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 Table of Contents  
Year : 2013  |  Volume : 26  |  Issue : 1  |  Page : 9-14

Mindfulness-based stress reduction training is associated with greater empathy and reduced anxiety for graduate healthcare students

1 New York College of Podiatric Medicine, New York, New York, USA
2 Samuel Merritt University, Oakland, California, USA
3 Children's Hospital and Research Center, Oakland, California, USA
4 Washington Hospital Center and Georgetown Hospital, Washington, D.C., USA
5 University of California, San Francisco, California, USA

Date of Web Publication31-May-2013

Correspondence Address:
Peter Barbosa
New York College of Podiatric Medicine, New York
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Source of Support: Supported in part by the Faculty Research Grant Program from the Offi ce of Academic Affairs at Samuel Merritt University., Conflict of Interest: None

DOI: 10.4103/1357-6283.112794

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Introduction: Graduate healthcare students experience significant stressors during professional training. Mindfulness-Based Stress Reduction (MBSR) is a behavioural intervention designed to teach self-regulatory skills for stress reduction and emotion management. This study examines the impact of MBSR training on students from five healthcare graduate programs in a quasi-experimental trial. Methods : A total of 13 students completed the MBSR program and were compared with 15 controls. Both groups answered validated questionnaires measuring anxiety, burnout and empathy at baseline, at conclusion of the course (week 8) and 3 weeks post-course completion (week 11). Results : Significant decrease in anxiety at weeks 8 and 11 compared with baseline (P<0.001 and P<0.01, respectively) was observed using the Burns Anxiety Inventory. Significant increase in empathy at week 8 (P<0.0096) was observed using the Jefferson Scale of Physician Empathy. Week 11 demonstrated a decrease in empathy from baseline (not statistically significant) across all subjects. No significant differences in burnout scores at weeks 8 and 11 were observed between those in the intervention and control groups. Conclusions : These results provide supportive evidence of MBSR as a behavioural intervention to reduce anxiety and increase empathy among graduate healthcare students.

Keywords: Anxiety, empathy, healthcare students, mindfulness-based stress reduction

How to cite this article:
Barbosa P, Raymond G, Zlotnick C, Wilk J, Toomey III R, Mitchell III J. Mindfulness-based stress reduction training is associated with greater empathy and reduced anxiety for graduate healthcare students. Educ Health 2013;26:9-14

How to cite this URL:
Barbosa P, Raymond G, Zlotnick C, Wilk J, Toomey III R, Mitchell III J. Mindfulness-based stress reduction training is associated with greater empathy and reduced anxiety for graduate healthcare students. Educ Health [serial online] 2013 [cited 2023 Jun 2];26:9-14. Available from:

  Introduction Top

Medical students experience a decline in empathy, as well as an increase in depression, anxiety and burnout, during their graduate education due to stress. [1],[2],[3],[4],[5],[6],[7],[8] Empathy has also been shown to decrease among dental students. [3] The Association of American Medical Colleges states that one objective of medical schools is to train selfless physicians who "must be compassionate and empathetic in caring for patients". [9] Hojat et al. defined empathy as "a cognitive attribute that involves an ability to understand the patient's inner experiences and perspective and a capability to communicate this understanding". [10] In healthcare settings, empathetic awareness enables the provider to be sensitive and to provide treatment in a humane and effective manner. Empathy is related to a number of positive outcomes related to an increased quality of patient-physician relationships. [10] Other studies have shown a correlation between greater empathy among internal medicine residents and fewer self-perceived medical errors. [11] Empathy is important to the foundation of healthcare, and developing skills in empathy within healthcare students could contribute to this principle.

Burnout is also a concern for medical students, nurses, podiatrists and primary care physicians. [6],[7],[12],[13],[14],[15] Burnout is a syndrome that encompasses three key components relative to healthcare providers: emotional exhaustion, depersonalisation and loss of sense of personal accomplishment in one's work. [16],[17] These components have a number of negative consequences for both the healthcare provider and the patients. Studies have shown a significant correlation between higher burnout scores and higher incidence of self-perceived medical errors. [11] The implications of provider burnout correlate with early exit from the healthcare field, various physical and psychological problems for the provider and negative patient perceptions of quality of care. [13]

Despite high educational standards for acquiring technical knowledge in graduate healthcare education, training in patient compassion is limited. The art of kindness and compassion, or learning empathy, begins with the ability to cultivate self-awareness or mindfulness. [18] This 'awareness work' centres on the development of strategies that foster compassion, doctoring ability and empathetic communication with future patients, thus expanding the biopsychosocial model of healthcare delivery. Systematically implementing programmes that facilitate this self-awareness work could provide important benefits for graduate healthcare education.

