Encouraging Mindfulness in Medical House Staff via Smartphone App: A Pilot Study

Online Mindfulness-Based Interventions for Healthcare Professionals: A Scoping Review

BACKGROUND

Health care professionals work in challenging environments with extended working hours and excessive workloads to provide high-quality care. However, they hardly get the time to care for themselves. Online mindfulness-based interventions-which are not restricted by time or location-can be a powerful strategy to help health care professionals.

OBJECTIVES

This scoping review aims to explore the current evidence about online mindfulness-based interventions for health care professionals.

DESIGN

A scoping review was conducted.

METHODS

A literature search was conducted to retrieve articles published between October 2016 and March 2023 in seven databases, including backward and forward citation tracking from the included articles. Among 1,278 articles retrieved, 33 met the criteria for review.

RESULTS

Two-thirds of the studies utilized commercialized mindfulness programs (n = 22). Duration of the mindfulness interventions varied from 1 week to 4 months, and half of the studies used audio-guided programs. Online mindfulness-based intervention studies were targeted to reduce burnout (n = 26), and the majority reported reduction in burnout (n = 18).

CONCLUSION

Most studies used individual audio-guided programs that warrant the use of diverse delivery methods such as video media, simulation, and virtual reality for interactions in the future. Although the literature has accumulated evidence for commercialized online mindfulness-based interventions, further studies are needed to develop and test tailored interventions for health care professionals.

A Mindfulness-Based Intervention for Acute Care Nursing Staff: A Pilot Study

Purpose:The purpose of this study was to determine if a mindfulness-based smartphone application, used for 5 minutes a day for 30 days, could address burnout among acute care nursing staff. Methods: A pretest-posttest design with a midpoint evaluation was utilized. The sample included 31 nursing staff from cardiovascular acute care units. The Copenhagen Burnout Inventory, Cognitive and Affective Mindfulness Scale-Revised, Perceived Stress Scale, and Brief Resilience Scale were used to measure the impact of the intervention on participants. Findings: In a repeated measures analysis, there were no statistically significant changes in scores on the Brief Resilience Scale across the three timeframes (F = 0.64, df = 1.42, p = .49). There were significant reductions over time for perceived stress (F = 10.56, df = 1.74, p = .002) and personal burnout (F = 11.8, df = 1.10, p = .007), and increased scores on mindfulness (F = 4.76, df = 1.57, p = .039). Conclusions: The utilization of a mindfulness-based smartphone application may promote the health and well-being of cardiovascular nurses in acute care units. Mindfulness-based smartphone apps should be considered as a method of self-care, along with other holistic approaches to improve well-being.

Design and Implementation of a Brief Digital Mindfulness and Compassion Training App for Health Care Professionals: Cluster Randomized Controlled Trial

BACKGROUND

Several studies show that intense work schedules make health care professionals particularly vulnerable to emotional exhaustion and burnout.

OBJECTIVE

In this scenario, promoting self-compassion and mindfulness may be beneficial for well-being. Notably, scalable, digital app-based methods may have the potential to enhance self-compassion and mindfulness in health care professionals.

METHODS

In this study, we designed and implemented a scalable, digital app-based, brief mindfulness and compassion training program called "WellMind" for health care professionals. A total of 22 adult participants completed up to 60 sessions of WellMind training, 5-10 minutes in duration each, over 3 months. Participants completed behavioral assessments measuring self-compassion and mindfulness at baseline (preintervention), 3 months (postintervention), and 6 months (follow-up). In order to control for practice effects on the repeat assessments and calculate effect sizes, we also studied a no-contact control group of 21 health care professionals who only completed the repeated assessments but were not provided any training. Additionally, we evaluated pre- and postintervention neural activity in core brain networks using electroencephalography source imaging as an objective neurophysiological training outcome.

RESULTS

Findings showed a post- versus preintervention increase in self-compassion (Cohen d=0.57; P=.007) and state-mindfulness (d=0.52; P=.02) only in the WellMind training group, with improvements in self-compassion sustained at follow-up (d=0.8; P=.01). Additionally, WellMind training durations correlated with the magnitude of improvement in self-compassion across human participants (ρ=0.52; P=.01). Training-related neurophysiological results revealed plasticity specific to the default mode network (DMN) that is implicated in mind-wandering and rumination, with DMN network suppression selectively observed at the postintervention time point in the WellMind group (d=-0.87; P=.03). We also found that improvement in self-compassion was directly related to the extent of DMN suppression (ρ=-0.368; P=.04).

CONCLUSIONS

Overall, promising behavioral and neurophysiological findings from this first study demonstrate the benefits of brief digital mindfulness and compassion training for health care professionals and compel the scale-up of the digital intervention.

TRIAL REGISTRATION

Trial Registration: International Standard Randomized Controlled Trial Number Registry ISRCTN94766568, https://www.isrctn.com/ISRCTN94766568.

Reflective Skills, Empathy, Wellbeing, and Resilience in Cognitive-Behavior Therapy Trainees Participating in Mindfulness-Based Self-Practice/Self-Reflection

Self-Practice/Self-Reflection (SP/SR) is an aspect of therapist training and professional development aimed at enhancing therapy skills, empathy, wellbeing, and resilience in the ultimate furtherance of client outcomes. For many decades, intensive SP/SR has been a required part of therapist training in many countries but relatively little is known about the effect of SP/SR. Studies have found cognitive-behavior therapy (CBT) therapists trained under a Beckian CBT paradigm benefitted from more time limited Beckian SP/SR. Mindfulness-based CBT is a more recent third-wave CBT paradigm with psychological process aims similar to those of SP/SR. While training in mindfulness-based CBT often has prominent SP/SR aspects, and mindfulness practice has been shown to benefit health care providers personally and professionally, to date no evaluations have been reported specifically of effects of participation of CBT trainees in stand-alone mindfulness-based SP/SR that meets regulatory requirements for more intensive SP/SR. A study on SP/SR training meeting German requirements is reported here. Post-graduate CBT trainees (N = 95) were assigned to delayed or immediate SP/SR with those in the delayed SP/SR condition crossing-over into SP/SR training after two baseline evaluations on a variety of reflective skill, wellbeing, and resilience measures spaced six to 9 months apart before participating in 120-150 hours of stand-alone mindfulness-based SP/SR followed by a third reevaluation on all study measures. Participants assigned to the immediate SP/SR condition underwent identical SP/SR training with pre/post assessments. Results indicate participation in intensive stand-alone mindfulness-based SP/SR resulted in favorable changes in measures operationalizing all variables. Findings are discussed in terms of their implications for training and professional development of CBT therapists.

Feasibility, acceptability and preliminary efficacy of a mental health self-management app in clinicians working during the COVID-19 pandemic: A pilot randomised controlled trial

COVID-19 affected the well-being of healthcare workers (HCWs) globally. Mental health app interventions (MHAIs) may offer appropriate and accessible means to support HCWs' mental health. We conducted a pilot randomised controlled crossover trial involving 34 clinicians randomised to either a MHAI or a waitlisted group. After one month, outcome assessments were repeated and the waitlisted group then crossed over to the MHAI; they again completed outcome assessments after a month. The primary outcomes were feasibility, assessed with the Systems Usability Scale (SUS), and acceptability, assessed with the Client Satisfaction Questionnaire (CSQ). Secondary outcomes included efficacy for various mental health parameters. The SUS and CSQ scores indicated above average feasibility and acceptability. There was a significant difference in anxiety from baseline to 1-month follow-up between the groups, with greater improvement in the MHAI group. The groups differed in resilience and patient-related burnout from baseline to 1-month follow-up, with a trend towards significance, with greater improvements in the MHAI group. Anxiety and acute stress disorder severity improved significantly from pre- to post-intervention. We demonstrated that MHAIs hold potential for improving well-being of HCWs, although these findings will need to be replicated in adequately powered trials.

Stress Management Apps: Systematic Search and Multidimensional Assessment of Quality and Characteristics

BACKGROUND

Chronic stress poses risks for physical and mental well-being. Stress management interventions have been shown to be effective, and stress management apps (SMAs) might help to transfer strategies into everyday life.

OBJECTIVE

This review aims to provide a comprehensive overview of the quality and characteristics of SMAs to give potential users or health professionals a guideline when searching for SMAs in common app stores.

METHODS

SMAs were identified with a systematic search in the European Google Play Store and Apple App Store. SMAs were screened and checked according to the inclusion criteria. General characteristics and quality were assessed by 2 independent raters using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality (range 1 to 5) on the following four dimensions: (1) engagement, (2) functionality, (3) esthetics, and (4) information. In addition, the theory-based stress management strategies, evidence base, long-term availability, and common characteristics of the 5 top-rated SMAs were assessed and derived.

RESULTS

Of 2044 identified apps, 121 SMAs were included. Frequently implemented strategies (also in the 5 top-rated SMAs) were psychoeducation, breathing, and mindfulness, as well as the use of monitoring and reminder functions. Of the 121 SMAs, 111 (91.7%) provided a privacy policy, but only 44 (36.4%) required an active confirmation of informed consent. Data sharing with third parties was disclosed in only 14.0% (17/121) of the SMAs. The average quality of the included apps was above the cutoff score of 3.5 (mean 3.59, SD 0.50). The MARS-G dimensions yielded values above this cutoff score (functionality: mean 4.14, SD 0.47; esthetics: mean 3.76, SD 0.73) and below this score (information: mean 3.42, SD 0.46; engagement: mean 3.05, SD 0.78). Most theory-based stress management strategies were regenerative stress management strategies. The evidence base for 9.1% (11/121) of the SMAs could be identified, indicating significant group differences in several variables (eg, stress or depressive symptoms) in favor of SMAs. Moreover, 38.0% (46/121) of the SMAs were no longer available after a 2-year period.

