Introduction
Burnout is a collection of symptoms, including exhaustion from one’s profession, loss of motivation, and decreased sense of accomplishment within the workplace [1]. Healthcare workers have reported a high prevalence of burnout compared to those in other industries [Reference Krisberg2,3]. The number of studies investigating burnout in healthcare has increased over the past few decades; however, most have focused on nurses and physicians [Reference Rotenstein, Torre and Ramos4–Reference Fendel, Burkle and Goritz8]. Of those studies, some have explored interventions for mitigating burnout [Reference Krasner, Epstein and Beckman6–Reference Fendel, Burkle and Goritz8]. There are substantially fewer studies examining burnout and interventions to address well-being experienced by other healthcare professionals, including physical therapists.
Many physical therapists resort to leaving the profession due to stress and burnout [Reference Anderson, Gould-Fogerite, Pratt and Perlman9,Reference Balogun, Titiloye, Balogun, Oyeyemi and Katz10]. In a 2022 report on the State of Rehab Therapy, rehabilitation therapy employees demonstrated greater turnover when compared to healthcare in general with physical therapists and physical therapist assistants reporting the most turnover [11,Reference Frogner and Dill12]. Seventy percent of rehabilitation therapy professionals had thoughts of a professional change with 27% either considering a non-clinical role or leaving the field entirely [11]. Physical therapists become morally distressed from moral injury (unable to provide high-quality care and healing), which ultimately leads to burnout symptoms involving depression, exhaustion, or anxiety [Reference Carpenter13]. High patient load, long work hours, and low salary were the top three contributors to 35% of therapy professionals feeling burnout [11]. In some institutions, physical therapists feel compelled to act unethically, including overbilling and high productivity requirements leading them to burnout [14]. Unfortunately, with increases in physical therapists’ responsibilities, complexities of the healthcare system, institutional constraints, and demand for physical therapy, symptoms of burnout and moral distress will likely proportionately increase.
As of 2020, the average balance for student loan debt of recent physical therapy graduates was more than $116,183 with the average salary ranging from $50,000 to $99,000 depending on location [15]. Student loan payback options were the most infrequently reported strategy used for promoting employee retention [11]. The growing loan debt-to-salary ratio along with the moral distress experienced in the clinic further compounds burnout symptoms in physical therapists and poses a concern for overall well-being [Reference Carpenter13,14,Reference Jette16]. As a result, the quality of care given to patients may be suffering, potentially leading to higher costs for the healthcare system. Despite all this, there is a lack of research addressing these issues within the physical therapy profession. The few studies that exist add to the available literature and confirm the experience of burnout among physical therapists; however, these studies employ cross-sectional surveys and do not provide interventions to help mitigate burnout [Reference Anderson, Gould-Fogerite, Pratt and Perlman9,Reference Balogun, Titiloye, Balogun, Oyeyemi and Katz10]. Further studies exploring specific interventions to ward off burnout and promote well-being in physical therapists are warranted.
The goal of this pilot study was to assess the impact of mindfulness-based training (MBT) on the well-being of physical therapists. We sought to introspectively explore personal and clinical experiences, as well as evaluate well-being outcomes. We hypothesized that participants in the intervention group receiving MBT would demonstrate higher work engagement, empathy, and job satisfaction, and lower depression, stress, anxiety, and moral distress compared to participants in the control group.
Materials and methods
This two-arm embedded QUAN(qual) mixed-methods pilot study (AZ 1258) was approved by the Institutional Review Board at Midwestern University in Glendale, AZ. The secondary analysis of the deidentified qualitative data (STUDY00008177) was exempt from review by the Research Subjects Review Board at the University of Rochester in Rochester, NY.
Participants
Community physical therapists were recruited through social media, established networks of the study team, and flyers permitted to be displayed in physical therapy clinical sites. Licensed physical therapists working full-time in a clinical setting and treating patients for at least 1 year were included.