The Mindfulness-Based Stress Reduction (MBSR) program was founded by Jon Kabat-Zinn, Ph.D., in 1979 at the University of Massachusetts Medical School to help patients reduce stress and manage emotions through mindfulness meditation. [19],[20],[21] MBSR is an 8-week behavioural program and educational course that offers first-hand experience of meditation techniques, including mindful awareness of daily activities and communication. [19],[22] The MBSR curriculum, facilitated by certified instructors, has become a life-affirming mind/body practice for comprehensive healthcare in education and mental health. [20]

Increased stress levels from managing coursework, clinical rotations and social challenges during medical education are well documented. [1],[18],[23] There is evidence that MBSR can mitigate stress in medical students, as well as nurses and primary care physicians. [13],[14],[17],[24] Evidence also suggests that MBSR can improve empathy skills in medical students, nurses and primary care physicians. [13],[24],[25] MBSR has also been shown to reduce burnout in primary care physicians. [13] Due to the demonstrated benefits, additional MBSR research is needed in graduate healthcare educational settings with students other than in medicine and nursing. The purpose of this study was to examine the effect of MBSR training on anxiety, burnout and empathy for students from five graduate healthcare education programs at Samuel Merritt University (SMU). Specifically the subjects in the study included students in podiatric medicine, occupational therapy, physical therapy, physician's assistant and graduate nursing programs.

  Methods Top

The study implemented a non-randomised pre- and post-test quasi-experimental design with matched control group, approved by the Institutional Review Board at SMU. Founded in 1909, SMU is a fully accredited private health sciences institution located in Oakland, California, committed to transform the experience of care in diverse communities. A general invitation email was sent to the student population of about 1300 students describing the study and offering two MBSR informational sessions. Thirty-three (33) students attended the informational sessions and screening surveys were administered to all prospective student participants. The survey included questions on demographics as well as additional information regarding inclusion and exclusion criteria. Inclusion criteria for the experimental and control groups required participants to be aged between 21 and 65, enrolled as full-time students at SMU for the 2009-2010 academic year and have a current grade point average of 2.5 or higher (4.0 maximum). Any subjects prescribed psychiatric medications in the previous 2 months or with plans to discontinue medication during the study were excluded. All of the 33 students interested in participating signed a consent form explaining the study as well as The Experimental Subject Bill of Rights.

Following informational sessions and completion of screening surveys, 16 students met the inclusion criteria. These 16 students were enrolled as experimental subjects for the study and preliminary analysis was conducted to determine the demographics of the experimental group (gender, age, program enrolled at SMU and year of enrolment). Based on these demographics a paid cohort was selected to match the composition of the experimental group. A total of 15 students were selected as part of this matched control group and did not participate in the MBSR training.

All students were assigned a secret identification code to uphold participant confidentiality. Students in both groups completed psychometrically sound tests for anxiety, empathy and burnout at three time-points: Baseline (week 0), immediately upon completion of the MBSR course (week 8) and 3 weeks post-course completion (week 11). Week 11 coincided with the week prior to final examinations. At the conclusion of the MBSR course (week 8), the experimental group only completed a post-course evaluation of the MBSR course.

The MBSR course began at the baseline time-point and followed the outline developed by Jon Kabat-Zinn, Ph.D. [19],[21] Students attended eight weekly classes for 2.5 hours each, plus an 8-hour silent day-long retreat during the 6 th week. Daily home assignments included 35 minutes of formal mindfulness practice and 5-15 minutes of informal practice for the duration of the course. Formal in-class and at-home meditation practice included: body scan, mindful movement (qi gong), mindful hatha yoga and sitting meditation. Informal practices included mindful awareness of daily routines, pleasant and unpleasant events and communication. [21],[26] Each class also had a group process component consisting of individual and group discussions of home assignments and experiences of the meditation practice.

Participants were asked to complete three questionnaires: Burns Anxiety Inventory (BAI), Jefferson Scale of Physician Empathy (JSPE) and Maslach Burnout Inventory (MBI). Students self-reported their awareness of anxiety-related symptoms for the BAI. The JSPE measures levels of cognitive attributes of empathy by having students rank their level of agreement or disagreement with statements addressing compassion, sympathy and altruism. For the MBI, students rank the frequency of their personal awareness of specific symptoms associated with burnout. These three inventories have been shown to be valid measures to assess anxiety, empathy and burnout, respectively. [12],[27],[28],[29],[30],[31],[32]

Scoring for each of the three instruments was conducted as recommended by instructions provided by the test developers. [28],[31],[33] The BAI is a 33-item list of statements ranked on a four-point Likert scale ranging from "Not at all0" to "A lot". The Total Score was categorised into one of six possible BAI anxiety categories: (1) Minimal or no anxiety; (2) Borderline anxiety; (3) Mild anxiety; (4) Moderate anxiety; (5) Severe anxiety and (6) Extreme anxiety or panic. Change in score was calculated based on change of category. The percentage of students who improved at least one BAI anxiety category was determined by comparing each student's BAI anxiety categories at weeks 8 and 11 to their baseline BAI anxiety category at week 0.

