Mindfulness, or mindful awareness, is derived from a Buddhist tradition, and includes a self-regulation of awareness toward present mental states and processes without judgment while accepting moment-to-moment experiences (Bishop et al, 2006). Mindful self-compassion, developed by Neff and Germer (2013), includes mindfulness as a core element in addition to developing the capacity to actively soothe and comfort oneself during challenging times. Mindful self-compassion is a new field of research arising from ‘an ancient idea’ (Friis et al, 2016).
Self-compassion concerns soothing and comforting the self in difficult times. It involves having an accepting, empathic and kind attitude toward oneself during moments of distress (Albertson et al, 2015). Mindfulness meditation has become increasingly used over the past two decades and can increase self-awareness and self-acceptance in patients (Neff and Germer, 2013).
Mindfulness meditation and mindfulness-based stress reduction (MBSR) training were designed to help reduce stress and improve overall psychological wellbeing during times of stress, pain and illness (Kabit-Zinn, 1990). MBRS training for people with cancer differs from support groups because it does not involve providing information and advice, and differs from psychotherapy, in that interpretations are not offered and people are not encouraged to explore issues Matousek and Dobkin (2010).
Mackenzie et al (2006), in a qualitative study of the effects of MBSR with a mixed group of patients with cancer, noted five key themes: openness to change; self-control through self-awareness; shared experience; personal growth; and spirituality.
One of the main functions of the Macmillan mindful compassion programme is to help promote health and reduce stress. David Oldham, the tutor delivering the study days evaluated here, reports that feedback from his courses shows meditation and mindfulness exercises, such as the 3-minute breathing space exercise, increase self-awareness and self-acceptance.
A diagnosis of cancer can be highly stressful (Bränström et al, 2012). In patients with prostate cancer and breast cancer, MBSR can help to improve quality of life, mental clarity and mental health as well as reduce stress significantly (Carlson et al, 2003; Kieviet-Stijnen et al 2008; Bränström et al, 2012; Würtzen et al, 2013).
In 2016, after attending a Macmillan mindful compassion taster session at the National Macmillan Cancer Support Professionals conference, the author attended a two-day Macmillan study retreat based around mindful compassion and resilience building. It seemed apparent that mindful compassion courses could help staff, patients and carers in stressful situations. Learning about mindfulness is known to help nurses (Healy, 2019).
The author's experience of this course was a catalyst to apply to Macmillan for funding to run six one-day study days on mindful compassion for staff, patients and carers. These were offered to anyone and supported by the author's trust. The study days were attended by 326 people. All were asked to complete a feedback form on the day.
This study describes an evaluation undertaken to examine this benefits of such training by analysing the results of initial feedback forms in 2016 and 2017, then 2–3 years later through an online survey 2019.
Study design
Objective and outcomes
The study aimed to identify the initial effects of attending the mindful compassion study days and again 2-3 years later to investigate whether the training had had a long-term impact.
The objectives were to:
Methodology
After ethical approval was obtained, SurveyMonkey was chosen to create an online survey so participants could respond anonymously. The platform allows simple analysis of results.
People who attended the study days in 2016 and 2017 were simultaneously emailed, given information about the study and invited to take part. The email included a link to the questionnaire and people had 2 weeks in which to complete it. Because all replies were anonymous, potential respondents could not be followed up and it was not possible to identify in which year the respondents had attended the courses.
The survey had 10 questions using multiple choice and free text. It focused on two areas: respondents' initial introduction to mindful compassion; and the use and impact of mindful compassion now. Respondents could skip questions, and seven of the 10 questions included spaces where people could add comments.
The first question was used to gain consent and ensure participants had read and understood the information sheet. Two questions covered how often people practised immediately after being taught the skills compared with 2–3 years later.
Participants were asked why they used mindful compassion when they were first introduced to it and why they would use it now. There were multiple options covering work, home, relationships, family, and all of the above, along with space where they could add their own comments.
To find out who had benefited, a multiple-choice option allowed people to give more than one answer including self, work, family and all of the above; participants could also add others not on the list. There were questions to elicit why some did not practise and what prevented them from doing so. A final question provided space for further comments so issues not covered by the survey could be captured for analysis.
Because multiple answers could be given to several questions, the percentage of respondents can total more than 100% in the results. A re-analysis of individual responses of the data showed what each respondent had ticked. Thematic analysis was undertaken for each question to elicit common themes emerging from the responses.
Sample and recruitment
Out of the 326 people attending the courses, 238 agreed to be contacted. Thirty-eight people could not be contacted because emails bounced back or they were away. The remaining 200 people were invited to take part, of whom 99 agreed and were sent surveys.
