key: cord-0700353-sjyyphwn authors: Azizoddin, Desiree R.; Kvaternik, Noelia; Beck, Meghan; Zhou, Guohai; Hasdianda, Mohammad Adrian; Jones, Natasha; Johnsky, Lily; Im, Dana; Chai, Peter R.; Boyer, Edward W. title: Heal the Healers: A pilot study evaluating the feasibility, acceptability, and exploratory efficacy of a Transcendental Meditation intervention for emergency clinicians during the coronavirus disease 2019 pandemic date: 2021-12-29 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12619 sha: 81536fe9f2f9b56d66373c41da2b86eb53794b84 doc_id: 700353 cord_uid: sjyyphwn OBJECTIVE: Emergency clinicians face elevated rates of burnout that result in poor outcomes for clinicians, patients, and health systems. The objective of this single‐arm pilot study was to evaluate the feasibility of a Transcendental Meditation (TM) intervention for emergency clinicians during the coronavirus disease 2019 (COVID‐19) pandemic and to explore the potential effectiveness in improving burnout, sleep, and psychological health. METHODS: Emergency clinicians (physicians, nurses, and physician‐assistants) from 2 urban hospitals were recruited to participate in TM instruction (8 individual or group in‐person and remote sessions) for 3 months. Session attendance was the primary feasibility outcome (prespecified as attending 6/8 sessions), and burnout was the primary clinical outcome. Participant‐reported measures of feasibility and validated measures of burnout, depression, anxiety, sleep disturbance, and stress were collected at baseline and the 1‐month and 3‐month follow‐ups. Descriptive statistics and linear mixed‐effects models were used. RESULTS: Of the 14 physicians (46%), 7 nurses (22%), and 10 physician‐assistants (32%) who participated, 61% were female (n = 19/32). TM training and at‐home meditation practice was feasible for clinicians as 90.6% (n = 29/32) attended 6/8 training sessions and 80.6% self‐reported meditating at least once a day on average. Participants demonstrated significant reductions in burnout (P < .05; effect sizes, Cohen's d = 0.43–0.45) and in symptoms of depression, anxiety, stress, and sleep disturbance (P values < .001; Cohen's d = 0.70–0.87). CONCLUSION: TM training was feasible for emergency clinicians during the COVID‐19 pandemic and led to significant reductions in burnout and psychological symptoms. TM is a safe and effective meditation tool to improve clinicians’ well‐being. Emergency medicine (EM) and frontline healthcare clinicians innately manage high-intensity, high-risk, and high-stress clinical scenarios. Unsurprisingly, emergency clinicians face high rates of burnout and exhaustion. Prevalence rates of burnout and psychological stress vary, with some reports suggesting 65% of emergency residents met the criteria for burnout 1,2 and another revealing around 85% of emergency medicine nurses experienced burnout and compassion fatigue. 3, 4 Physician and physician assistants are at equally high risk for burnout. 3, 5 Burnout often leads to increased medical errors, reduced adherence to safety protocols, increased costs, reduced patient satisfaction, job loss, depression, and substance use, and in severe cases suicide. [6] [7] [8] Clinician burnout is relevant not only to a clincian's quality of life but also results in compromised care. for infecting loved ones in addition to the ever-changing clinical landscape, demand, and extended nature of the pandemic. [9] [10] [11] [12] Unsurprisingly, 1 study noted that 53% of healthcare workers report experiencing high levels of burnout during the pandemic. 13 At this time, it is imperative that emergency clinicians receive better support to reduce current and future burnout. Burnout interventions at the system and hospital levels often have the greatest impact; however, clinician-focused interventions also have been found to provide meaningful improvements in burnout. [14] [15] [16] [17] Meditation and mindfulness interventions are increasingly more accessible in healthcare systems and popular in the mainstream media. These interventions are often low cost, low risk, and easy to practice. 18 A recent meta-analysis of resilience interventions for healthcare clinicians identified that although meditation results in improvements to clinician resilience, future studies need to evaluate the ability to sustain or maximize intervention effects with interventions that are longer than 1 week and include postintervention support. 19 Transcendental Meditation (TM) is a type of meditation practice that has been welldocumented as a non-pharmacologic method for stress reduction. 17, 19 Evidence suggests that meditation-based interventions such as TM and Mindfulness-Based Stress Reduction can result in decreased burnout, blood pressure, depression, anxiety, emotional exhaustion, and insomnia and increased resiliency in various clinical populations. 