The JSPE is a 20-item list of statements concerning cognitive attributes of empathy and was modified with permission from the developers by substituting the word "physician0" with "healthcare provider". The seven-point Likert scale had values ranging from "Strongly Agree" to "Strongly Disagree". The empathy score for an individual was calculated by adding the individual weights of the 20 items. Average empathy scores were calculated for baseline, week 8 and week 11 for both groups.

The MBI is a 16-item list of symptomatic statements associated with emotional exhaustion, depersonalisation and a decreased sense of personal accomplishment, such as "I have become less interested in my studies since I started this program". Students rank the frequency of their personal awareness of these symptoms on a 7-point Likert scale ranging from 0 (= Never) to 6 (= Everyday). Scoring of MBI is based on three separate subscales: (1) Exhaustion, (2) Cynicism and (3) Professional Efficacy, as defined and described by the scale's developer. [33] Average scores were calculated for each subscale at baseline, week 8 and week 11 for both groups.

Statistical Analysis

All analyses were conducted using SAS version 9.0. Chi-square test of Independence (or Fisher's Exact test for tables with small expected cell sizes) was used to compare frequencies of categorical variables. Paired t-tests were used to tabulate and compare mean differences between pre- and post-test scores from baseline to 8- and 11-week follow-up. Student t-tests were used to determine whether the control and experimental group's mean score differences (from pre-test to follow-up) varied significantly in the dependent variables of anxiety, empathy, and each of the three subcategories of burnout. Statistical significance was declared at P<0.05.

  Results Top

Demographics: Of the 16 students originally enrolled in the experimental group, 3 did not complete the MBSR course and were dropped from the data analysis. The experimental group included 12 females and 1 male who completed the study with an average age of 26.6 years (ranging from 23 to 30). The 15 students who were part of the control group included 14 females and 1 male, with an average age of 24.6 years (ranging from 22 to 30). Both Asian American and European/White races represented the control and experimental groups, with one participant in the control group self-reported as a Mixed-race individual, and one individual declining to state. The students of each group were represented by five different graduate healthcare programs at SMU including: podiatric medicine, physician assistant, physical therapy, occupational therapy and graduate nursing degrees. The number of individuals who completed the study by race and academic program for the control and experimental groups is indicated in [Table 1].
Table 1: Demographics of participants who completed the study

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Burns Anxiety Inventory: The baseline measure between the control and experimental group differed by one level, with experimental mean at "Moderate Anxiety" and control mean at "Mild Anxiety". The percentage of students whose BAI anxiety categories improved by at least one level during the course of the study is shown in [Figure 1]. BAI anxiety categories measured immediately upon completion of the MBSR course (week 8) and measured 3 weeks after the course (week 11), were compared with baseline (week 0). Significant differences between experimental and control groups were found at both the 8- and 11-week time points (P<0.001 and P<0.01, respectively). For the experimental group, 85% of students experienced diminished anxiety at both 8 and 11 weeks, while for the control group, 13% and 27% of students experienced diminished anxiety at weeks 8 and 11, respectively.

Jefferson Scale of Physician Empathy: The average empathy scores measured by JSPE are summarised in [Figure 2]. Scores are reported for baseline (week 0), week 8 and week 11 for both groups. A significant difference is observed between the experimental and control groups at week 8 (P<0.0096) that was not sustained at week 11. Week 11 demonstrated a decrease in empathy from week 8 across all subjects.
Figure 1: Burns Anxiety Inventory

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Figure 2: JSPE Average Scores, Footnote: The empathy score can range from 20 to 140, with higher values indicating a higher degree of empathy

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Maslach Burnout Inventory: The average scores for each of the three MBI subscales: Exhaustion, Professional Efficacy and Cynicism at baseline (week 0), week 8 and week 11 are summarised in [Table 2]. No statistical differences were observed between the experimental and control groups for any of the three subscales between weeks 8 or 11 when compared with baseline.
Table 2: Comparison of Mean Burnout Scores as Measured by Maslach Burnout Inventory*

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MBSR Post-Course Evaluation: The students' average rating for the overall course was 4.70, based on a post-course evaluation form with a rating of 1 to 5, with 1 = very poor and 5 = excellent. The overall rating in recommending MBSR to future SMU students on a regular basis was 4.75, with 1 = definitely not and 5=definitely yes.