Data analysis
Once the questionnaires had been completed, data were analysed using thematic analysis and checked by the author's mentor and the trust's research officer to reduce possible bias.
Findings
Early use of mindful compassion training
After being introduced to mindful compassion, the majority of participants practised as and when required, or when possible; 15 people practised it daily and 13 participants 3-4 times a week; seven participants were not practising it (Table 1).
| Response | Number of respondents | % of respondents* |
|---|---|---|
| Every day | 15 | 15.2 |
| 3–4 times per week | 13 | 13.1 |
| As and when required | 38 | 38.4 |
| As and when possible | 28 | 28.3 |
| None | 7 | 7.1 |
| Total | 101 |
People mainly used mindful compassion in all the circumstances listed (54 respondents), followed by work only (19 respondents) (Table 2). Because a large proportion of the attendees were taking part due to stress from work, caring while working, or off from work because of illness, this was to be expected.
| Capacity/environment | Number of respondents | % of respondents |
|---|---|---|
| All of them | 54 | 55.6 |
| Work only | 19 | 19.2 |
| Family only | 6 | 6.1 |
| Home only | 3 | 3.0 |
| Work and home | 7 | 7.1 |
| Work and family | 1 | 1.0 |
| Home and family | 1 | 1.0 |
| Work, home and family | 2 | 2.0 |
| Work, relationships and family | 2 | 2.0 |
| Home, relationships and family | 1 | 1.0 |
| Other | 3 | 3.0 |
| Total | 99 | 100.0 |
Early benefits
Key themes were identified from the free-text answers. One participant said they were already doing what the course covered.
Helpful
This came out strongly: 29 people stated that mindful compassion had helped them and 36 people said it was helpful in work and at home. One attendee stated: ‘It gave me permission to take a moment for myself from the busy work/life environment’, while another said: ‘It helps me deal with day-to-day problems.’
Focused and calm
Twenty-seven people found the course had helped them to feel more calm, with one saying that it had helped them to find ‘inner calm’.
One participant said it helped them ‘keep calm and think of the here and now’ and ‘more focused, as well as helping one carer who lost their mother to cancer’. Another said it stopped their ‘mind from wandering’. Eight people said it helped them to be more focused, with one saying: ‘It helps me control my mind and body from spiralling out of control.’
Psychological benefits
Twelve people said that the study day helped them to reduce anxiety, and 24 felt it had helped to reduce their own stress levels. Seven people found it helped them to sleep better.
Negative feedback
Not everyone was positive about mindful compassion. One found no benefits, while another was ‘sceptical’ and ‘unsure how effective it was’.
Control and coping
A key theme was gaining some control. One person said: ‘It enabled me to stop reacting to situations, and gave me a sense of perspective.’ One attendee described the skills learnt as ‘life changing’ and described how the body scanning technique had helped them stop migraines in early stages and to deal with pain. Another stated: ‘I learned to take time to calm my mind and ease tension and stress.’
Permission to be kind to themselves was highlighted as a benefit. Aiding relationships was another.
One person benefited from being in a ‘beautiful setting’ for the study day and that the change in location in itself had helped to clear the mind, adding that the course ‘gave me strategies to use in my daily life … to calm me down, make me think more clearly’.
One participant found that it had helped them cope and support their father after their mother died. Another said: ‘At the time I attended the session, I wasn't in a good place mentally. I had just found out my dad was gravely ill and my sister was going through treatment for cervical cancer. I have since lost my dad and still find some days harder than others.'
Another stated that it ‘allowed me to step back from issues [and]think more compassionately about others and myself, then move forward with a calmer perspective’.
Maintaining mindful compassion practice
The majority of people said they were still practising—42 when the need arose, and 23 as and when possible. Fifteen practised daily and 11 did so 3-4 times a week. One person skipped this question (Table 3).
| Response | Number of respondents | % of respondents |
|---|---|---|
| Every day | 15 | 15.3 |
| 3–4 times a week | 11 | 11.2 |
| As and when possible | 23 | 23.5 |
| When the need arises | 42 | 42.9 |
| I have not continued | 7 | 7.1 |
| Total responses | 98 | 100 |
| Response | Number of respondents | % of respondents |
|---|---|---|
| Work | 11 | 12.2 |
| Home | 9 | 10.0 |
| Relationships | 0 | 0.0 |
| Family | 6 | 6.7 |
| All of the above | 64 | 71.1 |
| Total responses | 90 | 100 |
When asked in what capacity or environment people were using mindful compassion skills now, 64 replied in all of the circumstances listed, which included work, home, relationships and family; 11 said work, nine said home and six said family. One found it helped while moving house. Seven said they were not using mindful compassion (Table 3), which matches earlier findings. One said it did not help them feel calm or find a direction.
