Original Research

Evaluation of the Mantram Repetition Program for Health Care Providers

An easy-to-learn meditative intervention program for health care providers addresses workplace stress and burnout without a significant investment of time.

Fed Pract. 2019 May;36(5):232-236

Author(s):

References

1. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH). Workplace safety and health topic: health care workers. http://www.cdc.gov/niosh/topics/healthcare. Updated May 9, 2018. Accessed April 8, 2019.

2. Voss Horrell SC, Holohan DR, Didion LM, Vance GT. Treating traumatized OEF/OIF veterans: how does trauma treatment affect the clinician? Prof Psychol Res Pract. 2011;42(1):79-86.

3. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Exposure to stress: occupational hazards in hospitals. http://www.cdc.gov/niosh/docs/2008-136/default.html. Published July 2008. Accessed April 9, 2019.

4. Fahrenkopf AM, Sectish TC, Barger LK. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336(7642):488-491.

5. Melnyk BM, Orsolini L, Tan A, et al. A national study links nurses’ physical and mental health to medical errors and perceived worksite wellness. J Occup Environ Med. 2018;60(2):126-131.

6. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.

7. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-1993.

8. Poghosyan L, Clarke SP, Finlayson M, Aiken LH. Nurse burnout and quality of care: cross-national investigation in six countries. Res Nurs Health. 2010;33(4):288-298.

9. Rios-Risquez MI, García-Izquierdo M. Patient satisfaction, stress and burnout in nursing personnel in emergency departments: a cross-sectional study. Int J Nurs Stud. 2016;59:60-67.

10. Vahey DC, Aiken LH, Sloane DM, Clarke SP, Delfino V. Nurse burnout and patient satisfaction. Med Care. 2004;42(2 suppl):II57-II66.

11. Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. Preventing occupational stress in health care workers. Cochrane Database Syst Rev. 2015;7(4):CD002892.

12. Elder C, Nidich S, Moriarty F, Nidich R. Effect of transcendental meditation on employee stress, depression, and burnout: a randomized controlled study. Perm J. 2014;18(1):19-23.

13. Prasad K, Wahner-Roedler DL, Cha SS, Sood A. Effect of a single-session meditation training to reduce stress and improve quality of life among health care professionals: a “dose-ranging” feasibility study. Altern Ther Health Med. 2011;17(3):46-49.

14. Jamieson SD, Tuckey MR. Mindfulness interventions in the workplace: a critique of the current state of the literature. J Occup Health Psychol. 2017;22(2):180-193.

15. Dharmawardene M, Givens J, Wachholtz A, Makowski S, Tjia J. A systematic review and meta-analysis of meditative interventions for informal caregivers and health professionals. BMJ Support Palliat Care. 2016;6(2):160-169.

16. Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):357-368.

17. Bormann JE, Smith TL, Becker S, et al. Efficacy of frequent mantram repetition on stress, quality of life, and spiritual well-being in veterans: a pilot study. J Holist Nurs. 2005;23(4):395-414.

18. Bormann JE, Oman D, Kemppainen JK, Becker S, Gershwin M, Kelly A. Mantram repetition for stress management in veterans and employees: a critical incident study. J Adv Nurs. 2006;53(5):502-512.

19. Buttner MM, Bormann JE, Weingart K, Andrews T, Ferguson M, Afari N. Multi-site evaluation of a complementary, spiritually-based intervention for veterans: the mantram repetition program. Complement Ther Clin Pract. 2016;22:74-79.

20. Bormann JE, Hurst S, Kelly A. Responses to mantram repetition program from veterans with posttraumatic stress disorder: a qualitative analysis. J Rehabil Res Dev. 2013;50(6):769-784.

21. Bormann JE, Thorp S, Wetherell JL, Golshan S. A spiritually based group intervention for combat veterans with posttraumatic stress disorder: feasibility study. J Holist Nurs. 2008;26(2):109-116.

22. Bormann JE, Thorp SR, Wetherell JL, Golshan S, Lang AJ. Meditation-based mantram intervention for veterans with posttraumatic stress disorder: a randomized trial. Psychol Trauma: Theory Res Pract Policy. 2013;5(3):259-267.

23. Bormann JE, Thorp SR, Smith E, et al. Individual treatment of posttraumatic stress disorder using mantram repetition: a randomized clinical trial. Am J Psych. 2018;175(10):979-988.

24. Bormann JE, Warren KA, Regalbuto L, et al. A spiritually-based caregiver intervention with telephone delivery for family caregivers of veterans with dementia. Fam Community Health. 2009;32(4):345-353.

25. Bormann JE, Becker S, Gershwin M, et al. Relationship of frequent mantram repetition to emotional and spiritual well-being in healthcare workers. J Contin Educ Nurs. 2006;37(5):218-224.

26. Leary F, Weingart K, Topp R, Bormann JE. The effect of mantram repetition on burnout and stress among VA staff. Workplace Health Saf. 2018;66(3):120-128.

27. Yong J, Kim J, Park J, Seo I, Swinton BD. Effects of a spirituality training program on the spiritual and psychosocial well-being of hospital middle manager nurses in Korea. J Contin Educ Nurs. 2011;42(6):280-288.

28. Bormann JE, Walter KH, Leary S, Glaser D. An internet-delivered mantram repetition program for spiritual well-being and mindfulness for health care workers. Spirit Clin Pract. 2017;4(1):64-73.