CONCLUSIONS

The moderate information quality, scarce evidence base, constraints in data privacy and security features, and high volatility of SMAs pose challenges for users, health professionals, and researchers. However, owing to the scalability of SMAs and the few but promising results regarding their effectiveness, they have a high potential to reach and help a broad audience. For a holistic stress management approach, SMAs could benefit from a broader repertoire of strategies, such as more instrumental and mental stress management strategies. The common characteristics of SMAs with top-rated quality can be used as guidance for potential users and health professionals, but owing to the high volatility of SMAs, enhanced evaluation frameworks are needed.

Mindfulness Applications: Can They Serve as a Stress, Anxiety, and Burnout Reduction Tool in Orthopaedic Surgery Training? A Randomized Control Trial

Stress and burnout are prevalent within the orthopaedic surgery community. Mindfulness techniques have been shown to improve wellness, yet traditional courses are generally time-intensive with low surgeon utilization. We sought to determine whether the introduction of a simple mindfulness-based phone application would help decrease stress, anxiety, and burnout in orthopaedic surgery residents.

Methods

Twenty-four residents participated in this prospective, randomized controlled trial. After simple 1:1 randomization, the treatment group received access to a mindfulness-based phone application for 2 months while the control group did not receive access. All participants completed the Perceived Stress Scale, Generalized Anxiety Disorder-7, and Maslach Burnout Inventory with emotional exhaustion (EE), depersonalization (DP), and personal accomplishment subscores to measure stress, anxiety, and burnout at baseline and after 2 months. Paired t tests were used to compare baseline scores and conclusion scores for both groups.

Results

There was no difference in baseline burnout scores between groups, but the treatment group had higher stress and anxiety scores at baseline. On average, the treatment group spent approximately 8 minutes per day, 2 days per week using the mindfulness application. After 2 months, the treatment group had significantly decreased stress (mean = -7.42, p = 0.002), anxiety (mean = -6.16, p = 0.01), EE (mean = -10.83 ± 10.72, p = 0.005), and DP (mean = -5.17 ± 5.51, p = 0.01). The control group did not have any significant differences in stress, anxiety, or burnout subscores.

Conclusions

Use of a mindfulness-based phone app for 2 months led to significant reductions in stress, anxiety, and burnout scores in orthopaedic surgery residents. Our results support the use of a mindfulness-based app to help decrease orthopaedic resident stress, anxiety, and burnout. Benefits were seen with only modest use, suggesting that intensive mindfulness training programs may not be necessary to effect a change in well-being. The higher baseline stress and anxiety in the treatment group may suggest that mindfulness techniques are particularly effective in those who perceive residency to be more stressful.

Level of Evidence

I.

Effectiveness of Daily Mindfulness Meditation App Usage to Reduce Anxiety and Improve Well-Being During the COVID-19 Pandemic: A Randomized Controlled Trial

Introduction This study examined the effect of 10-minute daily meditation app usage for 30 days on adult anxiety and mental well-being during the first year of the COVID-19 pandemic. Methods Participants were randomized into intervention (10 minutes of daily usage of the Insight Timer app) or control groups. Participants completed surveys to assess anxiety and well-being pre- and post-study. Data were analyzed using t-tests, analysis of variance (ANOVA), or nonparametric equivalents. Results Pre-study results were comparable between groups. The pre- vs. post-study General Anxiety Disorder-7 (GAD-7) scores for anxiety decreased in the intervention group (n=18, median 5.5 vs. 3.0 (pre vs. post), p=0.0233, d=0.50), but not in the control group (n=28). The intervention group had a lower median GAD-7 score than the control group post-study (3.0 vs. 8.0, p=0.0223, d=0.35). Pre- vs. post-study mean 5-item World Health Organization Well-Being Index (WHO-5) scores were improved in both the control (11.6 vs. 12.9 (pre vs. post), p=0.0408, d=0.36) and intervention groups (12.0 vs. 16.3 (pre vs. post), p=0.0001, d=0.77), although it was higher in the intervention group (16.3 vs. 12.9, p=0.0056, d=0.88). Conclusion Ten minutes of daily meditation app usage for 30 days may reduce anxiety and improve well-being in adults during the COVID-19 pandemic.

Resident Physician Perspectives on Mindfulness Education in Residency: A Multispecialty Qualitative Assessment of Clinical Care Impact

Background

Mindfulness training positively influences residents personally and professionally. Routine integration into residency may be impacted by limited understanding of the ways in which mindfulness training enhances clinical care.

Objective

We explored residents' direct experience and personal application of mindfulness in their clinical work following 10 hours of mindfulness training.

Methods

Mindfulness training sessions were facilitated between 2017 and 2019 for 5 groups of residents: pediatrics, ophthalmology, postgraduate year (PGY)-1 anesthesiology, and 2 different years of PGY-1 family medicine residents. Training was integrated into resident protected didactic time and attendance was expected, although not mandated, with the exception of pediatrics, in which the department mandated the training. Qualitative evaluation was conducted using a voluntary, semi-structured, de-identified phone interview within 2 months post-training. Reviewers independently coded the transcripts and then dialogued to reach consensus around emergent themes.

Results

Thirty-six of 72 residents (50%) who participated in the training completed interviews. Themes were similar across specialties. All residents acknowledged the potential usefulness of mindfulness training during residency. Six residents (17%) reported they had not applied the mindfulness training to their daily work by the end of the course. There were 4 emergent themes related to clinical application of mindfulness training: integrating brief moments of mindfulness practice, self-awareness, relational presence with patients, and maintaining perspective during clinical encounters and residency training as a whole.

Conclusions

After completing a 10-hour mindfulness training program, residents reported enhanced perspective-taking and relationship-building with themselves and their patients in clinical settings across medical and procedural specialties.

The Effects of COVID-19 on Orthopaedic Surgery Training Programs in the United States

INTRODUCTION

This study investigates the effects of the COVID-19 pandemic on medical education, research opportunities, and mental health in orthopaedic surgical training programs.

METHODS

A survey was sent to the 177 Electronic Residency Application Service-participating orthopaedic surgery training programs. The survey contained 26 questions covering demographics, examinations, research, academic activities, work settings, mental health, and educational communication. Participants were asked to assess their difficulty in performing activities relative to COVID-19.

RESULTS

One hundred twenty-two responses were used for data analysis. Difficulties were experienced in collaborating with others (49%), learning through online web platforms (49%), maintaining the attention span of others through online web platforms (75%), and in gaining knowledge as a presenter or participating through online web platforms (56%). Eighty percent reported that managing time to study was the same or easier. There was no reported change in difficulty for performing activities in the clinic, emergency department, or operating room. Most respondents reported greater difficulty in socializing with others (74%), participating in social activities with coresidents (82%), and seeing their family (66%). Coronavirus disease 2019 has had a significant effect on the socialization of orthopaedic surgery trainees.

DISCUSSION

Clinical exposure and engagement were marginally affected for most respondents, whereas academic and research activities were more greatly affected by the transition from in-person to online web platforms. These conclusions merit investigation of support systems for trainees and evaluating best practices moving forward.

Medical Student Experiences of Engaging in a Psychological Flexibility Skill Training App for Burnout and Well-being: Pilot Feasibility Study

BACKGROUND

Medical students are at higher risk of burnout than the general population. Interventions that facilitate adaptive coping behaviors (eg, Psychological Flexibility) in the context of inherent stressors associated with medical training could mitigate burnout risk and improve well-being. Delivering these interventions using smartphone apps offers advantages such as accessibility, scalability, mitigation of time and stigma barriers, and facilitation of individual tailoring (individualization). There is a need for feasibility trials with medical students in this emerging field. Formal evaluations of user experiences of app-based psychological skill training are required to identify barriers to and facilitators of engagement and optimize intervention development before implementation in efficacy trials and real-world settings.

OBJECTIVE

This study aimed to assess the feasibility of delivering an individualized Psychological Flexibility skill training intervention (Acceptance and Commitment Training [ACTraining]) to medical students using an app-based delivery format. We further aimed to explore how formal evaluation of user experiences might inform and guide the development of this app before implementation in an efficacy trial and future research involving app-delivered psychological skill training for medical students.

METHODS

This single-arm study was an early-phase feasibility trial of a stand-alone ACTraining app conducted with a sample of Australian medical students (n=11). We collected app usability and user experience data across a broad range of domains (eg, perceived helpfulness and relevance, learning experiences, and self-efficacy) using self-report questionnaires (quantitative and qualitative) and behavioral engagement outcomes.

RESULTS

Behavioral engagement data demonstrated that the app delivered the assessment procedures and individualized ACTraining intervention to medical students as intended. The subjective feedback provided by students who actively engaged with the app was generally positive across several indicators, including usability, perceived relevance and helpfulness, accessibility, maintenance of privacy, and opportunity for self-reflection. Disengagement from the app was an identified challenge throughout the trial. Participant feedback identified several factors that may have affected engagement, such as time, expectations regarding app interface functioning, and individual differences in confidence and self-efficacy when implementing skills.