Design and procedures
After expressing interest in the study, prospective participants completed a pre-screening questionnaire to determine satisfaction of the inclusion criteria (Fig. 1). All participants self-selected to take part in either the intervention or control group based on availability and voluntarily provided written informed consent. Participants who were able to satisfy the regular, ongoing commitment to the MBT curriculum opted to participate in the intervention group and those who still wanted to participate in the study, however, were unable to meet the time obligations of the intervention opted for the control group. The Utrecht Work Engagement Scale [Reference Fong and Ng17,Reference Torabinia, Mahmoudi, Dolatshahi and Abyaz18], Toronto Empathy Questionnaire (TEQ) [19], Minnesota Satisfaction Questionnaire [20,Reference Martins and Proença21], Depression, Anxiety, Stress Scale (DASS-21) [Reference Antony, Cox, Enns, Bieling and Swinson22–25], and Measure of Moral Distress for Healthcare Professionals (MMD-HP) [Reference Pauly, Varcoe and Storch26,Reference Epstein, Whitehead, Prompahakul, Thacker and Hamric27] were disseminated and returned through postal and/or electronic mail for the identified control participants at the start and end of the study period, and before the first and last MBT sessions for the intervention participants (Table 1).
Figure 1. Flow diagram of the methods [Reference Eldridge, Chan and Campbell49].
Table 1. Description of tools used to measure the well-being outcomes of physical therapists
The intervention group met for a total of six sessions. Participants were allowed one absence due to unexpected life events; however, they were asked to complete the missed study activities remotely. For any participant who was unable to meet the study’s time obligations, any specific measures that were willingly completed and data collected up to the point of the participant withdrawal were still included in the analysis. Roughly 2 weeks between sessions were allotted, allowing for practice of the introduced mindfulness strategies. Performance of the mindfulness strategies was not recommended at a specific frequency and how often the participant employed the strategies was not recorded. Study investigators discussed the most pertinent topic areas and adapted an educational program in mindful communication [Reference Krasner, Epstein and Beckman6] to the unique needs of community physical therapists. Once a schedule of predetermined dates was established, each session was assigned a representative topic area (Table 2). Two of the intervention topics (being with suffering or end-of-life care and attraction in the clinical encounter) in the previous work [Reference Krasner, Epstein and Beckman6] were deemed to be not as applicable; thus, study investigators abbreviated the intervention by reducing the number of study sessions from eight to six. The duration of each session was also changed from 150 to 90 minutes to allow for minimal disruption over the 3-month study period. The topics and narrative prompts that were more specific to medicine in the previous work [Reference Krasner, Epstein and Beckman6] were adapted to the context of physical therapy. For example, the topic of “awareness of pleasant and unpleasant sensations, feelings, or thoughts” was re-worded to “situational- and self-awareness” and the associated narrative prompt “a pleasant or an unpleasant experience during clinical work and its effect on the patient-physician relation” was changed to “…pleasant or unpleasant thoughts or feelings you may have experienced during clinical practice. Did these sensations have any effect on your professional relationship with the patient?” The topic of “meaning in medicine” was also changed to “meaning in physical therapy.” Mindfulness was woven throughout each session, which consisted of didactic delivery of the topic area, narrative and appreciative inquiry, small group discussions, and specific mindfulness strategies. The control group received no intervention and was followed over the roughly 3-month study period.
Table 2. Adapted mindfulness-based training (MBT) curriculum [Reference Krasner, Epstein and Beckman6] for physical therapists
Intervention
Didactic delivery of the topic area
The representative topic area for each session was introduced didactically (Table 2) for the first 10 minutes of each session by one of the study investigators. Introduction of the study was performed at the beginning of session one and a summary of the prior sessions was given at session six. Any participants who missed a session were sent information about the specific session’s didactic topic area via electronic communication.
Narrative and appreciative inquiry
Participants were issued designated composition notebooks, which served as a journal for the duration of the study. Study journals were secured in a study investigator’s office between sessions. During the second 10 minutes of each session, participants were encouraged to introspectively explore how the session’s narrative prompt (Table 2) resonated with their personal and clinical experiences through reflective writing. Participants were then guided to apply the appreciative inquiry framework to the session’s topic area. The appreciative inquiry framework consisted of the following prompts: discovery, dream, design, and destiny, or the 4Ds. These prompts encouraged participants to, respectively, consider “what is,” “what might be,” “what should be,” and “what will be [28].” A total of 20 minutes of appreciative inquiry (5 minutes per each framework prompt) was performed in each session. Any participants who missed a session were asked to complete the session’s narrative and appreciative inquiry reflections via electronic communication, which was later printed and added to the participant’s study journal for reference.