29. Hamilton S, Pinfold V, Cotney J. Qualitative analysis of mental health service users’ reported experiences of discrimination. Acta Psychiatr Scand. 2016;134(suppl 446):14-22.

30. Ryan GW, Bernard HR. Techniques to identify themes. Field Meth. 2003;15(1):85-109.

31. Hoge EA, Bui E, Marques L, et al. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. J Clin Psychiatry. 2013;74(8):786-792.

32. Lee RT, Seo B, Hladkyj S, Lovell BL, Schwartzmann L. Correlates of physician burnout across regions and specialties: a meta-analysis. Hum Resour Health. 2013;11(1):48.

According to the National Institute for Occupational Safety and Health (NIOSH), stress is a major problem for more than 18 million US health care workers (HCWs).¹ Increases in technology, high patient acuity, and new demands for meeting institutional benchmarks create stressful clinical work environments. HCWs at the US Department of Veterans Affairs (VA) are perhaps at particular risk of experiencing burnout due to the unique needs of VA patients and bureaucratic demands.² Stress may lead to depression, decreased job satisfaction, and other psychological distress among HCWs.³ This, in turn, affects the delivery of care. High levels of burnout have been associated with increased medication errors, lower quality of care, and lower patient satisfaction scores.^4-10

A Cochrane Review found that mental and physical relaxation reduce stress in HCWs.¹¹ Among these, meditative interventions (eg, mindfulness, meditation, yoga) have demonstrated promise.^12-14 Results from a systematic meta-analysis of meditative interventions for HCWs indicated small-to-moderate improvements in emotional exhaustion, sense of personal accomplishment, and life satisfaction. Additional research is needed to determine effects of meditative interventions on burnout and caregiver burden.¹⁵

Unfortunately, many meditative intervention programs are lengthy and require a significant investment of time. They also require some form of sitting meditation every day, placing additional demands on busy HCWs. There remains a need for practical strategies to reduce HCW stress that are easier to master and practice.

Background

We developed, implemented, evaluated, and modified an evidence-based meditative intervention called the Mantram Repetition Program (MRP) to address workplace stress and burnout. The MRP is a mind-body, spiritually enhanced intervention that offers benefits similar to other types of meditative interventions.¹⁶ MRP is composed of 3 primary components: (1) silently repeating a self-selected, meaningful word or phrase (here called a mantram); (2) intentionally slowing down thoughts and behaviors; and (3) developing the ability to focus on a single task at a time (ie, one-pointed attention). The MRP does not require participants to set aside a specific place to practice, and mantram repetition can be initiated intermittently and privately throughout the day (eg, between tasks, while walking or waiting). Examples of 4 sessions (eg, Mantram 1, 2, 3, and 4) can be found on the PsychArmor Institute website (www.psycharmor.org; San Diego, CA).

Initially, the MRP was offered in a group format, in 6 or 8 weekly, 90-minute face-to-face sessions to both patient and nonpatient populations. Studies in veterans with chronic diseases demonstrated improvements in perceived stress, anxiety, and anger, and increased levels of spiritual well-being and quality of life (QOL).^17-19 Veterans with posttraumatic stress disorder (PTSD) reported improvements in PTSD symptoms, QOL, and spiritual well-being.^20-23 Family caregivers of veterans with dementia reported significant reductions in caregiver burden, depression, and anxiety after participating in the MRP.²⁴

Similar results have substantiated the effects of the MRP among HCWs, including reductions in perceived stress, stress of conscience (ie, the conflict that results from competing values and behaviors in the workplace), and burnout.^25-27 HCWs also reported improvements in mindfulness and spiritual well-being.²⁸ In a randomized controlled trial, South Korean nurse managers who completed the MRP demonstrated significant improvements in psychosocial and spiritual well-being and leadership practice and experienced reductions in burnout compared with that of the control group.²⁷ In a qualitative study, the most frequently reported benefits of the MRP were improvements in managing symptoms of stress, anxiety, and feeling out of control.¹⁸

HCWs reported they found it difficult to attend the 8-week MRP face-to-face group classes. Therefore, we developed a shorter online version of the MRP consisting of six 1-hour educational sessions: 4 online self-learning modules, and 2 live meeting webinars with the course facilitator.²⁸ VA employees were invited to enroll in the program from June 2013 through 2016 through group e-mails and announcements in the VA Employee Education Service newsletters. Those eligible to participate could earn up to 6 hours of continuing education.

Although the program was generally well accepted, feedback from HCWs indicated that providers still lacked enough time to participate fully. We therefore condensed the MRP into one 90-minute, videotaped webinar entitled “Mind-Body-Spiritual Strategies for a Healthy Workforce: The Mantram Repetition Program.” The webinar was delivered in real time in June 2013 and archived for viewing later. This condensed course provided an overview of the development, theory, and practice of MRP core components. Specific instructions included how to choose and use a mantram; the importance of acting slowly with intention to avoid mistakes; and ways of developing single-pointed attention. Participants were invited to complete a standard course evaluation using an online survey.

This article presents results from qualitative analyses of participant feedback for the condensed MRP in a nationwide sample of more than 1,700 HCWs within the VA. We used template summary analysis to identify themes in participants’ responses to 2 open-ended questions: “What about this learning activity was most useful to you?” and “What about this learning activity was least useful to you?” These results have implications for reducing HCW stress and developing training programs for HCWs.