CONCLUSIONS

This study reports user experience data that have been largely absent from the literature on digital psychological interventions for medical students. Our findings demonstrate the preliminary feasibility of an app-delivered ACTraining intervention for medical student well-being and burnout and support the value of future assessment of the efficacy of this approach with larger samples. We consider subjective feedback from medical students in relation to observed engagement and propose how this information might be used to inform the development of this app and future research in this nascent field.

Burnout, depression, anxiety and insomnia among medical staff during the COVID-19 epidemic in Shanghai

Background

Coronavirus disease 2019 (COVID-19) has progressively impacted our daily lives, resulting in unexpected physical and mental stress on medical staff. This study is designed to investigate the levels of and risk factors for burnout, depression, anxiety, and insomnia among medical staff during the COVID-19 epidemic breakout in Shanghai, China.

Methods

This cross-sectional survey was conducted from May 1 to May 31, 2022, among medical staff who were on the frontline during the epidemic breakout in Shanghai from different institutions. The MBI-HSS was used to assess burnout, PHQ-9, GAD-7 and ISI were used to evaluate mental status and insomnia.

Results

A total of 543 valid questionnaires were collected. The depersonalization, depression, anxiety, and insomnia scores of medical staff were significantly higher during the pandemic in Shanghai compared with norms, while lack of personal achievement scores were decreased. Working time, work unit, work environment and age are important influencers of burnout, depression and anxiety of medical staff. Long working hours are the most likely causes of burnout and emotional disorders. Medical staff in primary hospitals were most likely to suffer from burnout and emotional disorders, while medical staff in tertiary hospitals had a reduced sense of personal achievement. Young medical staff are prone to negative emotions such as depression and anxiety, while older medical staff have a lower sense of personal accomplishment. Medical staff who were not in the shelter hospitals or designated hospitals were more likely to have problems of emotional exhaustion, depersonalization and anxiety than those who were in the shelter hospitals or designated hospitals. Contracting COVID-19 had no effect on medical staff. Emotional exhaustion and depersonalization were positively correlated with anxiety, depression, and sleep disorders while personal achievement was negatively correlated with these factors.

Conclusion

Medical staff in Shanghai had high burnout, depression, anxiety and insomnia levels during the epidemic outbreak in Shanghai. During the COVID-19, medical staff may suffer different psychological problems which should be concerned. Care and supports about burnout, mental health and insomnia need to be taken to promote the mental health of medical staff according to different characteristics of medical staff.

Mindfulness training for community-based psychotherapists: a feasibility study

BACKGROUND

While mindfulness training's feasibility has been assessed in many health care settings, the feasibility of teaching mindfulness to psychotherapists of various orientations for both self- and patient-care has not been explored. The objectives of this feasibility assessment were to determine the degree to which clinic psychotherapists were willing to complete a skills-based mindfulness training program; evaluate the acceptability of integrating mindfulness interventions into an urban community mental health clinic; examine the training's influence on both personal mindfulness practice and integration into patient care; and explore the impact of a support group following the training.

METHODS

Data on six aspects of feasibility were gathered through quantitative surveys, semi-structured qualitative interviews, and group observation and feedback, analyzed using grounded theory.

RESULTS

Sixteen therapists and one administrator attended at least one session of this voluntary program and responded to the associated surveys. At 1-year post-training, 7 participants had attended one or more group support sessions, and 4 more than 50% of sessions. The following factors were identified as contributing to the training's success: significant interest on the part of clinic staff to receive the training; diversity of the teaching staff, buy-in from clinic administration, provision of meditation scripts, role-play exercises, the variety of practices taught, and case presentations. Therapists indicated that the training helped them create a personal mindfulness practice, and several proceeded to integrate mindfulness into client sessions. A bi-weekly support group organized after the training encompassed group practice, discussion, case presentations, and information about trauma-sensitive mindfulness. Clinicians identified the following challenges to integrating mindfulness into sessions: lack of scripts in client languages other than English, the unacceptability of mindfulness to some clients' religious beliefs, the lack of appropriateness for clients facing ongoing psychosocial crises, the lack of interest on the part of some clients, and the time constraints posed by brief therapy sessions.

CONCLUSIONS

These findings indicate that such training may be feasible in community mental health settings given support from leadership and the presence of qualified facilitators within the organization. Adaptations to the training based on participant feedback can inform a larger scale trial that compares our protocol with another intervention in the treatment of a psychological disorder or condition identified by the participants as having responded favorably to the program.

The impact of mindfulness practice on physician burnout: A scoping review

Background

Physician burnout is a growing phenomenon in current health systems worldwide. With the emergence of COVID-19, burnout in healthcare is progressively becoming a serious concern. Increasing emotional exhaustion, depersonalization, and reduced personal accomplishment threaten the effective delivery of healthcare. Compassion fatigue and moral injury are a considerable risk to the doctor-patient relationship. These issues can potentially be mitigated by mindfulness practice, which has shown promising results in reducing burnout, restoring compassion, and preventing moral injury in physicians.

Methodology

A scoping review was conducted to investigate the effects of mindfulness practice on physician burnout. High-ranking journals were targeted to analyze high-quality studies and synthesize common themes in the literature. Studies conducted on current practicing physicians were included. Mindfulness practice of varying forms was the main intervention studied. Gray literature and studies conducted only on allied health personnel were excluded from this review.

Results

31 studies were included in this scoping review. Mindfulness practice decreased emotional exhaustion and depersonalization while improving mood, responses to stress, and vigor. Self-awareness, compassion, and empathy were also increased in study participants. From this review, four themes emerged: innovations in mindfulness practice, mindfulness and positive psychology, the impact of mindfulness on work and patient care, and barriers and facilitators to physician mindfulness practice.

Conclusion

Mindfulness was widely reported to benefit mental health and well-being, but the studies reviewed seemed to adopt a mono focus and omitted key considerations to healthcare leadership, systems-level culture, and practices. Mindfulness practice is a quintessential component of positive psychology and is inherently linked to effective leadership. A mindful and compassionate physician leader will play a crucial role in addressing current practice gaps, prioritizing staff mental health, and providing a supportive platform for innovation.

Well-Being in Anesthesiology Graduate Medical Education: Reconciling the Ideal with Reality

Addressing burnout through well-being initiatives in anesthesiology residency training has been well described. Our intervention of in-person mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) as a means of addressing burnout among anesthesiology trainees proved unfeasible given attitudinal and logistic variables. We subsequently found success with a "confessions session" model structured as a modification of the Delphi method; this led to organizational changes associated with reduced resident burnout and well-being measured through internal (GME) and external (the Accreditation Council for Graduate Medical Education (ACGME)) annual anonymous surveys.

Mindfulness and music interventions in the workplace: assessment of sustained attention and working memory using a crowdsourcing approach

Background

Occupational stress has huge financial as well as human costs. Application of crowdsourcing might be a way to strengthen the investigation of occupational mental health. Therefore, the aim of the study was to assess Danish employees’ stress and cognition by relying on a crowdsourcing approach, as well as investigating the effect of a 30-day mindfulness and music intervention.

Methods

We translated well-validated neuropsychological laboratory- and task-based paradigms into an app-based platform using cognitive games measuring sustained attention and working memory and measuring stress via. Cohen’s Perceived Stress Scale. A total of 623 healthy volunteers from Danish companies participated in the study and were randomized into three groups, which consisted of a 30-day intervention of either mindfulness or music, or a non-intervention control group.

Results

Participants in the mindfulness group showed a significant improvement in the coefficient of sustained attention, working memory capacity and perceived stress (p < .001). The music group showed a 38% decrease of self-perceived stress. The control group showed no difference from pre to post in the survey or cognitive outcome measures. Furthermore, there was a significant correlation between usage of the mindfulness and music app and elevated score on both the cognitive games and the perceived stress scale.

Conclusion

The study supports the nascent field of crowdsourcing by being able to replicate data collected in previous well-controlled laboratory studies from a range of experimental cognitive tasks, making it an effective alternative. It also supports mindfulness as an effective intervention in improving mental health in the workplace.

Effects of Mindfulness Exercise Guided by a Smartphone App on Negative Emotions and Stress in Non-Clinical Populations: A Systematic Review and Meta-Analysis

Background

Studies have acknowledged that mindfulness exercise guided by a smartphone app has a positive impact on mental health and physical health. However, mindfulness guided by a smartphone app on mental health is still in its infancy stage. Therefore, we conducted a meta-analysis evaluating the effect of mindfulness intervention guided by a smartphone app on negative emotions and stress in a non-clinical population with emotional symptoms.

Methods

We searched major databases, namely, Web of Science, PubMed, Scopus, China National Knowledge Infrastructure (CNKI), and Wanfang, to identify all of the relevant studies published in English or Chinese from their inception until November 9, 2021. The methodological quality of the included studies was assessed with Cochrane risk-of-bias bias assessment tool. Two researchers independently conducted document retrieval, study selection, data extraction, and methodological quality evaluation.

Result

A total of eight studies were included in the study, with 574 subjects (experimental group: 348; control group: 226). A random effects model was selected to combine effect sizes. The results of the meta-analysis showed that mindfulness exercise guided by a smartphone app reduced negative emotions [standardized mean difference (SMD) = −0.232, 95% CI: −0.398 to −0.066, p = 0.006], depressive symptoms (SMD = −0.367, 95% CI: −0.596 to −0.137, p = 0.002), and anxiety symptoms (SMD = −0.490, 95% CI: −0.908 to −0.071, p = 0.022).