Small group discussions
After completing the narrative and appreciative inquiry, the intervention group was divided into three small groups of two to three participants each facilitated by one of the study investigators for 30 minutes. Study investigators made every effort to establish a secure environment, where the participants would feel safe sharing their work experiences. During the MBT curriculum development, the study team agreed on different tactics to prompt natural discussion in small groups. Mainly, participants were encouraged to express their thoughts, feelings, and emotions based on the session’s topic area and, if comfortable, share what they wrote in their journals during the narrative and appreciative inquiry reflections. Out of respect for one another’s privacy, participants were asked to keep the information shared and discussed throughout the MBT curriculum contained within the study setting.
Mindfulness strategies
Following the small group discussions, specific mindfulness strategies concluded each session and were facilitated by the clinical psychologist investigator for 20 minutes. Such strategies were designed to help participants create simple anchors when needing to bring attention back to the present moment or become aware of the afferent signals from within the body to better respond to stressful internal stimuli. Mindfulness walking [Reference Teut, Roesner and Ortiz29,30] was introduced during the first session (Table 2). Participants were instructed to walk around our local campus community while simultaneously exploring their senses, such as observing the color of the buildings, the smell of the air, or any sounds outside. The five senses exercise [31,32] and the body scan [33,Reference Fischer, Messner and Pollatos34] were introduced during the second session. The five senses exercise asked participants to use sight to observe their surroundings, notice specific tastes in their mouths, detect scent and sound in the room, and identify the touch of their hands, feet, and other body parts upon the surface in which they were sitting. During the body scan, participants were invited to close their eyes and verbally guided to observe physical sensations from their feet to their heads. Mindful walking, five senses, and body scan were reviewed in the third session. Deep breathing [Reference Aggarwal, Deutsch, Medina and Kothari35,36] and visualization [Reference Mastropieri, Schussel, Forbes and Miller37,38] were introduced during the fourth session. Participants were instructed to inhale for 4 seconds, hold their breath for another 4 seconds, and then exhale for 6 seconds for a minimum of 2 minutes. Participants were also provided with handouts of visualization techniques, like a serene beach scene, blue light, a ball of yarn, liquid quiet, and a double-paned window. Mindfulness walking, five senses, body scan, deep breathing, and visualization were reviewed in the fifth session. Guided imagery [Reference Kemper and Khirallah39] was introduced during the sixth and final session. The clinical psychologist investigator read a narrative script that guided participants through scenic imaginations. In addition to engaging in the mindfulness strategies as a component of each study session, participants were advised to trial the different strategies while at work in between study sessions. Any participants who missed a session were sent information about the specific session’s mindfulness strategies via electronic communication.
Data analysis
Pre- and post-questionnaires were collected from both groups approximately 3 months apart. The questionnaires were dispensed and collected at the same time for the intervention group and at different times for the control group as participant recruitment was ongoing. All questionnaires were appropriately scored and scores were compiled (Microsoft Excel, v.2021, Microsoft, Redmond, WA). Descriptive statistics (mean±SD) were calculated from the raw data. Because normality assumption was not achieved, non-parametric statistics were used to compare across and within groups. Separate Mann–Whitney U tests were used to evaluate pre-questionnaire scores across groups, and separate Wilcoxon signed-rank tests were used to compare pre- to post-questionnaire differences within each group. Chi-square tests evaluated differences across groups in the covariates of age, gender, years of clinical experience, and total hours worked per week. With significance as p < 0.05, all quantitative statistical analyses were performed using SPSS (v.29, IBM, Armonk, NY).
