Studies have found burnout is prevalent among mental health workers (Paris & Hoge, 2010), with 21% to 67% endorsing “high” levels of burnout (Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012). Burnout occurs when individuals are unable to effectively cope with high levels of prolonged occupational stress. Burnout can be characterized by three distinct dimensions: emotional exhaustion, depersonalization or cynicism, and reduced personal accomplishment (Maslach, Schaufeli, & Leiter, 2001). Recently, there has been a growing interest in the impact of burnout on direct care staff (e.g., Gray-Stanley & Muramatsu, 2011), who assist in activities of daily living and recreational activities, and provide supervision and crisis counseling to patients in treatment facilities. Due to the emotional and physical demands of direct care work, these employees are considered to be particularly susceptible to burnout, although the prevalence rate of burnout in this population is not known (Ito, Kurita, & Shiiya, 1999).

Burnout negatively impacts both individual employees and the organizations for which they work. Burnout has been associated with poor physical and mental health in employees (Ahola et al., 2005; Peterson et al., 2008; Saleh & Shapiro, 2008; Toppinen-Tanner, Ojajarvi, Vaananen, Kalimo & Jappinen, 2005). It is correlated with high levels of staff absenteeism and turnover, which negatively impact the effectiveness of mental health organizations and potentially impair client care (Martin & Schinke, 1998; Parker & Kulik, 1995; Toppinen-Tanner et al., 2005). Patients report lower levels of satisfaction when they are cared for by staff members who endorse high levels of burnout (Garman, Corrigan, & Morris, 2002; Leiter & Harvie, 1998). In addition, staff members who endorse symptoms of burnout are more likely to perceive their clients in a negative fashion (Holmqvist & Jeanneau, 2006).

Researchers have begun to explore the impact of mindfulness on burnout among health care professionals. For example, Goodman and Schorling (2012) found health professionals who participated in an eight-week Mindfulness Based Stress Reduction course and a seven-hour retreat showed a significant decrease in burnout level. This research suggested mindfulness interventions may be effective in targeting burnout, but researchers have not used mindfulness techniques with direct care staff specifically (Bernier, 1998; Innstrand, Espnes, & Mykletun 2004; Scarnera, Bosco, Soleti, & Lancioni, 2009).

This mixed method study intended to address this gap in the literature by conducting a pilot study on mindfulness intervention with direct care staff. We predicted direct care staff would report high levels of burnout at baseline. There is overlap between the construct of burnout and symptoms of depression; however, research also suggests they are separate constructs (e.g., Ahola et al., 2005). Hence, we predicted there would be an inverse relationship between burnout and mindfulness, even when controlling for depressive symptoms. We predicted individuals who participated in a mindfulness intervention would endorse decreased levels of burnout and increased mindfulness. Finally, this study looked at the subjective experience of direct care staff to better understand their experience of burnout, and the role of mindfulness.

Methods

Participants

Participants were recruited from a residential treatment facility providing psychiatric care to young adults. Recruitment involved informational flyers and presentations at staff meetings. A total of 22 direct care staff members (9 males and 13 females) completed the baseline questionnaires (seeTable 1). The average length of tenure for direct care staff at this facility was 7.41 years (SD = 7.66 years).

Measures

Burnout was measured with the Maslach Burnout Inventory – General Survey (MBI- GS; Maslach & Jackson, 1986), a 22-item scale assessing for burnout across three dimensions: emotional exhaustion, cynicism, and personal achievement. The authors of the scale provided cutoffs for low, moderate, and high levels of burnout. Meta-analyses indicated reliabilities of 0.88, 0.71 and 0.78 for the three dimensions (Aguayo, Vargas, de la Fuente, Lozano, 2011; Shapiro, Astin, Bishop, & Cordova, 2005). Cronbach’s alpha for this study was 0.79.

Staff members also completed the Center of Epidemiological Studies Depression Scale (CES-D; Klinedinst, Dunbar, & Clark, 2013), a 20-item scale assessing depressive symptoms. Reliability for this measure produced an alpha coefficient of 0.76 to 0.91. Cronbach’s alpha for this study was 0.85.

Participant mindfulness was measured with the Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith & Allen, 2004), a 39-item scale measuring mindfulness across four subscales to assess observation, describing observed phenomena acting with awareness, and accepting without judgment. The KIMS has demonstrated high test-retest reliability and internal consistency (Baer et al., 2004). Cronbach’s alpha for this study was 0.76.

Semi-structured interviews with participants who completed the mindfulness training intervention were conducted via telephone and recorded by the first author. Interviews were later transcribed and de-identified. The interviews were coded and analyzed by the first author using grounded theory methodology (Auerbach & Silverstein, 2003).