Conclusions

The findings indicate the potentially beneficial effect of mindfulness exercise guided by a smartphone app on symptoms of depression and anxiety among individuals in a non-clinical population with emotional symptoms. Considering the small number and overall methodological weakness of the included studies and lack of randomized controlled trials (RCTs), the results should be interpreted with caution, and future rigorously designed RCTs are warranted to provide more reliable evidence.

The Relationship of Breathing and COVID-19 Anxiety When Using Smart Watches for Guided Respiration Practice: A Cross-Sectional Study

COVID-19 mortality rates are increasing worldwide, which has led to many highly restrictive precautionary measures and a strong sense of anxiety about the outbreak for many people around the world. There is thus an increasing concern about COVID-19 anxiety, resulting in recommending approaches for effective self-care. From a positive psychology perspective, it is also important for people to have positive affect when dealing with this pandemic. According to previous literature, respiration is considered to be an effective way to enhance people's mental health. Among all the wearable devices, Apple Watch has the largest market share, so this study recruited Chinese users that use respiration exercise function on Apple Watch; a total of 316 valid data were retrieved. Meanwhile, to understand one approach related to using Apple Watch to practice respiration to reduce COVID-19 anxiety about being infected during the COVID-19 outbreak, this study used a web-based cross-sectional survey to examine anxiety about being infected by COVID-19 among Chinese people who had been using the Apple Watch to practice respiration during the period of the COVID-19 outbreak. The study was based on the Health Theoretical Model, and the model was developed with four dimensions and was validated with structural equation modeling. The results of this study showed that practicing few minutes had a positive relationship on positive attitude, and positive attitude had a negative relationship on pandemic anxiety and a positive relationship on continuance use intention. Anxiety about the pandemic had a negative relationship on the intention to continue using the function. This showed that respiration practice can help to suppress the increase in anxiety levels regarding this pandemic.

Mindfulness-based online intervention increases well-being and decreases stress after Covid-19 lockdown

Mindfulness interventions were shown to be effective in improving well-being and reducing perceived stress in several conditions. These effects were also found in online mindfulness-based training, especially in employees in organizational environments. The aim of this study was to test the effectiveness of an online mindfulness intervention on healthy employees, especially after the first Italian Covid-19 lockdown. Participants in the intervention group underwent an 8-week mindfulness online training program based on the Mindfulness-Based Stress Reduction (MBSR) protocol compared to a control (no-intervention) group. All participants filled in weekly surveys for the whole intervention duration via online questionnaires to measure their habits, mindfulness (FFMQ-15), emotion regulation (ERQ), positive and negative affect (PANAS), depression, anxiety and stress (DASS-21), resilience (RSA) and insomnia (ISI). 69 participants in the intervention group and 63 in the no-treatment control group were considered in the longitudinal analyses. We found significant differences between the intervention and control groups over time in the measures of mindfulness (in particular the nonreactivity subscale), positive affect, depression, and insomnia. Moreover, we found that the frequency of practice and ease perceived in practicing were positively correlated to several indices of well-being (mindfulness, positive affect, cognitive reappraisal) and negatively correlated to several indices of stress (negative affect, depression, anxiety, stress, insomnia, expressive suppression). These results show the importance and effectiveness of online mindfulness training programs to cope with stress among employees, especially after the Covid-19 lockdown.

A Mindfulness Application for Reducing Prenatal Stress

INTRODUCTION

Up to 40% of patients report depression or anxiety symptoms in pregnancy; feelings of increased stress are nearly universal. Antepartum stress is linked to adverse outcomes including preterm birth, low birthweight, postpartum depression, and maternal self harm. Unfortunately, limited treatment options exist, and patients are often hesitant to initiate medications prenatally. Thus, the development of efficacious nonpharmacologic interventions is crucial. This pilot study investigated the feasibility and impact of an application (app)-based mindfulness practice, begun in the first trimester, on maternal stress and pregnancy outcomes.

METHODS

The study enrolled patients prior to 15 weeks' gestation and followed them prospectively through birth. Patients were provided with a free subscription to Expectful, a commercially available prenatal mindfulness app, and asked to complete daily meditations. Patients completed the Perceived Stress Scale (PSS) self-assessment at 15 weeks and 28 weeks. PSS scores and pregnancy outcomes were compared with a historical control group of pregnant people who did not use the app.

RESULTS

Of 68 patients approached, 59 consented to enrollment. Of these, 21 used the app, with an average use of 170 minutes (range, 1.3-1315 min). The average PSS score was significantly lower in the app group at 28 weeks. Additionally, the change in PSS score for app users was greater compared with that of the historical control between enrollment and 28 weeks (-6.3 vs -0.95, P = .0008). Pregnancy outcomes were similar for app users and the historical control.

DISCUSSION

Our recruitment rate suggests pregnant patients are eager for a nonmedication intervention to decrease stress. However, adherence after enrollment was limited. For a subset of motivated patients, an app-based mindfulness practice significantly reduced perceived stress between the second and third trimesters compared with non-app users. Prenatal mindfulness apps represent an important low-intervention, low-cost, highly accessible tool for managing perinatal mood and stress.

Effects of Meditation for Surgeons: A Systematic Review of the Scientific Literature

OBJECTIVE

The aim of this study was to systematically review the available evidence about meditation's effects on surgeons.

SUMMARY BACKGROUND DATA

Meditation and Mindfulness are positively associated with better mental health and performance in different types of workers and professionals needing high levels of concentration. Surgery is one of the activities with the greatest need for high concentration.Even though these findings are supported by a number of studies, evidence is lacking on the effect of meditation on surgeons.

METHODS

We searched PubMed for meditation-related studies that focused on surgeons. A total of 243 articles were retrieved and after screening 8 were selected for data extraction. Four of these studies were pilot studies; 3 of them were randomized controlled trials.

RESULTS

Meditation was found to be beneficial for surgeons. Benefits span from motor skills to mental and physiological improvements.

CONCLUSION

More awareness and attention on this subject could improve surgeons' well-being as well as patients' outcomes.

Breaking the Data Value-Privacy Paradox in Mobile Mental Health Systems Through User-Centered Privacy Protection: A Web-Based Survey Study

BACKGROUND

Mobile mental health systems (MMHS) have been increasingly developed and deployed in support of monitoring, management, and intervention with regard to patients with mental disorders. However, many of these systems rely on patient data collected by smartphones or other wearable devices to infer patients' mental status, which raises privacy concerns. Such a value-privacy paradox poses significant challenges to patients' adoption and use of MMHS; yet, there has been limited understanding of it.

OBJECTIVE

To address the significant literature gap, this research aims to investigate both the antecedents of patients' privacy concerns and the effects of privacy concerns on their continuous usage intention with regard to MMHS.

METHODS

Using a web-based survey, this research collected data from 170 participants with MMHS experience recruited from online mental health communities and a university community. The data analyses used both repeated analysis of variance and partial least squares regression.

RESULTS

The results showed that data type (P=.003), data stage (P<.001), privacy victimization experience (P=.01), and privacy awareness (P=.08) have positive effects on privacy concerns. Specifically, users report higher privacy concerns for social interaction data (P=.007) and self-reported data (P=.001) than for biometrics data; privacy concerns are higher for data transmission (P=.01) and data sharing (P<.001) than for data collection. Our results also reveal that privacy concerns have an effect on attitude toward privacy protection (P=.001), which in turn affects continuous usage intention with regard to MMHS.

CONCLUSIONS

This study contributes to the literature by deepening our understanding of the data value-privacy paradox in MMHS research. The findings offer practical guidelines for breaking the paradox through the design of user-centered and privacy-preserving MMHS.

Mobile Apps That Promote Emotion Regulation, Positive Mental Health, and Well-being in the General Population: Systematic Review and Meta-analysis

BACKGROUND

Among the general public, there appears to be a growing need and interest in receiving digital mental health and well-being support. In response to this, mental health apps (MHapps) are becoming available for monitoring, managing, and promoting positive mental health and well-being. Thus far, evidence supports favorable outcomes when users engage with MHapps, yet there is a relative paucity of reviews on apps that support positive mental health and well-being.

OBJECTIVE

We aimed to systematically review the available research on MHapps that promote emotion regulation, positive mental health, and well-being in the general population aged 18-45 years. More specifically, the review aimed at providing a systematic description of the theoretical background and features of MHapps while evaluating any potential effectiveness.

METHODS

A comprehensive literature search of key databases, including MEDLINE (via Ovid), EMBASE (via Ovid), PsycINFO (via Ovid), Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL), was performed until January 2021. Studies were included if they described standalone mental health and well-being apps for adults without a formal mental health diagnosis. The quality of all studies was assessed against the Mixed Methods Appraisal Tool. In addition, the Cochrane Risk-of-Bias tool (RoB-2) was used to assess randomized control trials (RCTs). Data were extracted using a modified extraction form from the Cochrane Handbook of Systematic Reviews. A narrative synthesis and meta-analysis were then undertaken to address the review aims.