A thematic framework matrix was established by way of qualitative description using MaxQDA 2020 (v20.4.2, VERBI, Berlin, Germany) for the qualitative analysis [Reference Spencer, Richie, Ormston, O’Connor, Barnard, Ritchie, Lewis, McNaughton Nicholls and Ormston40,Reference Gale, Heath, Cameron, Rashid and Redwood41]. Because of the mixed-methods embedded QUAN(qual) research design for this study, we opted for the straightforward description of the phenomena using this approach [Reference Sandelowski42]. One study investigator (GR) manually transcribed the reflective writing from the journals into electronic format. Two investigators (AP and GR) separately reviewed the transcriptions and initially coded the qualitative data within each topic area. Over a period of weeks, AP and GR worked together to triangulate common themes and subthemes relating to the narrative and appreciative inquiry reflections until reaching a consensus. After three total hours of reflective writing across the six MBT sessions for each participant, saturation occurred when no new themes or subthemes emerged in their responses to the presented narrative prompt or across the 4Ds for each session’s topic area. Finally, quantitative and qualitative data were integrated to accentuate any concordant or discordant findings [Reference Creamer43].
Results
Participants
Thirteen physical therapists (10 female/3 male; 35.38 ± 9.32 years old) working across nine different healthcare organizations completed this pilot study. Nine participants (8 female/1 male; 37.22 ± 10.79 years old) were involved in the intervention group. Intervention participants had 9.50 ± 9.90 years of clinical experience and worked 41.67 ± 8.72 total hours per week. Four intervention participants worked in outpatient settings, two in inpatient settings, one in skilled nursing, and two across multiple settings. Four participants (2 female/2 male; 31.25 ± 2.06 years old) were involved in the control group. Control participants had 5.25 ± 2.75 years of clinical experience and worked 40.00 ± 0.00 total hours per week. One control participant worked in an outpatient setting, two in inpatient settings, and one in skilled nursing. There were no differences across groups in age (p = 0.195), gender (p = 0.079), years of clinical experience (p = 0.234), and total hours worked per week (p = 0.221). Clinical specialty by the American Board of Physical Therapy Specialties was maintained by four participants (two Geriatric Clinical Specialists; two Orthopaedic Clinical Specialists) in the intervention group and by one participant (Orthopaedic Clinical Specialist) in the control group. There was a 100% retention rate in the control group, whereas two of the participants in the intervention group were unable to complete the study due to the time obligations yielding a retention rate of 84.6% (Fig. 1). Each participant in the intervention group missed one of the six sessions.
Pre-scores across intervention and control groups were compared for the well-being outcomes. For work engagement, no differences were analyzed for pre-vigor, dedication, and absorption (p ≥ 0.437). For empathy, no differences were analyzed across groups for pre-TEQ (p = 0.815). No differences were analyzed across intervention and control groups for pre-overall, intrinsic, and extrinsic (p ≥ 0.392) job satisfaction. For mental health, no differences were analyzed for pre-overall, depression, and anxiety (p ≥ 0.120). There were differences detected across groups for pre-stress (p = 0.042) with the intervention group reporting greater pre-stress (14.44 ± 8.99) than the control (7.50 ± 1.91) (Table 3). Finally, no differences were measured across groups for pre-moral distress (p = 1.000).
Table 3. A comparison of pre- to post-scores within intervention and control groups (mean±SD)
UWES-17 = Utrecht Work Engagement Scale; TEQ = Toronto Empathy Questionnaire; MSQ-20 = Minnesota Satisfaction Questionnaire; DASS-21 = Depression, Anxiety, Stress Scale; MMD-HP = Measure of Moral Distress for Healthcare Professionals.
* =p < 0.05.
Quantitative outcomes
Pre- to post-scores within the intervention group and the control group were compared for the outcomes of work engagement, empathy, job satisfaction, mental health, and moral distress. Notable work engagement differences were observed within the intervention group for pre- to post-dedication (p = 0.042) and absorption (p = 0.018) (Table 3). No changes were measured within the intervention group for pre- to post-vigor, and no changes were observed within the control group for any of the pre- to post-work engagement outcomes. The intervention group had an increase in dedication and absorption of 11.47% and 17.18% while the control group had a decrease of 5.49% and 11.72%, respectively. Although significant changes were not detected within the intervention or control groups for pre- to post-empathy, the intervention group had a 7.72% increase in empathy compared with a 2.01% decrease in the control group. No changes were measured within the intervention or control groups for pre- to post-overall, intrinsic, or extrinsic job satisfaction. Notable differences were observed within the intervention group for pre- to post-overall mental health (p = 0.042) and depression (p = 0.043). No changes were measured within the intervention group for pre- to post-anxiety or stress, and no changes were observed within the control group for pre- to post-overall, depression, anxiety, or stress. The pre- to post-overall mental health improvement in the intervention group was much larger (52.53%) when compared with the control group (16.07%). In addition, the pre- to post-depression improvement in the intervention group was much larger (74.36%) when compared with the control group (38.89%). There were notable changes measured within the intervention group (p = 0.043), and no changes were observed within the control group from pre- to post-moral distress. The intervention group had a 35.32% reduction in moral distress compared with a 0% change in the control group.