16, 20, 21 Mechanistically, it is theorized that the TM practice varies from other mindfulness meditation practices and leads to reduced psychological and physiologic response to stress, evidenced by decreased sympathetic nervous system and hypothalamic-pituitary-adrenal axis responsivity and reduced cortisol levels. 22, 23 Specifically, 2 studies identified that those practicing meditative interventions, such as TM, experienced increased tumor necrosis factor α mRNA, 24 reduced blood pressure, 25 and increased cortical connectivity in emotion and reward systems. 26 Theoretically, reduced stress reactivity decreases anxiety and burnout for clinicians over time. TM training could therefore provide prolonged improvements in resilience and burnout for clinicians. Timely support during stressful situations can prevent further worsening of burnout 23, 27 ; however, burnout interventions during pandemics pose unique challenges for implementation. The objectives of this single-arm pilot study were to examine whether training emergency clinicians in TM during the COVID-19 pandemic was feasible and acceptable, and to explore whether TM had an impact on clinician burnout and psychological well-being at 3 months after initial training. Emergency clinicians were screened and enrolled to engage in this single-arm pilot study to learn TM and evaluate the feasibility, acceptability, and potential efficacy of this program during the COVID-19 pandemic. Emergency clinicians completed baseline (1-3 days before meditation training), 1-month (since the initial training session), and 3month (since the initial training session) measures to measure the perceived acceptability and feasibility and to explore the impact of TM practice on clinician burnout and psychological well-being. REDCap is a secure, web-based application designed to support data capture for research studies. 28, 31, 32 Clinicians were not provided remuneration. TM is a simple meditation practice that allows the participant to expe- As a primary feasibility outcome of this pilot study, we sought to evaluate whether engaging in a TM intervention was feasible and acceptable for emergency clinicians during the COVID-19 pandemic. Feasibility was prespecified as attending 6 of the 8 training sessions by 80% of the cohort. Participation of each training session was recorded for each participant by the meditation teacher. We evaluated whether participants practiced meditation after the primary instruction period (Week 1) through the 3-month follow-up self-report assessment. Adherence to at-home meditation practice has been identified in other TM studies as practicing TM at least once daily for most days of the week. 22 Lastly, participants completed self-report acceptability and feasibility ratings of the TM training during the 3-month followup assessment. Acceptability was prespecified with a score of 4 or 5 on a 5-point Likert scale for ≥80% of the sample. Questions evaluated whether they found the TM training and meditation feasible, whether they enjoyed meditation, and if they would recommend TM to a friend or colleague. As a primary clinical outcome, we explored trends in changes of burnout, in addition to psychological well-being at baseline (T1), 1 month (T2), and 3 months (T3) after TM training. The Maslach Burnout Inventory (MBI) is a validated and highly used measurement tool to evaluate clinician burnout. 39 The MBI includes the following 3 subscales: emotional exhaustion, depersonalization, and professional accomplishment. Total scores range from 0-100, and higher scores equate to higher ratings of that factor. Depressive symptoms were measured using the Patient Health Questionnaire 8-item scale (PHQ-8) 40 ; item 9 evaluating suicidality was removed for this study. Anxiety symptoms were measured using the Generalized Anxiety Disorder 7-item (GAD-7) scale. 27 Frequencies and mean scores were calculated for demographics, attendance, and other self-report measures of acceptability and feasibility. To explore the impact of TM on burnout and psychological well- A total of 32 participants were enrolled in the study between October 2020 and February 2021, with 31 participants completing training and follow-up assessments (see Figure 1 ). Of note, enrollment and study participation continued through the second peak of the COVID- Table 1 ). Table 2 and Figure 2 for complete feasibility and acceptability measures. Emergency clinicians liked the intervention and stated "feeling less anxious, more focused, and sleep[ing] better" and that they felt "less reactive." Of the participants, 2 described disliking