RESULTS

In total, 3156 abstracts were identified. Of these, 52 publications describing 48 MHapps met the inclusion criteria. Together, the studies evaluated interventions across 15 countries. Thirty-nine RCTs were identified suggesting some support for the role of individual MHapps in improving and promoting mental health and well-being. Regarding the pooled effect, MHapps, when compared to controls, showed a small effect for reducing mental health symptoms (k=19, Hedges g=-0.24, 95% CI -0.34 to -0.14; P<.001) and improving well-being (k=13, g=0.17, 95% CI 0.05-0.29, P=.004), and a medium effect for emotion regulation (k=6, g=0.49, 95% CI 0.23-0.74, P<.001). There is also a wide knowledge base of creative and innovative ways to engage users in techniques such as mood monitoring and guided exercises. Studies were generally assessed to contribute unclear or a high risk of bias, or to be of medium to low methodological quality.

CONCLUSIONS

The emerging evidence for MHapps that promote positive mental health and well-being suggests promising outcomes. Despite a wide range of MHapps, few apps specifically promote emotion regulation. However, our findings may position emotion regulation as an important mechanism for inclusion in future MHapps. A fair proportion of the included studies were pilot or feasibility trials (k=17, 33%), and full-scale RCTs reported high attrition rates and nondiverse samples. Given the number and pace at which MHapps are being released, further robust research is warranted to inform the development and testing of evidence-based programs.

The Impact of Psychological Interventions with Elements of Mindfulness (PIM) on Empathy, Well-Being, and Reduction of Burnout in Physicians: A Systematic Review

Introduction: Physician’s burnout has been recognized as an increasing and significant work-related syndrome, described by the combination of emotional exhaustion (EE) and depersonalization (D), together with low personal accomplishment (PA). It has many negative consequences on personal, organizational, and patient care levels. This systematic review aimed to analyze research articles where psychological interventions with elements of mindfulness (PIMs) were used to support physicians in order to reduce burnout and foster empathy and well-being. Methods: Systematic searches were conducted in May 2019, within six electronic databases PubMed, EBSCOhost MEDLINE, PsycArticles, Cochrane Library, JSTOR, and Slovenian national library information system. Different combinations of boolean operators were used—mindfulness, empathy, medicine/family medicine/general practice/primary care, burnout, doctors/physicians, intervention, and support group. Additional articles were manually searched from the reference list of the included articles. Studies with other healthcare professionals (not physicians and residents) and/or medical students, and those where PIMs were applied for educational or patient’s treatment purposes were excluded. Results: Of 1194 studies identified, 786 screened and 139 assessed for eligibility, there were 18 studies included in this review. Regardless of a specific type of PIMs applied, results, in general, demonstrate a positive impact on empathy, well-being, and reduction in burnout in participating physicians. Compared with other recent systematic reviews, this is unique due to a broader selection of psychological interventions and emphasis on a sustained effect measurement. Conclusions: Given the pandemic of COVID-19, it is of utmost importance that this review includes also interventions based on modern information technologies (mobile apps) and can be used as an awareness-raising material for physicians providing information about feasible and easily accessible interventions for effective burnout prevention and/or reduction. Future research should upgrade self-reported data with objective psychological measures and address the question of which intervention offers more benefits to physicians.

Burnout and Well-Being: Evaluating Perceptions in Bone Marrow Transplantation Nurses Using a Mindfulness Application

BACKGROUND

Oncology nurses are at increased risk for developing burnout. Although various interventions have been researched, mindfulness has been proven to be beneficial in mitigating burnout while improving well-being.

OBJECTIVES

The aim was to evaluate whether the use of a mindfulness mobile application (app), Headspace®, increases perceptions of well-being and decreases perceptions of burnout among inpatient bone marrow transplantation (BMT) staff nurses and nurse practitioners (NPs).

METHODS

This evidence-based practice quality improvement initiative introduced the Headspace app to BMT nurses and evaluated its impact on burnout and well-being at baseline and every 30 days for 90 days.

FINDINGS

There were significant improvements in burnout and well-being in staff nurses and NPs from baseline to each time point. Sleep hygiene meditations were the most widely used programs within the Headspace app for both nursing groups.

The impact of a smartphone meditation application on anesthesia trainee well-being

STUDY OBJECTIVE

Physician burnout is a pervasive problem in the United States. The goal of this study was to investigate use of the smartphone meditation application Headspace® as a well-being improvement tool in anesthesia trainees.

DESIGN

Prospective self-controlled observational study.

SETTING

Anesthesia training program in an academic hospital.

SUBJECTS

Resident and fellow trainees in the Department of Anesthesiology and Perioperative Medicine at the University of Pittsburgh Medical Center.

INTERVENTIONS

Resident and fellow trainees were given a free 1-year subscription to the mindfulness application. Participation was voluntary and included questionnaires at baseline, 1 month, and 4 months for assessment of burnout and well-being. Questionnaires were linked with the use of de-identified codes and completed via REDCap. Questionnaires included the abbreviated Maslach Burnout Inventory, Becks Depression Index, Cohens Stress Score, Pittsburgh Sleep Quality Index, and a Headspace® Self-Reporting Questionnaire.

MEASUREMENTS

Depression, stress, sleep quality, emotional exhaustion, depersonalization, and personal achievement.

MAIN RESULTS

Of 112 trainees eligible to participate, 71 completed baseline questionnaires, 54 created application accounts, and 29 completed the entire questionnaire protocol with 4 months of app use. Application use was associated with reduced depression scores and increased feelings of personal achievement at both 1 month (p = 0.003, p = 0.066) and 4 months (p = 0.011, p = 0.005). Burnout from feelings of depersonalization and emotional exhaustion did not improve with application use. Over the study period, trainees completed 786 meditation sessions, accounting for 6123 min of app engagement.

CONCLUSIONS

Findings of decreased depression scores and improved feelings of personal achievement suggest that Headspace® could serve as a mindfulness tool for incorporating meditation into the daily practice of anesthesia trainees in an effort to improve well-being.

Just-in-Time Adaptive Mechanisms of Popular Mobile Apps for Individuals With Depression: Systematic App Search and Literature Review

BACKGROUND

The number of smartphone apps that focus on the prevention, diagnosis, and treatment of depression is increasing. A promising approach to increase the effectiveness of the apps while reducing the individual's burden is the use of just-in-time adaptive intervention (JITAI) mechanisms. JITAIs are designed to improve the effectiveness of the intervention and reduce the burden on the person using the intervention by providing the right type of support at the right time. The right type of support and the right time are determined by measuring the state of vulnerability and the state of receptivity, respectively.

OBJECTIVE

The aim of this study is to systematically assess the use of JITAI mechanisms in popular apps for individuals with depression.

METHODS

We systematically searched for apps addressing depression in the Apple App Store and Google Play Store, as well as in curated lists from the Anxiety and Depression Association of America, the United Kingdom National Health Service, and the American Psychological Association in August 2020. The relevant apps were ranked according to the number of reviews (Apple App Store) or downloads (Google Play Store). For each app, 2 authors separately reviewed all publications concerning the app found within scientific databases (PubMed, Cochrane Register of Controlled Trials, PsycINFO, Google Scholar, IEEE Xplore, Web of Science, ACM Portal, and Science Direct), publications cited on the app's website, information on the app's website, and the app itself. All types of measurements (eg, open questions, closed questions, and device analytics) found in the apps were recorded and reviewed.

RESULTS

None of the 28 reviewed apps used JITAI mechanisms to tailor content to situations, states, or individuals. Of the 28 apps, 3 (11%) did not use any measurements, 20 (71%) exclusively used self-reports that were insufficient to leverage the full potential of the JITAIs, and the 5 (18%) apps using self-reports and passive measurements used them as progress or task indicators only. Although 34% (23/68) of the reviewed publications investigated the effectiveness of the apps and 21% (14/68) investigated their efficacy, no publication mentioned or evaluated JITAI mechanisms.

CONCLUSIONS

Promising JITAI mechanisms have not yet been translated into mainstream depression apps. Although the wide range of passive measurements available from smartphones were rarely used, self-reported outcomes were used by 71% (20/28) of the apps. However, in both cases, the measured outcomes were not used to tailor content and timing along a state of vulnerability or receptivity. Owing to this lack of tailoring to individual, state, or situation, we argue that the apps cannot be considered JITAIs. The lack of publications investigating whether JITAI mechanisms lead to an increase in the effectiveness or efficacy of the apps highlights the need for further research, especially in real-world apps.

A Mixed-Method Assessment of a 10-Day Mobile Mindfulness Intervention

Mobile mindfulness interventions represent a promising alternative to traditional in-person interventions that are resource demanding and have limited accessibility, preventing use by many populations. Despite greater accessibility and popularity of mobile mindfulness applications (apps), research is needed testing the effectiveness of brief interventions delivered via these platforms. The present study assessed the efficacy of a brief mobile mindfulness intervention compared to an active control for increasing state and trait mindfulness and improving mood, as well as the acceptability of the app, in a sample of undergraduate students. Participants (N=139; M_age=19.43years, 80.6% female, 83.5% White) were randomly assigned to either a 10-day mobile mindfulness (Headspace) or cognitive training (Peak) condition. Trait mindfulness was measured pre- and post-intervention. During the 10-day intervention, participants completed 10-min daily exercises on the assigned app, responded to daily questionnaires of state mindfulness and mood, and completed a daily written log of their reactions to the app exercises. Attrition was low (90% completion rate) and did not differ by condition. Participants in the mindfulness condition spent an average of 88.15min (SD=24.75) meditating out of the full 100min prescribed by the intervention. State mindfulness significantly increased across the 10-day intervention for participants in the mindfulness, but not the cognitive training, condition beginning around days 5 and 6. Some aspects of trait mindfulness increased and mood improved from pre- to post-intervention, but these changes were observed in both conditions (i.e., no significant differences were observed by condition). Qualitative analysis of open-ended reactions to the mindfulness app indicated that participants reported more likes than dislikes. Common themes for likes were that participants experienced feelings of calm and focus following the daily mindfulness exercises. Dislikes included discomfort and anxiety associated with increased awareness of thoughts and physical sensations. These findings suggest that while a brief mobile mindfulness intervention is acceptable to undergraduate college students and effective at increasing state mindfulness, a longer intervention may be needed in order to elicit corresponding changes in trait-level mindfulness or mood.

