Journal of Integrative Medicine 17 (2019) 173–180

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Journal of Integrative Medicine

journal homepage: www.jcimjournal.com/jim
www.journals.elsevier.com/journal-of-integrative-medicine

Original Research Article

Burnout in the emergency department: Randomized controlled trial of

an attention-based training program
Pádraic J. Dunne a,⇑,1, Julie Lynch b,1, Lucia Prihodova b, Caoimhe O’Leary b, Atiyeh Ghoreyshi c,
Sharee A. Basdeo d, Donal J. Cox d, Rachel Breen b, Ali Sheikhi d, Áine Carroll e, Cathal Walsh d,
Geraldine McMahon f, Barry White g
a
Trinity Translational Medicine Institute, Trinity College, Dublin D08 W9RT, Ireland
b
Research Department, Royal College of Physicians of Ireland, Dublin D02 E434, Ireland
c
Department of Innovation, Fitbit Inc., San Francisco, CA 94105, USA
d
Health Research Institute, Main Building, University of Limerick, Limerick V94 X5K6, Ireland
e
Health Service Executive, Dr Steevens’ Hospital, Dublin D08 W2A8, Ireland
f
Department of Emergency Medicine, St. James’s Hospital, Dublin D08 W9RT, Ireland
g
National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin D08 W9RT, Ireland

a r t i c l e i n f o a b s t r a c t

Article history: Background: Burnout (encompassing emotional exhaustion, depersonalization and personal accomplish-
Received 23 November 2018 ment) in healthcare professionals is a major issue worldwide. Emergency medicine physicians are partic-
Accepted 14 March 2019 ularly affected, potentially impacting on quality of care and attrition from the specialty.
Available online 29 March 2019
Objective: The aim of this study was to apply an attention-based training (ABT) program to reduce
burnout among emergency multidisciplinary team (MDT) members from a large urban hospital.
Keywords: Design, setting, participants and interventions: Emergency MDT members were randomized to either a no-
Burnout
treatment control or an intervention group. Intervention group participants engaged in a four session
Emotional exhaustion
Meditation
(4 h/session) ABT program over 7 weeks with a practice target of 20 min twice-daily. Practice adherence
Healthcare professional was measured using a smart phone application together with a wearable Charge 2 device.
Sleep Main outcome measures: The primary outcome was a change in burnout, comprising emotional exhaus-
Stress tion, depersonalization and personal achievement. The secondary outcomes were changes in other psy-
Cytokines chological and biometric parameters.
Cortisol Results: The ABT program resulted in a significant reduction (P < 0.05; T1 [one week before intervention]
Randomized controlled trial vs T3 [follow-up at two months after intervention]) in burnout, specifically, emotional exhaustion, with
an effect size (probability of superiority) of 59%. Similar reductions were observed for stress (P < 0.05) and
anxiety (P < 0.05). Furthermore, ABT group participants demonstrated significant improvements in heart
rate variability, resting heart rate, sleep as well as an increase in pro-inflammatory cytokine expression.
Conclusion: This study describes a positive impact of ABT on emergency department staff burnout com-
pared to a no-treatment control group.
Trial registration: ClinicalTrials.gov identifier NCT02887300.

Please cite this article as: Dunne PJ, Lynch J, Prihodova L, O’Leary C, Ghoreyshi A, Basdeo SA, Cox DJ,
Breen R, Sheikhi A, Carroll Á, Walsh C, McMahon G, White B. Burnout in the emergency department:
Randomized controlled trial of an attention-based training program. J Integr Med. 2019; 17(3): 173–180.
Ó 2019 Shanghai Changhai Hospital. Published by Elsevier B.V. All rights reserved.

1. Introduction

International data report a high prevalence of burnout among

healthcare professionals. In the 1970s, burnout was first defined
⇑ Corresponding author. as a syndrome, primarily related to an individual’s relationship to
E-mail address: padraicdunne@rcsi.com (P.J. Dunne). work and incorporates a triad of high emotional exhaustion (EE)
1
Pádraic J Dunne and Julie Lynch contributed equally to this manuscript.