Qualitative outcomes
There were several important themes and subthemes that emerged in response to the narrative prompts (Table 4). “My ability to work with this patient population, to have Parkinson’s Disease not be an end to life but something to work through, allowed me to help this patient help himself (Physical Therapist 1)” was representative of the regaining independence theme for the topic area of meaning in physical therapy in session one. Mobility improvements in patients with dementia, patient gratitude, and explaining the why behind treatment to ensure a successful discharge were other overarching themes in session one. Keeping an open mind, frustration when patients are not receiving the needed care, and wasted time and energy were themes for the topic area of situational- and self-awareness in session two. For session three, the topic area of compassion fatigue/burnout elicited the theme of existential struggle when patients are non-adherent, “I will have days at work where I feel like my buttons are pushed to the last point. I’ll have patients who will not participate or complain the whole time or something similar to where I feel like there’s nothing I can do to help anyone (Physical Therapist 9).” Increasing hours/workload, inability to effect change (lack of support from referring provider), and infiltration into personal life were also themes in response to the narrative prompt for session three. “There are many incidents when I review a patient chart and I hypothesize the type of person that will walk through the door. Due to my biases and past experiences, however, I am sometimes extremely off (Physical Therapist 3)” reflected the aging patients’ level of function theme for the topic area of implicit biases in session four. Other themes in session four were secondary gain and adapting to differences. Amicable collaboration, diffusing difficult situations, and patients who want personal relationships were the themes for the topic area of establishing boundaries and managing conflict in session five. Lastly, in session six, the themes in response to the narrative prompt for the topic area of self-care were sacrifice with guilt, actionable self-care, work-life integration, and the effects of stress and anxiety on personal health.
Table 4. Reflective writing in response to the narrative prompt
There also were several important themes and subthemes that emerged upon exploring the 4Ds of appreciative inquiry (Table 5). Reflections on meaning in physical therapy during session one evoked the themes of patient education, motivation, and adherence, clinical operations and patient care, personal and professional growth, and work-life integration. Barriers to providing care, documentation, and productivity and billing were some of the underpinnings of the clinical operations and patient care theme. More time for teaching, more time to engage and learn from colleagues, and more time for research were some expressions of the physical therapists’ goals for greater personal and professional growth. Pay and student loan debt were linked to the theme of work-life integration. Physical therapists’ in this study desired greater pay to alleviate debt-related stress and reduce the need for maintaining multiple jobs. Similar to session one, the situational- and self-awareness topic area in session two evoked the themes of management of patient care and physical therapy operations. “Conflict between professionalism and morals, and impact on rapport (Discovery) (Physical Therapist 4),” a desire for “improved ethics in practice (Destiny) (Physical Therapist 6),” and “more consistent internal feelings regardless of the patient interaction to produce more mental stability and clinical presence (Destiny) (Physical Therapist 2)” reflected the ethics and morals and mental stability and clinical presence subthemes of communication with patients, another theme for session two. Negative emotions, fostering a supportive environment during patient recovery, more time and resources, the desire for organizational receptiveness and to feel present, stimulated, challenged, part of a team, and suggestions for education and team building were the many components of the physical therapists’ appreciative inquiry reflection on the topic area of compassion fatigue/burnout during session three. Within the topic area of compassion fatigue/burnout, Physical Therapist 5 expressed the impact of clinician quality of life on patient care, “More compassionate, happy healthcare workers, which leads to better care and patient outcomes (Destiny).” Session four on implicit biases gathered thoughts on cognitive bias, provider’s goals versus patient’s goals, patient’s biases, and physical therapist’s biases. Thoughts about establishing boundaries and managing conflict using the 4Ds in session five were categorized between the front desk, supervisors, and clinical staff, between co-workers, between physical therapists and patients, and between management and physical therapists. Finally, when reflecting on self-care in session six, difficulty prioritizing self/limited personal time was paramount.