One participant is now teaching compassion courses in the community. Another had made mindfulness part of their life; they had used it to benefit themselves in a new role and were now advocating its use throughout the organisation.
Benefits 2–3 years after the course
Ninety-one people answered and eight skipped the question on current benefits. All responses were in the form of free text.
Again, ‘helpful’ was a common theme, identified by 21 people. One said it had improved their overall health, while another said it made them ‘more able to cope with life's ups and downs’. One found it ‘very empowering’.
Recurring themes included ‘enabling’, ‘reflective’, ‘better perspective’ and ‘more focused’.
Fourteen people said it helped reduce anxiety, 27 found it reduced their stress levels and nine said it helped them sleep better. Eighteen respondents said it made them feel calmer.
One person gave a detailed response:
‘It helps me with home life and coping with children and family stresses. It helps me sleep better at night. It makes me focus more on the present. I am a much calmer person. I see things with more clarity. I don't react to stress in the same way now. I feel I have a tool in my tool box now for when stress at home or work arises. I am more compassionate to myself and in turn more compassionate to those around me. It has shown me how important taking care of myself is, so I can therefore give to others. I feel it has enhanced my productivity as I am mindful of what's real and what's not. I think much more logically. I am more productive at home and work.’
Coping better with difficult situations was also highlighted, with one respondent stating: ‘My new saying, adopted by family and friends, is “It is what it is”.’
Further comments included: ‘I can look up to the sky and reflect without crying’ and ‘It has totally changed my life and those around me.’
However, out of the 91 respondents, 9 said ‘not applicable’ in their free text analysis. Eight had skipped the question.
Who has benefited?
Nine respondents did not feel that there was any benefit: they either skipped the question, gave a ‘not applicable’ response or stated they were not practising (Table 5).
| Capacity/environment | Number of respondents | % of respondents | % with positive response |
|---|---|---|---|
| All of the them | 56 | 56.6 | 62.2 |
| Self only | 17 | 17.2 | 18.9 |
| Family only | 1 | 1.0 | 1.1 |
| Self and family | 4 | 4.0 | 4.4 |
| Self and work | 3 | 3.0 | 3.3 |
| Self, family and work | 7 | 7.1 | 7.8 |
| Self, family and friends | 1 | 1.0 | 1.1 |
| Self, work, and colleagues | 1 | 1.0 | 1.1 |
| Skipped answer, n/a, nothing or not practising | 9 | 9.1 | - |
| Total respondents | 99 | 100.0 | 100.0 |
Excluding these respondents and focusing on those who were still practising mindful compassion, more than 60% indicated that they, their family, their friends and their work environment had all benefited. Nearly 20% felt that they themselves had benefited, while the remainder gave combinations of self, work, family and friends. This reinforces the message that the study day attendees were looking for ways of addressing their work-life balance.
Respondents were asked about what prevented them from practising. Of the 59 who answered, 31 said ‘nothing prevented me’ or ‘not applicable’, so only 28 responses described what had prevented them from continuing. One said time pressures and being busy had prevented them from practising, and having to juggle childcare and work were cited by three respondents.
One claimed that they didn't practise as often as they would like to, ‘which is a shame … as I do benefit from it when I do’.
A small number replied that they did not need to practise because they were not as stressed as they previously had been and five said they ‘have practised when needed’.
One said: ‘It's perhaps more embedded in my everyday activities so I don't recognise it as practice.’ A few respondents said they had to be reminded of the benefits but appreciated it when they did practise.
Open comments
The final question allowed the respondents to add further comments. Out of the 99 respondents, 37 replied and 62 skipped this question.
The majority of comments said how helpful and enjoyable the course had been. The venue —a large country house—was a contributing factor.
Some participants said they had since learnt more around mindfulness and had downloaded apps or attended online training. One participant had started teaching mindful compassion in their community while another was looking at becoming a qualified teacher in this field.
Some attendees had shared their skills with family members such as children who were experiencing panic attacks or with grandchildren who were experiencing bullying in school and struggling with insomnia.
One said mindfulness skills had helped them with their postnatal depression and post-traumatic stress disorder before attending the course and the study day had reminded them to continue practising it.