a few aspects of the TM training, indicating that it was "difficult to find time to meditate twice a day" and that they felt the training sessions could have been shortened and in-person training was difficult. Overall, participants reported feeling more "at ease" and "less stressed/anxious" and "sleeping better." See Table 3 for further participant reports/quotes. Table 3 ). Qualitatively, most of the participants reported that TM added to their overall well-being and "feeling more at ease" and that TM positively impacted their career as they noted being able to "make decision[s] easier at work" and feeling like TM "makes me a better doctor, teacher, and colleague on shift" (see Table 4 ). • "Clears my mind. I feel that I am thinking more clearly after." Male, MD • "I feel less anxious, more focused, and I sleep better." Female, RN • "Turning attention inwardly has a self-nurturing quality that is rewarding." Male, MD • "Able to make decisions easier at work and take time to breathe during the stress." Female, PA-C • "Makes me a better doctor, teacher, and colleague on shift." Male, MD • "Many times, I am more relaxed and happy to be at work. This has been quite significant since the COVID pandemic has made work less enjoyable than usual." Female, MD Intervention effects should be evaluated with caution as this was a single-arm pilot study and participants' TM practice was self-reported. Future studies should include a randomized trial with an appropriate control group to reduce bias in interpretation and to accurately evaluate the effects of TM on emergency clinician burnout. Mobile phonebased delivery of TM may increase accuracy in participants' meditation practice reporting. Anecdotally, participants who practiced more frequently reported greater benefits from TM; however, the study was underpowered to evaluate these relationships. In addition, this study was conducted during the second wave of the pandemic in Mas- This single-cohort pilot study found that TM training was feasible and acceptable to emergency clinicians during the COVID-19 pandemic, and emergency clinicians reported significant reductions in burnout, psychological symptoms, and poor sleep quality. Of this cohort, 90% were able to attend 6 of the 8 sessions, and the majority found TM to be easy to learn and would recommend it to a colleague. Of note, >80% of participants self-reported compliance and maintenance of their meditation practice for the 3 months after instruction, indicating that meditation at least once daily on most days was a sustainable self-management tool. Emergency clinicians reported that TM had a significant impact on their feelings of burnout and well-being and that TM helped to improve their sleep. Emergency clinicians were able to attend, learn, and practice TM during the second peak of the COVID-19 pandemic. During enrollment, many emergency clinicians identified that attending 4 consecutive sessions was the primary barrier to participation; however, we saw that for clinicians who enrolled, 100% were able to attend the 4 consecutive core TM sessions with minor scheduling modifications. Identifying accurate yet appropriate timing of burnout interventions either during or after catastrophic events remains complex. Our study sought to evaluate whether a meditation-based burnout intervention could be delivered and prove effective during a pandemic for frontline emergency healthcare workers. Emotional exhaustion F I G U R E 3 Continued at baseline was higher in this sample compared with other nonemergency clinician cohorts measured before COVID-19 35 Participants also shared that the TM teachers' flexibility when schedul- intervention to support clinician burnout and should be implemented alongside wellness initiatives that focus on hospital-wide structural and administrative changes, which have been shown to have the largest impact on burnout. 8, 27 Our findings are consistent with other TM literature that suggests that TM results in significant decreases in anxiety 20 and emotional exhaustion with improvements in resilience, perceived stress, fatigue, and depression in teachers and clinicians. 21, 24, 25, 36, 37, 38 Delivery of TM training content online would likely increase the overall scalability of this intervention as the pandemic continues to persist. 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The fixed effects β 2 and β 3 represent the mean change scores in the outcome, respectively, for T2 versus baseline and T3 versus baseline, and with estimates (95% confidence intervals) and p values presented in Table 3 . The residual versus fitted diagnostic plots below show that the models are approximately unbiased for all outcomes with residuals roughly scattered around 0.