Table 5. Appreciative inquiry reflective writing
4Ds=discovery or “what is;” dream or “what might be;” design or “what should be;” destiny or “what will be [28].”
Integration
The narrative and appreciative inquiry reflections (Tables 4 and 5) further emphasized the significant differences in the intervention group’s pre- to post-scores for work engagement, mental health, and moral distress (Table 3). As an expression of how the MBT intervention positively impacted overall well-being, Physical Therapist 4 wrote, “I’ve been working on maintaining awareness of my emotions, where they come from, and what they’re truly reflective of to avoid misplacing them. Also, mindfulness to address my general fatigue, emotional and physical” in response to the narrative prompt for the session on compassion fatigue/burnout. For the appreciative inquiry reflection on situational- and self-awareness, Physical Therapist 2 committed to “Work on grounding in the moment, acknowledge my own reaction or response to behavior while staying as emotionally neutral in my outward response (Design).” Using the 4Ds in the session on self-care, Physical Therapist 3 shared, “I have found it very helpful to have some mindfulness strategies to just take a few minutes to reset/organize my thoughts/actions in the midst of everyday chaos to manage these stressful bouts more efficiently (Destiny).”
Discussion
The goal of this work was to explore the impact of an adapted MBT curriculum [6] in decreasing factors that may contribute to burnout in community physical therapists. We hypothesized that physical therapists would demonstrate higher work engagement, empathy, and job satisfaction, and lower depression, stress, anxiety, and moral distress following the MBT sessions. No differences were detected at baseline across the intervention and control groups except when comparing pre-stress scores. In partial support of this study’s hypothesis, physical therapists in the intervention group demonstrated greater dedication and absorption in their work engagement, improved overall mental health and decreased depression, and reduced moral distress. Absorption demonstrated the greatest change, indicating improved concentration and immersion in occupational duties. The control group did not experience any differences in their pre- to post-questionnaire scores demonstrating that outcomes largely remained unaffected without intervention. Our findings showed that periodic mindfulness strategies can be utilized to promote well-being. In the appreciative inquiry sentiments about “what should be [28],” many physical therapists in this study expressed the intent of incorporating mindfulness strategies into their work. “…allot a small amount of time for quick self-care, such as deep breathing for three to five minutes or a body scan (Design),” Physical Therapist 3 wrote when reflecting on self-care. “…start deep breathing moments with co-workers… (Design),” Physical Therapist 8 shared in the compassion fatigue/burnout session. In addition to the mindfulness strategies, integration of mindfulness throughout the narrative and appreciative inquiry and small group discussions within each session implied that reflective writing, verbalizing stressors or happy moments related to personal and clinical experiences, and social support likely also contributed to improved well-being.
Sample size, time commitment from participants, and inability to offer continuing education credits and monetary compensation were the differences between this study and the Krasner et al. [Reference Krasner, Epstein and Beckman6] study. The educational program in mindful communication [Reference Krasner, Epstein and Beckman6] involved 70 primary care physicians who received $250 to participate in an 8-week intensive phase (2.5 hours per week) inclusive of a 7-hour retreat followed by a 10-month maintenance phase (2.5 hours per month), whereas this work involved 13 physical therapists who received no remuneration to participate in a biweekly training (1.5 hours roughly every 2 weeks) for the duration of 11.5 weeks with no long-term maintenance. This study demonstrated that the basic framework from the Krasner et al. [Reference Krasner, Epstein and Beckman6] study can be successfully abbreviated and adapted to the everyday lives of participating physical therapists, allowing for minimal disruption and practical application of the mindfulness strategies in between sessions.
