (2003). Mindfulness-based stress reduction lowers psychological distress in medical students. Teaching and Learning in Medicine 15, 88–92.CrossRefGoogle ScholarPubMed
Ryback, CJ, Russell-Chaplin, LA (1998). The teaching well: experience, education and counselling. International Journal for the Advancement of Counseling 20, 131–139.Google Scholar
Schenström, A, Rönnberg, S, Bodlund, O (2006). Mindfulness-based cognitive attitude training for primary care staff: a pilot study. Complemenatry Health Practices Review 11, 144–152.Google Scholar
Schure, MB, Christopher, J, Christopher, S (2008). Mind-body medicine and the art of self-care: teaching mindfulness to counseling students through yoga, meditation and qigong. Journal of Counseling and Development 86, 47–54.CrossRefGoogle Scholar
Segal, ZV, Williams, JMG, Teasdale, JD (2002). Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York: Guilford Press.Google Scholar
Shanefelt, TD, Bradley, KA, Wipf, JE, Back, AL (2002). Burnout and self-reported patient care in an internal medicine residency program. Annals of Internal Medicine 136, 358–367.Google Scholar
Shapiro, SL, Astin, JA, Bishop, SR, Cordova, M (2005). Mindfulness-based stress reduction for health care professionals: results from a randomised trial. International Journal of Stress Management 12, 164–176.Google Scholar
Shapiro, SL, Brown, KW, Biegel, GM (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, 105–115.Google Scholar
Shapiro, SL, Burnham, CL (2011). Mindfulness and healthcare professionals. In: The Art and Science of health Care (ed. Kirkcaldy, B. D.), pp. 243–262. Cambridge, MA: Hogrefe.Google Scholar
Shapiro, SL, Carlson, LE (2009). The Art and Science of Mindfulness: Integrating Mindfulness into Psychology and the Helping Professions. Washington DC: American Psychological Association.Google Scholar
Shapiro, SL, Carlson, LE, Astin, JA, Freedman, B (2006). Mechanisms of mindfulness. Journal of Clinical psychology 62, 373–386.CrossRefGoogle ScholarPubMed
Spickard, A, Gabbe, S, Christensen, J (2002). Mid-career burnout in generalist and specialist physicians. Journal of the American Medical Association 288, 1447–1450.Google Scholar
Teasdale, JD, Segal, ZV, Williams, JMG, Ridgeway, VA, Soulsby, JM, Lau, MA (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology 68, 615–623.Google Scholar
Thomas, MR, Dyrbye, LN, Huntington, JL, Lawson, KL, Novotny, PJ, Sloan, JA, Shanafelt, TD (2007). How do distress and well-being relate to medical student empathy? A multicenter study. Journal of General Medicine 22, 1497–1525.Google Scholar
Tyssen, R, Vaglum, P, Gronvold, NT, Ekeberg, O (2001). Suicidal ideation among medical students and young physician: a nationwide and prospective study of prevalence and predictors. Journal of Affective Disorders 64, 69–79.Google Scholar
UK Network for Mindfulness-based Teacher training Organisations (2012). Good Practice Guidelines for teaching mindfulness-based courses (http://mindfulnessteachersuk.org.uk/pdf/teacher-guidelines.pdf).Google Scholar
UNISON (2014). Running on Empty: NHS Staff Stretched to the Limit. London: UNISON.Google Scholar
Vahey, DC, Aitken, M, Sloane, DM, Clarke, SP, Vargs, D (2004). Nurse burnout and patient satisfaction. Medical Care 42, 57–66.Google Scholar
Van Dam, NT, Sheppard, SC, Forsyth, JP, Earleywine, M (2011). Self-compassion is a better predictor than mindfulness of symptom severity and quality of life in mixed anxiety and depression. Journal of Anxiety Disorders 25, 123–130.Google Scholar
Wong, J (2008). Doctors and stress. The Hong Kong Medical Diary 13, 4–7.Google Scholar
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