https://doi.org/10.1016/j.joim.2019.03.009
2095-4964/Ó 2019 Shanghai Changhai Hospital. Published by Elsevier B.V. All rights reserved.
174 P.J. Dunne et al. / Journal of Integrative Medicine 17 (2019) 173–180
and depersonalization (DP), accompanied by low personal accom-
plishment (PA) [1]. One in three doctors in Ireland meets the crite-
ria for burnout [2]. Furthermore, up to 70% of American emergency
physicians [3] and over 66.5% of Chinese physicians [4] suffer from
burnout.
Detrimental implications for both the individual and the wider
healthcare system are evident, with research linking burnout to
psychological ill-health [5], absenteeism [6], early retirement [7],
increased risk for medical errors [8], increased workload [9] and
compromised patient safety [10]. In 2014, the economic cost of
physician burnout to the Canadian Exchequer was estimated to
be $213.1 million [10]. Interventions to reduce the prevalence of
burnout are therefore important from professional, patient safety
and economic perspectives. A recent meta-analysis has highlighted
the potential for overlap between burnout and anxiety among
stressed workforces [11]. Therefore any future interventions in this
area should also examine this phenomenon.
The efficacy of mind–body interventions on physician wellness
has attracted attention in the literature, with a number of studies
reporting on alleviated stress, anxiety and burnout following
mindfulness-based interventions [12]. The attention-based train-
ing (ABT) program employed in this study is based on the practice
of mantra meditation (similar to transcendental meditation),
which has been shown to reduce stress and anxiety among health-
care professionals [13] and non-clinical populations [14]. Data
from a pilot study conducted by O’Leary, ‘‘The Program Helped Me
to Look at Life”: Pilot Study of a Mantra Meditation Program for
Healthcare Professionals” (unpublished manuscript), revealed a sig-
nificant reduction in burnout, specifically EE as a principle burnout
component, following a ten-session mantra meditation program
(t = 2.26, P = 0.04). Therefore, we conducted this study to investi-
gate the impact of an ABT program on burnout in an emergency
department multidisciplinary team (MDT).
2. Methods
2.1. Study design
A randomized controlled trial using two study groups (no-
treatment control and intervention) with single-blind outcome
assessors, based at a single center, was conducted. The study
design conforms to the guidelines for non-pharmacological clinical
trials by the Consolidated Standards of Reporting Trials (CONSORT)
group [15]. Institutional ethics committee approval was in place
from the SJH/AMNCH Research Ethics Committee Secretariat
(reference number REC2016-07).
2.2. Sample size
Statistical power was calculated as follows: in a previous
unpublished study, burnout (specifically EE scores, as part of the
Maslach Burnout Inventory [MBI] instrument) was normally dis-
tributed with an average of 26.8 pre- and 22 post-intervention
(n = 19). According to these calculations, 51 pairs of subjects are
required to reject the null hypothesis with a power of 0.8. Power
calculations were made using online software, developed by
Vanderbilt Biostatistics [16].
2.3. Recruitment
Emergency MDT participants were stratified by role and gender
and allocated to intervention or no-treatment control group using
an online randomization tool [17]. Volunteers meeting inclusion
and exclusion criteria were recruited to the study and allocated a
unique identification code post-randomization. Inclusion criteria
included: a current staff member of the emergency department
of St. James’ Hospital; preference to participate in the study and
to be over 18 years of age. Exclusion criteria included: alcohol or
substance abuse within the past 6 months; more than four consec-
utive classes of meditation or other mind–body practices (includ-
ing yoga and Tai-chi) in the past 2 years; a diagnosis of
schizophrenia; currently using (at time of enrollment) anti-
psychotic medication or recently started on anti-depressant medi-
tation (less than 3 months at the time of enrollment). Participants
on a stable dose of anti-depressant medication (for more than
3 months) were permitted but advised to consult with their
general practitioner or psychiatrist prior to enrollment.
Staff at the adjacent Clinical Research Facility (CRF) to St. James’
Hospital undertook the recruitment and data control. Participants
were recruited by the local CRF through posters, emails, participa-
tion information leaflets in seminar rooms and presentations to
staff regarding the study details. Outcome assessors were blind
to individual participant identification.
2.4. ABT program intervention
2.4.1. ABT program
Many meditative approaches employ attention training as part
of overall practice, including transcendental and other mantra-