Procedures

Direct care staff were invited to complete the questionnaires and to participate in a mindfulness group. Direct care staff who agreed to complete only the questionnaires formed the control group, and were entered into a lottery to win a $15 gift card. Staff who agreed to complete both the questionnaires and the mindfulness group made up the experimental group, and were entered into a lottery to win a $75 gift card.

Staff members who agreed to participate in mindfulness training were asked to attend an initial session introducing the fundamental principles of mindfulness and burnout. Participants were provided with psychoeducation about the role of physical sensations, thoughts, and emotions in the experience of stress, and also about mindfulness. Participants were introduced to informal mindfulness practices such as the Raisin Exercise (Williams, Teasdale, Segal, & Kabat-Zinn, 2007), and formal mindfulness practice, such as a guided body scan. Participants were provided with materials to encourage them to develop their own practices. They were then invited to attend follow-up group sessions. After a month of offered follow-up sessions, the experimental group completed the questionnaires again and were invited to participate in a semi-structured interview conducted via telephone.

Results

Levels of burnout among direct care staff at baseline

The average level of emotional exhaustion among direct care staff was 15.86 (SD 8.31), the mean for cynicism was 12.23 (SD = 10.54), and the average score of personal achievement was 26.5 (SD = 6.38), which all fell in the moderate range (Maslach & Jackson, 1986). In addition, 45.5% of participants scored in the high range of emotional exhaustion, cynicism, and personal achievement (see Table 2).

Relationship between burnout and mindfulness

A partial correlation was used to explore the relationship between burnout and mindfulness, while controlling for depression (see Table 3). Contrary to our hypothesis, the relationships between the components of burnout and mindfulness were nonsignificant and most were small in size. The largest correlation was between emotional exhaustion and acting with awareness (r = -.289, n = 17, p = .230).

Impact of mindfulness invention

Seven staff members expressed interest in participating in the mindfulness group, but only three, two men and a woman, were able to commit to the time requirements. An independent t-test was used to compare the experimental and control groups at baseline. For the cynicism subscale, the Levene test indicated a violation of the assumption of homogeneity, so the separate variance version of the t-test was used to analyze this subscale. There was a significant difference in cynicism scores between the control group (M = 12.61, SD = 10.94) and the experimental group [M =5.67, SD = 1.53; t(19) 2.55, p = .02]. There were no significant between-group differences in mindfulness (see Table 4).

The three staff members who agreed to participate in mindfulness training were asked to attend an initial group session introducing the fundamental principles of mindfulness and burnout, and were then offered additional scheduled trainings. Participants expressed a desire to attend the additional trainings but had to cancel several times due to extenuating circumstances (e.g., being called in to work another shift). Two staff members attended one training session while the third staff member attended a total of two sessions. The participants were unable to attend the trainings at the same time, so the training sessions were conducted individually.

Staff members completed the questionnaires for a second time after the mindfulness intervention. A paired t-test was used to compare participants’ baseline scores to their scores after the mindfulness intervention (see Table 5). There were no significant changes in overall levels of mindfulness, as measured by the KIMS (Baer, Smith & Allen, 2004). Additionally, there were no significant differences in the levels of cynicism and personal achievement. Participants’ levels of emotional exhaustion were reduced (pre-test M = 12.33, SD = 5.50; post- test M = 4.33, SD = 4.50) and this approached significance [t(2) = 4.00, p = .057].

Qualitative Results

The results of the qualitative analysis of the interviews are summarized below. Repeating ideas were identified when all three participants endorsed the idea or when two out of three participants endorsed the idea with at least one of those individuals endorsing it more than once. The repeating ideas were grouped into themes. The themes were then grouped into two overarching constructs of Burnout and Mindfulness.

Burnout

The participants noted burnout negatively impacted their work environment, and led some of their colleagues to use ineffective coping skills, while others struggled to maintain an empathetic stance toward clients and co-workers (theme of Prevalence and Negative Impact of Burnout). They attributed the development of burnout to the overwhelming demands, which they felt often superseded their own needs, and they reported these sacrifices were generally unappreciated (theme of Feeling Unsupported; repeating ideas of feeling under-appreciated and suppressing own needs to meet job demands). They reported that burnout was associated with a sense of enormous demand, resulting in difficulty focusing and the development of ineffective habits (theme of Burnout as the Antithesis of Mindfulness; repeating ideas of difficulty focusing on the present moment and formation of ineffective habits).