Other common themes coming out through the findings are characterised by comments, such as:
‘It's my port of call if I feel stress or anxiety’
‘It helped lots of people in my trust with their anxieties.’
‘It made me feel special at a difficult time in my life.’
‘It enabled me to identify how much benefit I do get from practising it.’
‘Skills taught are vital in today's lifestyles.’
‘It was informative, challenging and nurturing in equal parts.’
‘It keeps things in perspective.’
‘Mindfulness is a great tool for coping with life's ups and downs. It's always there to call on and I encourage others to give it a try.’
One person said they incorporated the practice into daily walks after work to lower stress. Another said the course ‘opened my eyes and mind to endless possibilities with simple practices. This has literally changed my life. I really think everyone should have access to this course.’
Methodology limitations
The method has limitations. Because the initial feedback questionnaire was not linked to the online survey, no relationship between the two could be identified. In addition, those who did not respond to the online survey could not be identified because they were anonymous.
SurveyMonkey was used to save time, but it was not as time efficient as expected—the individual responses had to be reanalysed by the researcher because the platform double-counted the multiple-choice responses.
As the GDPR [General Data Protection Regulation] was introduced after the first evaluation, only attendees who gave contact details could be included. This affected the number of participants who were invited to take part in the online surveys.
Discussion
The course was developed in line with programmes that focus on the stress reduction and self-compassion training designed for non-clinical environments.
Findings from the first survey showed how much people enjoyed the course. Both the content and method of delivery were valued. It is interesting to note that the venue played an important role in the enjoyment of our course.
The responses to the surveys highlighted common themes regarding the benefits of the study days included reducing stress and anxiety, finding inner calm, having ‘me time’ and learning techniques such as the 3-minute breathing space. The course benefited those attending in the areas of family and work.
Some respondents had no knowledge of or had never experienced mindful compassion before attending this course and some were sceptical. A few attendees already had knowledge or experience of mindfulness, meditation or yoga breathing and found that the course was a useful reminder of the benefits of regular practice.
The immediate response was positive and this was shown in the comments. It is not known whether those who did not respond felt the same way so this may be a bias response. However, similar themes occurred throughout both evaluations and reflect findings found in the literature review, which gives the author confidence that the findings are valid.
People said that it benefited themselves and their families, as well as work; comments made included:
‘It was very helpful in all my relationships with friends, family and colleagues.’
‘It benefited me at work and home, practical thinking about the moment I was in at the time and not worrying about things in the future.’
‘It helped with the stresses of work.’
‘I used mindfulness compassion for work and at home with my son to de-stress.’
‘It increased my awareness of how to practise it and how it could benefit my everyday home and working life.’
‘This has enabled me to have better relationships at both home and work.’
Feedback from the findings immediately after the course showed that time out or ‘me time’ were beneficial. In the follow-up survey, a lack of time was the main reason for not practising as much. Some participants said they did not have the time to practise even though the positive comments immediately after the course showed how making time has a positive impact.
One continued to practise mindfulness meditation and had embarked on a university course to teach it: ‘I think mindfulness should be available to all staff free of cost for the benefit it offers them, their patients and the organisation.’
Attendees were recruited to help them reduce their stress levels and offer coping strategies. The majority of people had never experienced mindful compassion before attending. Many appreciated being given a tool to help them improve their quality of life.
A recurring theme was ‘this is life changing’, which was seen throughout the initial feedback questionnaire; the same message is reflected in the responses of the online survey, albeit by fewer respondents.
Management of stressful situations, clearer perspectives, logical thinking and being more focused were highlighted in both survey findings alongside feeling more relaxed and finding inner calm.
Anecdotally, the trust's previous HR director, who supported and helped to fund a number of the courses, reported seeing a positive impact from them; however, because of a change in staffing, cause and effect cannot be established. However, the trust's current HR director says: ‘It impacted positively on the attendance levels and enabled colleagues to access support in a group setting, which had not previously been considered.’ Attendees also thought other people should be encouraged to attend the course.
Conclusion
The mindful compassion course was developed specifically for those affected by cancer. This study demonstrates that practising mindful compassion benefits staff, patients and carers.
The study is timely because The NHS Long Term Plan (NHS England, NHS Improvement, 2020) highlights the importance of employers supporting their staff to stay well and in work (Alderwick and Dixon, 2019). In addition, the Royal College of Nursing (2015) recommends staff use mindfulness and mediation to help relax when struggling.
This study has provided the foundation for further study, informing and influencing the development of a pilot programme in the organisation and for this pilot to be evaluated using a case study methodology.