  Discussion Top

In this pilot study, we sought to examine the effect of the MBSR course on graduate healthcare students' anxiety, empathy and burnout. Previously published studies have demonstrated various effects of MBSR on the development of attributes impacting nurses' performance at work. [14],[16],[17],[34] Other studies have explored the effects of MBSR on students, both medical and nursing, and more recently on primary care physicians. [13],[18],[24],[25] None of these studies evaluated the effects of MBSR on subjects from more than a single healthcare discipline simultaneously. This study examined the impact of MBSR on a group of students across five healthcare graduate programs: podiatric medicine, occupational therapy, physical therapy, physician's assistant and graduate nursing students.

Empathy is critical in developing well-rounded medical professionals. [10] Healthy habits related to wellness established during educational training have the potential to produce career-long benefits for both the practitioner and the patients. [4] Early MBSR training for healthcare students may prevent the high levels of distress that occur in semesters that include both clinical and didactic workload. [5],[24] Exposing students to MBSR as a curriculum requirement during key periods of formative training as a healthcare provider could provide a sustainable impression.

Evidence has also shown that the MBSR program improves empathy skills in medical students, nurses and primary care physicians. [13],[24] This MBSR study shows a significant increase in empathy scores as measured using the JSPE. However, these results were not sustained 3 weeks subsequent to the conclusion of the course. It should be noted that even though it was not significant, there was also a decrease in empathy scores for the control groups at this time point. Contributing factors may include higher stress levels due to final examinations (for both groups) and perhaps departure from daily mindfulness meditation practice (for the experimental group). Correlations have also been established between a lack of empathy and increased medical errors. [11] These correlations between empathy and healthcare practices suggest that MBSR training during graduate healthcare studies could improve the quality of healthcare and clinical interventions.

Evidence indicates that MBSR can mitigate stress in medical students, nurses and primary care physicians. [13],[16],[17],[24] This MBSR study also provides supportive evidence of significant reduction in students' levels of anxiety as demonstrated by reductions in the students' BAI assessment tool. The baseline levels of anxiety were higher by one category in the experimental group. It is possible that this higher perceived anxiety was a motivational factor for those students to enrol in the study as experimental subjects. To correct this deviation, changes in scores from baseline to final scores were compared, thereby reducing the difference obtained at baseline.

Recent reports show that formal training in mindful communication reduced burnout, as well as increased empathy among practicing primary care physicians. [13] Mindfulness-based interventions like MBSR could not only impact future healthcare practices, but may also improve the overall student experience in healthcare education. However, in this study, no difference was observed in burnout following the MBSR course as measured using the MBI. These results may have been due to the relatively short follow-up time in regards to measurements, as well as the limited number of students available. However, these findings require investigation into the differences between burnout in physicians, and their student counterparts.

The results of this study provide support for the hypotheses that MBSR training could reduce anxiety and increase empathy in healthcare students, but does not diminish burnout. The ramifications of this pilot study are not only for improvement in healthcare students' educational experience and self-care behaviours, but also for potential improvement in their abilities to communicate empathetically with patients and to understand the biopsychosocial model of healthcare delivery. Since empathy is related to a significant number of positive outcomes in healthcare, improving empathy among these students has a likely positive impact on the healthcare system as a whole. [10]

Study limitations included a small sample size and the quasi-experimental design. Since a limited number of students volunteered for the study, it was impossible to utilise a randomised study design. Although the entire student population-at-large received an invitation email, the large variety of health programs offered at the institution requires 17 academic calendars. The general demands for most of the academic programs prohibited the great majority of students to get involved in extracurricular activities, such as a time-demanding MBSR course.

An additional limitation included the differences regarding learning environments between groups within the study. Students in different disciplines may experience various levels of stress based on individual curriculum and workload.

In addition, three students were not able to complete the course due to personal circumstances. While this dropout rate is common among MBSR courses, it further reduced the number of subjects in the experimental arm.

Additional instruments are available to measure anxiety and empathy, but were not used due to limited accessibility.

In conclusion, this study provides some evidence that MBSR, as a behavioural intervention, could decrease anxiety and increase empathy among graduate healthcare students. Additional studies are necessary to determine long-term effects and potential impact of MBSR on the educational healthcare system as a whole.

  Acknowledgements Top

This work was supported in part by the Faculty Research Grant Program from the Office of Academic Affairs at Samuel Merritt University. The authors of the paper want to thank Dr. Carol Gilson, Ricardo Negron and Michael Huchital for editorial assistance to the manuscript.

  References Top

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