Mindfulness

The participants observed their experience of mindfulness practice to be in stark contrast with their subjective experience of burnout (theme of Mindfulness as a Form of Coping). They explained that mindfulness practice was rejuvenating and soothing (repeating idea of mindfulness as a “break”). They reported mindfulness practice allowed them greater insight into internal processes, such as the sensation of stress in their bodies and their thought processes (repeating idea of increasing awareness of the internal process), and noted a desire to share their feelings with an impartial person (repeating idea of making the internal external through sharing). The participants thought mindfulness would be beneficial for all staff members, but expressed concerns about significant barriers to implementing this strategy (theme of barriers to effective coping). Some concerns were concrete in nature, such as juggling busy schedules, while other concerns related to a sense of distrust among staff members about new interventions. Staff also identified a stigma against feeling stress at work, which might reduce willingness to openly discuss stress or burnout and participate in interventions to reduce it.

Discussion

Burnout in direct care staff

In this sample of direct care staff (n=22), almost half the participants scored in the high range of emotional exhaustion and cynicism, but the average level across the three domains of the burnout inventory fell in the moderate range. Interestingly, only 22.7% of staff reported a low level of personal efficacy, while 45.5% of workers reported high levels, suggesting that staff received a sense of identity, purpose, and pleasure from their work. In fact, only three participants out of 22 (14 %) displayed a profile of high levels of emotional exhaustion and cynicism paired with a low sense of personal achievement. The sense of personal accomplishment among the direct care staff in this sample may help to explain the relatively long tenure at this facility (average of 7.41 years). Contrary to our predictions, we did not find a significant inverse relationship between burnout and mindfulness levels.

We were only able to recruit three staff members to participate in a mindfulness group. The qualitative analysis of the three staff members’ interviews identified themes of burnout being prevalent and having a negative impact on the work environment, staff members feeling unsupported, and burnout as the antithesis of mindfulness. The participants endorsed less burnout after the mindfulness intervention, but only the difference in emotional exhaustion approached statistical significance. These results must be interpreted with caution due to the very small sample size, but these findings suggest the mindfulness intervention shows promise in helping staff reduce their sense of feeling emotionally overwhelmed at work. These findings are consistent with the theme that emerged from the qualitative analysis of mindfulness as a helpful way to cope with burnout. The participants in the mindfulness group did not display a significant increase in mindfulness levels following the intervention. This suggests mindfulness practice may have an immediate positive impact on emotional exhaustion, while the acquisition of mindfulness skills in a meaningful and long-lasting way may require more sustained practice.

Limitations

This study relies on a small sample, so the results may not accurately represent the relationship between burnout and mindfulness. Staff members who were willing to participate may not have been representative of direct care staff at this site. Participants were not randomly assigned to the control group and the intervention group, and the intervention group showed lower levels of cynicism at baseline. Additionally, the participants were recruited from a single mental health agency, and thus the results from this study may not generalize to direct care staff at other facilities. Finally, results of this study may be limited by some staff members’ desire to respond in a socially acceptable manner. To this point, during the initial phase of this study, staff members expressed reluctance to complete surveys because they were worried their results could potentially be traced back and result in negative repercussions from administration. Initially, we had planned to assess all participants’ levels of burnout and mindfulness at two time points. However, participants’ concern about the administration gaining access to their data was so great that we modified our protocol to assess the control group at only one time point, in order to allow for completely anonymous responses.

Clinical Implications and Future Directions

While only a few participants in this study fit the high emotional exhaustion and cynicism and low personal achievement profile, many endorsed moderate to high levels of burnout on at least one of the categories. Furthermore, during interviews, staff members noted burnout negatively impacted staff members. This suggests the need for effective interventions to combat burnout. The pilot mindfulness intervention showed promise for reducing emotional exhaustion. The high levels of personal efficacy reported by many participants point to a potential protective factor that is worthy of additional research: in spite the challenges of direct care work, many direct care staff derive a high degree of personal achievement from their jobs.

The difficulties we encountered in conducting this study were themselves important findings. Our struggles with recruitment highlight barriers to reducing burnout levels: (a) the stigma against admitting stress, which was evident from staff members’ concerns that acknowledging burnout would be perceived negatively by the administration; and (b) the difficulty of scheduling mindfulness interventions with participants who often work more than one job and are caregivers outside of work as well. These concrete issues may need to be addressed at an institutional level. Interventions, such as including mindfulness in trainings during the work day, could provide staff with tools for coping, as well as help to change the culture of the institution by creating a safe space for staff to acknowledge job stress and receive support and appreciation for their contributions to patient care. Finally, while mindfulness interventions with direct care staff may help them cope with stress, we were also impressed by the need for systemic change to reduce their stress, by decreasing the demands of a difficult job.

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Francesca Lewis-Hatheway, Psy.D.