Mindfulness-based mobile app reduces anxiety and increases self-compassion in healthcare students: A randomised controlled trial

OBJECTIVE

To compare the effect of a mindfulness-based mobile application versus an in-person mindfulness-based training program in terms of reducing anxiety and increasing empathy, self-compassion, and mindfulness in a population of healthcare students.

METHODS

The authors conducted a single-blind, randomised controlled trial with three parallel groups. Participants were allocated to the mobile app, the in-person mindfulness-based program (IMBP), or a control group. Assessments at baseline and postintervention (8 weeks) included measures of anxiety, empathy, self-compassion, and mindfulness.

RESULTS

Of 168 students randomised, 84 were analysed on an intention-to-treat basis (app: n = 31; IMBP: n = 23; control: n = 30). The mobile app group showed a large effect size for reductions in trait anxiety compared with controls (g = 0.85, p = 0.003), and a medium, nonsignificant effect compared with the IMBP group (g = 0.52, p = 0.152). Participants from both interventions experienced a significant increase in self-compassion and mindfulness compared with controls. Levels of empathy remained unchanged for the 3 arms.

CONCLUSIONS

A mobile app can be as effective as an IMBP in reducing anxiety and increasing self-compassion and mindfulness among healthcare students.

Mindfulness-Based Interventions to Reduce Burnout and Stress in Physicians: A Systematic Review and Meta-Analysis

PURPOSE

To perform a systematic review and meta-analysis of studies evaluating the effectiveness of mindfulness-based interventions (MBIs) in reducing burnout and stress among physicians.

METHOD

The authors searched records in MEDLINE, Embase, PsycINFO, PSYNDEX, Web of Science, CINAHL, and CENTRAL from database inception to August 8, 2019, using combinations of terms for mindfulness, interventions, and physicians. Eligible studies were randomized controlled trials (RCTs) and nonrandomized trials (NRTs), including controlled and noncontrolled before-after studies, all assessing burnout and stress among physicians preintervention and postintervention via validated instruments. Two reviewers independently screened records, extracted data, assessed risk of bias, and rated overall quality of evidence. The authors used random-effects modeling to calculate pooled effect sizes and conducted prespecified subgroup and sensitivity analyses to explore potential moderators.

RESULTS

Of 6,831 identified records, 25 studies (with 925 physicians) were ultimately included. MBIs were associated with significant small reductions in burnout in between-group analyses (5 comparisons: standardized mean difference [SMD] = -0.26; 95% confidence interval [CI] = -0.50, -0.03) and pre-post analyses (21 comparisons: SMD = -0.26; 95% CI = -0.37, -0.15), and with a significant medium reduction in stress in between-group analyses (4 comparisons: SMD = -0.55; 95% CI = -0.95, -0.14) and a significant small reduction in stress in pre-post analyses (17 comparisons: SMD = -0.41; 95% CI = -0.61, -0.20). Versions of established MBIs showed higher effectiveness in reducing stress than other forms of MBIs or a mindfulness app. Reductions were maintained over an average follow-up of 5.3 months. The risk of bias was moderate with RCTs and high with NRTs. The overall quality of evidence was low to very low.

CONCLUSIONS

MBIs can be effective in reducing physicians' burnout and stress. Shortcomings in the quality of evidence highlight the need for high-quality controlled trials providing long-term follow-up data.

The effects of app-based mindfulness practice on the well-being of university students and staff

Mental health problems like anxiety, depression, and stress have been increasing in many countries and the 2020 COVID-19 pandemic has further exacerbated their toll. Mindfulness-based interventions have been shown to provide evidence-based treatments for anxiety and depression, and accumulating evidence is emerging in support of using mindfulness apps yielding small-to-moderate treatment effects. The study was a 4-week randomized controlled trial with 561 university students and staff as participants, divided into a treatment group (mindfulness app) and an active control group (psychoeducational online content). Depression, anxiety, and stress were evaluated as primary study outcomes. Saliva cortisol samples were also collected from a subgroup of the treatment arm (n = 29). Using the mindfulness app for four weeks resulted in small reductions in stress (d = .16), and depression (d = .16). Attrition was 28.0%. Subjects who practiced more did not experience additional improvement in wellbeing. Mindfulness apps offer modest but clear benefits to users in terms of improved mental health. They present a promising supplement to traditional mental health services.

A Systematic Review of Interventions to Improve Humanism in Surgical Practice

INTRODUCTION

Humanism in surgery is an emerging priority in surgical education. Its emphasis on the patient experience is a key component of the therapeutic relationship between surgeons and their patients. However, the documented high rates of compassion fatigue and burnout among surgical trainees and staff can serve as a barrier in delivering care with empathy and compassion. As such, this systematic review seeks to characterize the outcomes regarding interventions that aim to broadly improve humanism within surgery.

METHODS

A systematic search of 4 electronic databases (EMBASE, MEDLINE, PsycINFO, and Cochrane CENTRAL) was conducted through an independent double selection and extraction process from database inception to March 20, 2020. The inclusion criteria consisted of interventional studies aiming to improve humanism in surgery at all levels of training. A qualitative synthesis and thematic analysis were performed.

RESULTS

A total of 19 studies (1 RCT, 14 prospective cohort, and 4 cross-sectional studies), with 20 intervention arms, were included from the initial 745 studies that were eligible for title screening. Studies included a total of 1763 surgical trainees at varying levels of training. Two major strategies for improving humanism were identified: (1) directly through the development of empathetic communication skills (n = 11) and (2) indirectly through programs aimed at reducing levels of compassion fatigue and emotional exhaustion by addressing trainee burnout (n = 9). A total of 70% (14/20) of the studied interventions were successful in improving empathy in surgical trainees.

CONCLUSION

Interactive workshops around the principles of empathetic communication with patient simulations and small group learning were effective at improving empathy in surgical trainees. Furthermore, mindfulness-based training and the provision of physical resources to support trainee well-being consistently improved rates of burnout among surgical trainees. Overall, further investigation is necessary to better understand methods of improving empathy in surgery.

The efficacy of mindfulness meditation apps in enhancing users' well-being and mental health related outcomes: a meta-analysis of randomized controlled trials

BACKGROUND

Mindfulness applications are popular tools for improving well-being, but their effectiveness is unclear. We conducted a meta-analysis of randomized controlled trials (RCTs) that employed a mindfulness meditation app as the main intervention to improve users' well-being and mental-health related outcomes.

METHODS

A systematic search was conducted in PsycINFO, PubMed, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Library, Open Grey and ResearchGate through June, 2020. Effects were calculated as standardized mean difference (Hedges' g) between app-delivered mindfulness interventions and control conditions at post-test and pooled with a random-effects model.

RESULTS

From 2637 records, we selected 34 trials (N = 7566). Significant effect sizes were found at post-test for perceived stress (n = 15; g = 0.46, 95% CI [0.24, .68], I²= 68%), anxiety (n = 15; g = 0.28, 95% CI [0.16, .40], I²= 35%), depression (n = 15; g = 0.33, 95% CI [0.24, .43], I²= 0%), and psychological well-being (n = 5; g = 0.29, 95% CI [0.14, .45], I²= 0%). No significant effects were found for distress at post-test (n = 6; g = 0.10, 95% CI [-0.02, .22], I²= 11%) and general well-being (n = 5; g = 0.14, 95% CI [-0.02, 0.29], I² = 14%).

CONCLUSION AND LIMITATIONS

Mindfulness apps seem promising in improving well-being and mental-health, though results should be interpreted carefully due to the small number of included studies, overall uncertain risk of bias and heterogeneity.

Anesthesia in the modern world of apps and technology: Implications and impact on wellness

Recent decades have seen an unprecedented leap in digital innovation, with far-reaching implications in healthcare. Anesthesiologists have historically championed the adoption of new technologies. However, the rapid evolution of these technologies has outpaced attempts at studying their potential impact on healthcare providers' well-being. This document introduces several categories of workplace technologies commonly encountered by the anesthesiologist. We examine examples of novel technology and the impact of these digital interventions on the anesthesiologist's well-being. We also review popular personalized technology aimed at improving wellness and the impact on well-being examined. Finally, technology acceptance models are introduced to improve technology adoption, which, when appropriately applied, may minimize the negative impacts of technology on anesthesiologists' well-being. Incorporating quantitative, serial assessments of well-being as part of technology implementation are proposed as a future direction for examining the wellness impact of technology on anesthesiologists.