Normative or mean values have been established for the TEQ, DASS-21, and MMD-HP. Greater than average empathy [Reference Spreng, McKinnon, Mar and Levine19] at baseline was measured in this study’s combined group of participants, as well as within the respective subgroups, which may help to explain the lack of significant change in pre- to post-empathy scores in the intervention group. Baseline overall mental health scores on the DASS-21 in this study’s intervention group fell within the mid- to high-range of normal. Baseline scores for the intervention group’s mental health subscales fell within the mid- to high-range of normal for depression, the mid-range of normal for anxiety, and the high-range of normal for stress [Reference Antony, Cox, Enns, Bieling and Swinson22,Reference Lovibond and Lovibond23]. This interpretation helps us to understand why we were possibly unable to impact change on the anxiety subscale, as it was within the mid-range of normal, and why we were able to impact change on the overall mental health score and depression subscale, as they fell within the mid to upper range of normal. However, it does not help further explain why we were unable to impact change on the stress subscale for the intervention group participants. There was a high prevalence of participants with moral distress in this study. Fifty-four percent of the total sample, 55.56% and 50.00% within the respective intervention and control groups had baseline moral distress scores greater than the average value for healthcare professionals (score = 108.90) [Reference Epstein, Whitehead, Prompahakul, Thacker and Hamric27]. After completion of the MBT, only 14% of intervention group participants still measured greater than the average value for moral distress, and the control group remained unchanged at 50%.
There were a few limitations to this study. The primary limitation was the small sample size. Intervention group participants were recruited across the vast metropolitan area of Phoenix, Arizona. Intervention group sessions were held in person on predetermined dates in the evening during the week, which may have limited the number of physical therapists available to participate. Self-selection bias was introduced by allowing participants to choose whether to take part in either the intervention or control group and likely explains the high stress and moral distress at baseline of the intervention participants. A power analysis was not conducted to determine the sample size in this pilot study; thus, these analyses may be underpowered. How often the participants employed the mindfulness strategies in between study sessions was not prescribed or recorded. Although some qualitative data indicated that participants used the specific strategies while at work, we were unable to report the degree to which this application played a role in the reported outcomes of the study. Investigators were not blinded to the control or intervention group allocation for purposes of scoring the outcomes or conducting the data analysis before the interpretation. Many of the control group participants completed the pre- and post-questionnaires at different timeframes than the intervention group. Accordingly, the variability of the clinical environment during certain times of the year may have impacted the outcomes for the control group. Because of the pilot nature of this study, we did not control for the multiple comparisons, thus introducing a greater likelihood of false positive results. Finally, it is difficult to ascertain if the overall MBT curriculum or a specific component of the curriculum was more impactful on the outcomes that were significant or could have been more impactful on the outcomes that were not significant, as this was not specifically measured or analyzed. Future research should continue to explore the efficacy and effectiveness of MBT and/or other interventions to reduce burnout symptoms and promote well-being with a larger randomized sample of physical therapists. This will help to control for any confounding variables and allow for more robust statistical analysis. Future iterations of similar research should also explore further intervention optimization by distinguishing which aspects of the curriculum were most impactful on the designated outcomes and carry only those components forward in the research progression. Because of the high turnover rate of rehabilitation therapy employees, future work should also include physical therapist assistants, occupational therapists, and occupational therapy assistants [Reference Balogun, Titiloye, Balogun, Oyeyemi and Katz10,11].
The job growth rate for physical therapists and physical therapist assistants is expected to be much faster than average [44,45]. Practicing components involved in MBT to lessen burnout may benefit the well-being of physical therapists while simultaneously enhancing employee retention and improving patient care [Reference Krasner, Epstein and Beckman6,Reference Reith46,Reference Epstein, Marshall and Sanders47]. These practices may even be implemented into other facets of physical therapy including the role of a clinical educator where burnout may be prevalent [Reference Kellish, Gotthold, Tiziani, Higgins, Fleming and Kellish48]. Human resource departments and benefits committees might consider including MBT as an employee benefit option if it does not already exist, or incentivizing employees who take advantage of MBT as a benefit, if it does already exist. Also, physical therapy education programs might consider integrating MBT throughout their curricula, so these strategies for combating burnout and promoting well-being are acquired early. While these authors recognize that organizational-level factors, like patient load, work hours, and salary, need to be addressed to further positively impact the occupational health of physical therapists, implementing an MBT program demonstrates promise with improving the individual-level factors of work engagement, mental health, and moral distress.
Acknowledgments
The authors would like to thank the participants in this study for their time and dedication to reducing moral distress and burnout in physical therapists.
Funding statement
The project described in this publication was supported by start-up funding (Roman) from the University of Rochester.
Competing interests
The authors have no conflicts of interest to declare.
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