Heart rate variability is enhanced during mindfulness practice: A randomized controlled trial involving a 10-day online-based mindfulness intervention

OBJECTIVES

The goal of the present study was to probe the effects of mindfulness practice in a naturalistic setting as opposed to a lab-based environment in the presence of continuous heart rate variability (HRV) measurements. The specific experimental goals were to examine the effects of a brief 10-day online-based mindfulness intervention on both chronic and acute HRV responses.

METHOD

We conducted a fully randomized 10-day longitudinal trial of mindfulness practice, explicitly controlling for practice effects with an active-control group (music listening) and a non-intervention control group. To assess chronic cardiovascular effects, we asked participants in the 3 groups to complete 2-day HRV pre- and post-intervention measurement sessions. Using this experimental setup enabled us to address training effects arising from mindfulness practice to assess physiological impact on daytime as well as nighttime (i.e. assessing sleep quality) on the underlying HRV response. To assess acute cardiovascular effects, we measured HRV in the 2 active intervention groups during each of the 10 daily mindfulness or music sessions. This allowed us to track the development of purported training effects arising from mindfulness practice relative to the active-control intervention in terms of changes in the HRV slope over the 10-day time-course.

RESULTS

Firstly, for the acute phase we found increased HRV during the daily practice sessions in both the mindfulness and active-control group indicating that both interventions were effective in decreasing acute physiological stress. Secondly, for the chronic phase we found increased HRV in both the day- and nighttime indicating increased sleep quality, specifically in the mindfulness group.

CONCLUSION

These results suggest causal effects in both chronic and acute phases of mindfulness practice in formerly naïve subjects and provides support for the argument that brief online-based mindfulness interventions exert positive impact on HRV.

Mindfulness and engagement in COVID-19 preventive behavior

The novel coronavirus disease 2019 (COVID-19) pandemic represents a significant risk to population health. Health organizations worldwide have recommended numerous preventive health behaviors to slow the spread of COVID-19. Yet, considerable variability exists in individual-level adherence to these recommendations. Mindfulness has been associated with greater engagement in health promotive behavior (e.g., physical activity, healthy eating), and may serve as an individual difference factor that encourages adherence. However, no study to date has examined the extent to which mindfulness is associated with preventive health behaviors during a global pandemic. The purpose of the present study was to assess the relations between mindfulness and recommended preventive health behaviors for COVID-19. A national U.S. sample (N = 353; M age = 41.47 years, range: 19-84; 50.2% female) completed an online survey via Amazon's Mechanical Turk from April 3rd to 15th, 2020, including measures of mindfulness and frequency of avoiding touching one's face, handwashing, disinfecting/cleaning frequently used surfaces, social distancing, and self-quarantining. Personality, health risk, and demographic factors were also assessed to test the unique association between mindfulness and preventive health behaviors. Mindfulness was significantly correlated with greater engagement in all of the COVID-19 preventive health behaviors. However, when accounting for demographics, health risk, and personality, mindfulness was only uniquely associated with engagement in social distancing. This research highlights mindfulness as an individual-level characteristic associated with engagement in COVID-19 preventive health behavior and may inform future prevention efforts aimed at improving adherence to recommendations for curbing the spread of infectious disease.

Standalone Smartphone Cognitive Behavioral Therapy-Based Ecological Momentary Interventions to Increase Mental Health: Narrative Review

BACKGROUND

A growing number of psychological interventions are delivered via smartphones with the aim of increasing the efficacy and effectiveness of these treatments and providing scalable access to interventions for improving mental health. Most of the scientifically tested apps are based on cognitive behavioral therapy (CBT) principles, which are considered the gold standard for the treatment of most mental health problems.

OBJECTIVE

This review investigates standalone smartphone-based ecological momentary interventions (EMIs) built on principles derived from CBT that aim to improve mental health.

METHODS

We searched the MEDLINE, PsycINFO, EMBASE, and PubMed databases for peer-reviewed studies published between January 1, 2007, and January 15, 2020. We included studies focusing on standalone app-based approaches to improve mental health and their feasibility, efficacy, or effectiveness. Both within- and between-group designs and studies with both healthy and clinical samples were included. Blended interventions, for example, app-based treatments in combination with psychotherapy, were not included. Selected studies were evaluated in terms of their design, that is, choice of the control condition, sample characteristics, EMI content, EMI delivery characteristics, feasibility, efficacy, and effectiveness. The latter was defined in terms of improvement in the primary outcomes used in the studies.

RESULTS

A total of 26 studies were selected. The results show that EMIs based on CBT principles can be successfully delivered, significantly increase well-being among users, and reduce mental health symptoms. Standalone EMIs were rated as helpful (mean 70.8%, SD 15.3; n=4 studies) and satisfying for users (mean 72.6%, SD 17.2; n=7 studies).

CONCLUSIONS

Study quality was heterogeneous, and feasibility was often not reported in the reviewed studies, thus limiting the conclusions that can be drawn from the existing data. Together, the studies show that EMIs may help increase mental health and thus support individuals in their daily lives. Such EMIs provide readily available, scalable, and evidence-based mental health support. These characteristics appear crucial in the context of a global crisis such as the COVID-19 pandemic but may also help reduce personal and economic costs of mental health impairment beyond this situation or in the context of potential future pandemics.

A Mobile Health Mindfulness Intervention for Women With Moderate to Moderately Severe Postpartum Depressive Symptoms: Feasibility Study

BACKGROUND

Approximately 20% of women suffer from postpartum depression (PPD). Due to barriers such as limited access to care, half of the women with PPD do not receive treatment. Therefore, it is critical to identify effective and scalable interventions. Traditional mindfulness programs have been effective in reducing depressive symptoms, however access remains a barrier. A self-paced mobile health (mHealth) mindfulness program may fit the lifestyle of busy mothers who are unable to attend in-person classes. However, little is known regarding the feasibility or efficacy of mHealth mindfulness interventions in postpartum women with depressive symptoms.

OBJECTIVE

This study aims to assess the feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness intervention for postpartum women with moderate to moderately severe depressive symptoms.

METHODS

We conducted a single-arm feasibility trial of an mHealth mindfulness intervention within Kaiser Permanente Northern California (KPNC), a large integrated health care system. Participants were identified through clinician referral and electronic health records via KPNC's universal perinatal depression screening program and recruited by the study team. Inclusion criteria included the following: English-speaking, up to 6 months postpartum with a Patient Health Questionnaire (PHQ-8) score of 10 to 19, and no regular mindfulness/meditation practice. Participants were asked to use a mindfulness app, Headspace, 10 to 20 min/day for 6 weeks. Baseline and postintervention surveys captured data on patient-reported outcomes (depression and stress symptoms, sleep quality, and mindfulness). Semistructured interviews captured acceptability. Retention and adherence were used to assess feasibility.

RESULTS

Of the 115 women who were contacted and met the eligibility criteria or declined participation before eligibility assessment, 27 (23%) were enrolled. In addition, 70% (19/27) completed the study. The mean age of participants was 31 years (SD 5.2), 30% (8/27) were non-Hispanic White, and, on average, participants were 12.3 weeks postpartum (SD 5.7). Of the women who completed the study, 100% (19/19) used the Headspace app at least once, and nearly half (9/19, 47%) used the app on ≥50% of the days during the 6-week intervention period. Of the 16 participants who completed the postintervention interview, 69% (11/16) reported that they were very or extremely satisfied with the app. Interviews indicated that women appreciated the variety of meditations and felt that the program led to reduced anxiety and improved sleep. Significant improvements in pre- and postintervention scores were observed for depressive symptoms (PHQ-8: -3.8, P=.004), perceived stress (10-item Perceived Stress Scale: -6.0, P=.005), and sleep quality (Pittsburgh Sleep Quality Index: -2.1, P=.02, indicating less sleep disturbance). Improvements in mindfulness were also significant (Five Facet Mindfulness Questionnaire-Short Form: 10.9, P=.01).

CONCLUSIONS

An mHealth mindfulness intervention for postpartum women with moderate to moderately severe depressive symptoms is feasible and acceptable. An efficacy trial is warranted.

Practical Strategies for Identifying and Managing Burnout in Plastic Surgeons

BACKGROUND

Physician burnout is a well-known problem and widespread issue in the field of medicine. Recently, more attention has been given to the significance of burnout among plastic surgeons. The cause of burnout is multifactorial, with emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment all playing a role. The objective of this article is to provide practical measures to help plastic surgeons in identifying the signs of burnout, thereby mitigating its consequences.

METHODS

A literature review was performed to determine the comprehensive findings of previous research conducted on burnout among plastic surgeons. Particular interest was given to successful tactics used in managing work-related stress. Wellness strategies and resources from both academic and private medical settings were also obtained to further review methods for burnout management.

RESULTS

There is a wide range of causes and risk factors for burnout among plastic surgeons. The majority of cases correlate with increased workload, loss of physician autonomy, and, in the context of trainees, lack of mentorship. Managing burnout can be supported by identification through survey tools. Establishing a wellness committee is also useful to develop institution-specific interventions. Equally as important, individuals must take steps to manage and minimize their burnout.

CONCLUSIONS

This article provides practical strategies for institutions to identify and manage burnout among plastic surgeons. It is obvious that causes of burnout vary in different settings such as academic and community hospitals; therefore, it is critical for institutions to individualize their approach to burnout.

A Systematic Review of Educational Mobile-Applications (Apps) for Surgery Residents: Simulation and Beyond

INTRODUCTION

The number of mobile-applications (Apps) increases daily. The regulation of App content is minimal yet surgical residents use these in daily educational practice. Surgical educators must be aware of the quality, efficacy, and validity of Apps available to effectively educate residents. The aim of this review was to determine the quality, efficacy, and validity evidence for educational Apps used by surgical residents.

MATERIALS AND METHODS

We searched PubMed, Embase, and ERIC for articles published before September 1, 2019. Controlled vocabulary and natural language describing Apps/surgical residents were used. Two reviewers evaluated abstracts for inclusion.

INCLUSION CRITERIA

studies measuring the quality, efficacy, or validity of educational Apps for surgical residents. Data was extracted from full text of included articles: study design, participants, App investigated, App development, evidence for efficacy, or validity of App.

RESULTS

Initial search identified 278 articles. 64 articles were duplicates and 214 articles were screened. A further 156 were excluded with 58 full text articles assessed for eligibility. Forty-five were included in analysis. Simulation (9/45) and Feedback (15/45) Apps were the most commonly studied in surgical residents. These were the main Apps that provided validity evidence for their use in education.

CONCLUSION

Surgical education is evolving as educational technology becomes more prevalent. To be effective as surgical educators we must understand and appropriately use available tools. Of the educational Apps studied (21 Apps in 8 categories), only 3 categories reported validity evidence. Future studies should take care to measure validity and efficacy of educational Apps for surgical education to ensure quality control.

Is there a trial bias impacting user engagement with unguided e-mental health interventions? A systematic comparison of published reports and real-world usage of the same programs

Trial settings that include proactive recruitment, human contact, and assessment procedures may substantially impact the way users engage with unguided e-mental health programs and the generalizability of reported findings. This study examined the impact of trial setting on user behavior by directly comparing reported user engagement in trial-based research and objective measures of real-world usage of the same unguided mental health programs. The authors conducted a systematic search for papers reporting user engagement with off-the-shelf unguided e-mental health programs. Real-world usage was obtained from a panel that presents aggregated nonpersonal information on user engagement with digital programs across the world. A total of 13 papers yielding 14 comparable usage metrics met all inclusion criteria. In three papers reporting the use of programs by lay users without any proactive trial procedures, the ratios calculated by dividing the usage reported in the paper by the usage documented within the objective dataset were 0.84, 1.05, and 1.27-suggesting a sufficient criterion validity for our examination. In studies that proactively recruited users and included pre- to post-assessment procedures (11 comparisons), the median program usage rate reported was 4.06 times higher (IQR = 4.49) than the real-world usage of the same program. Severity of clinical symptoms, in-person versus remote assessment procedures, study design, and program cost had no impact on these differences. The results suggest that trial settings have a large impact on user engagement with unguided interventions and, therefore, on the generalizability of the findings to the real world.

Mindfulness Education for Otolaryngology Residents: A Pilot Study

This pilot project was designed to (1) implement a mindfulness-based wellness curriculum for otolaryngology residents, (2) determine the impact of a mindfulness-based curriculum on resident mood, and (3) examine the use of mindfulness among otolaryngology residents. Otolaryngology residents participated in a 6-week course guided by the Headspace mindfulness mobile application. Resident use of mindfulness was measured by the validated Mindful Attention Awareness Scale (MAAS). Changes in mood before and after each session were assessed using the validated Positive and Negative Affect Schedule (PNAS). Residents reported a statistically significant decrease in postsession negative affect scores (P < .001). A moderate positive correlation was noted between mindfulness scores and presession positive mood (Pearson r = 0.597, P < .001). This pilot study supports the feasibility and impact of including mindfulness training as part of a resident wellness curriculum.

Mindfulness, Compassion, and Self-Compassion Among Health Care Professionals: What's New? A Systematic Review

Health care professionals (HCPs) are a population at risk for high levels of burnout and compassion fatigue. The aim of the present systematic review was to give an overview on recent literature about mindfulness and compassion characteristics of HCPs, while exploring the effectiveness of techniques, involving the two aspects, such as MBSR or mindfulness intervention and compassion fatigue-related programs. A search of databases, including PubMed and PsycINFO, was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines and the methodological quality for this systematic review was appraised using AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews-2). The number of articles that met the inclusion criteria was 58 (4 RCTs, 24 studies with pre-post measurements, 12 cross-sectional studies, 11 cohort studies and 7 qualitative studies). MBSR intervention was effective at improving, and maintaining, mindfulness and self-compassion levels and to improve burnout, depression, anxiety, stress. The most frequently employed interventional strategies were mindfulness-related trainings that were effective at improving mindfulness and self-compassion, but not compassion fatigue, levels. Compassion-related interventions have been shown to improve self-compassion, mindfulness and interpersonal conflict levels. Mindfulness was effective at improving negative affect and compassion fatigue, while compassion satisfaction may be related to cultivation of positive affect. This systematic review summarized the evidence regarding mindfulness- and compassion-related qualities of HCPs as well as potential effects of MBSR, mindfulness-related and compassion-related interventions on professionals' psychological variables like mindfulness, self-compassion and quality of life. Combining structured mindfulness and compassion cultivation trainings may enhance the effects of interventions, limit the variability of intervention protocols and improve data comparability of future research.

Feasibility and Acceptance Testing of a Mobile Application Providing Psychosocial Support for Parents of Children and Adolescents With Chronic Pain: Results of a Nonrandomized Trial

Objective To conduct a single-arm pilot study assessing the feasibility and acceptability of a 30-day parent-focused mindfulness and psychosocial support mobile app intervention for parents of children with chronic pain. Methods Thirty parents completed the intervention, which included a mindfulness curriculum, peer support videos, and written psychoeducational content. Twelve healthcare providers also assessed the app and provided feedback. Feasibility was assessed by server-side documented usage on ≥50% of the days in the intervention period and completion of ≥70% of the mindfulness content. Parent and provider acceptance were assessed by ≥70% of participants rating each acceptance test question as ≥5 on a 7-point Likert scale. Parents completed measures of solicitousness, stress, mindful parenting, and resilience prior to and following the intervention. Results Feasibility results were mixed: parents completed mindfulness content on an average of 11.2 days during the intervention period, slightly under the pre-established criterion. However, parents completed an average of 72.1% of the content, which met feasibility criterion. Acceptance criteria were met for the majority of parent acceptance test questions and all of the provider acceptance test questions. Exploratory analyses of the psychosocial measures revealed significant decreases in parental solicitous behavior and perceived stress, and a significant increase in mindful parenting. Conclusions The current study extends the emerging body of research on mindfulness-based interventions for parents of children with chronic illness and suggests that it may be acceptable to deliver this content through a mobile device. Future research is needed to assess the intervention's efficacy compared to standard of care.

Feasibility and Acceptability of a Mobile Mindfulness Meditation Intervention Among Women: Intervention Study

Background

Traditional mindfulness-based stress reduction programs are resource intensive for providers and time- and cost-intensive for participants, but the use of mobile technologies may be particularly convenient and cost-effective for populations that are busy, less affluent, or geographically distant from skilled providers. Women in southern Louisiana live in a vulnerable, disaster-prone region and are highly stressed, making a mobile program particularly suited to this population.

Objective

This study aimed to (1) assess the feasibility and acceptability of a mobile mindfulness app in real-world conditions in a pilot study of a community sample of women residing in southern Louisiana, (2) describe predictors of app usage, and (3) assess the effect of the app on secondary health outcomes.

Methods

Women were recruited from an oil spill study on health. A total of 236 women completed a baseline survey, were offered the mobile mindfulness program, and completed a follow-up survey. Subjects were asked to download and use the app for at least 30 days for 10 min. All study procedures were completed on the web. Primary outcomes were feasibility and acceptability of the app and characteristics of app utilization. Secondary outcomes included mindfulness, depression, perceived stress, sleep quality, physical activity, BMI, and healthy eating.

Results

Overall, 74.2% (236/318) of subjects completed the follow-up survey, and 13.5% (43/318) used the app. The main barrier to app usage was lack of time, cited by 37% (16/43) of users and 48.7% (94/193) of nonusers of the app. Women who chose to use the app were more highly educated (16/43, 63% had a college education vs 65/193, 33.7% of nonparticipants; P<.001), had higher incomes (23/43, 58% had incomes >US $50,000 per year vs 77/193, 43.0% of nonparticipants), and were employed (34/43, 79% vs 122/193, 63.2% of nonparticipants; P=.047). Those who engaged with the app did so at high levels, with 72% (31/43) of participants self-reporting the completion of some or all sessions and 74% (32/43) reporting high levels of satisfaction with the app. Participation with the app had a beneficial impact on depression (odds ratio [OR] 0.3, 95% CI 0.11-0.81), sleep quality (OR 0.1, 95% CI 0.02-0.96), sleep duration (OR 0.3, 95% CI 0.07-0.86), sleep latency (OR 0.3, 95% CI 0.11-0.81), and physical activity (2.8 95% CI 1.0-7.8), but mindfulness scores did not change from baseline to follow-up.

Conclusions

The Headspace mobile mindfulness app was easy and cost-effective to implement and acceptable to those who participated, but few women elected to try it. The unique characteristics of this southern Louisiana population suggest that more intense promotion of the benefits of mindfulness training is needed, perhaps in conjunction with some therapist or researcher support. Several short-term benefits of the app were identified, particularly for depression and sleep.