based meditations; the breath or chosen phrases are commonly
used as the focus of repeated attention. We selected the ABT
approach because of its simplicity and ease of training, in accor-
dance with input from active healthcare professionals. On a practi-
cal level, ABT can be practiced over a short-time window, in any
location and without any special tools. We concluded that ABT rep-
resented an attractive option for busy emergency MDT members.
Participants allocated to the intervention group attended four
sessions (4 h/session) over 7 weeks (weeks 2 to 8 of the study)
between T1 (one week before intervention) and T2 (one week after
intervention). The program and materials (facilitator manual and
participant handbook) were developed by an education specialist,
meditation expert and a healthcare professional. Each session con-
sisted of ABT practice and discussion on the importance of focused
attention and the meaning of healthcare. ABT practice involved
repeatedly focusing one’s attention on a chosen non-English
phrase (maranatha) for 20 min, twice daily; the combined target
was two 20-minute sessions over 7 days (280 min in total). Two
facilitators delivered each session and remained independent of
the study outcome assessment. Fidelity to the program manual
was ensured by an impartial researcher observing each session.
Intervention group participants were asked not to discuss the
program with colleagues in order to reduce contamination bias.
No-treatment control participants were offered the ABT program
upon completion of the intervention group study.
2.4.2. Technology used to measure ABT practice adherence as well as
physiological metrics
A bespoke smart phone app designed by TickerFit (Inner-
strength Ltd.), linked to a wearable Charge 2 device by Fitbit was
used to both measure and promote practice adherence. Heart rate
variability (HRV), heart rate and sleep quality were measured by
the Charge 2 device. The smart phone app recorded the duration
and frequency of daily practice. Participants from both groups
wore Charge 2 devices throughout. All data were anonymized
and gathered for analysis at the end of the program.
2.5. Outcomes and measurements
2.5.1. Outcomes
The primary outcome measure was a change from baseline in
burnout, which is comprised of EE, DP and PA, defined previously
 P.J. Dunne et al. / Journal of Integrative Medicine 17 (2019) 173–180
by Maslach in MBI [1]. Secondary outcome measures included
changes from baseline in anxiety and stress measured by the
Depression, Anxiety and Stress Scale (DASS). Changes in biometric
data included 24-hour ambulatory blood pressure (ABP), HRV and
sleep quality. Salivary cortisol and pro-inflammatory cytokine
mRNA levels were also measured.
2.5.2. Study questionnaires
2.5.2.1. MBI. The MBI-Human Services Survey [18] was designed to
assess burnout in human services professionals and comprises
three subscales: EE, DP and PA. The response format for the
22 items of the MBI utilizes a 7-point Likert scale ranging from
0 (never) to 6 (everyday). The MBI has been widely validated as
a reliable and reproducible survey instrument and is considered
the criterion standard tool for measuring burnout [19]. In this sam-
ple, the subscales of the MBI demonstrate good internal consis-
tency as measured by Cronbach’s a (EE a = 0.92; PA a = 0.85; DP
a = 0.74).
2.5.2.2. DASS. The DASS [20] is a widely used, valid and repro-
ducible screening tool to identify symptoms of anxiety and stress
in different community settings, including hospitals. The DASS
has 21 statements and adopts a response format which allows
the respondent to indicate how much each statement applied to
them over the past week (0 reflects the statement not applying
to the respondent at all, whereas 3 reflects the statement applying
to the respondent most of the time). The subscales of the DASS
demonstrate appropriate internal consistency in this population
as measured by Cronbach’s a (depression a = 0.87; anxiety
a = 0.73; stress a = 0.85).
2.6. Data collection and management
Study participants completed MBI and DASS questionnaires at
three time points. Blood and saliva samples were taken at T1 and
T2 and stored at –80 °C. All data were pseudo-anonymized and
stored in compliance with General Data Protection Regulation
guidelines (May 2018) [21]. Statistical analysis and collation of
data were supervised by study statisticians (authors CW and AS)
and the CRF data controller.
2.6.1. Pro-inflammatory cytokine analysis
Total RNA was extracted from whole blood using Isolate II Mini
RNA kit (Bioline), and treated with DNase I (Bioline). RNA yields
were measured by NanoDrop (Thermo Scientific). cDNA was gener-
ated using SensiFASTTM cDNA synthesis kit (Bioline). Gene expres-
sion was examined with the QuantStudio 5 (Applied Biosystems)
using SensiFASTTM Probe Hi-ROX Kit (Bioline). Primers (FAMTM
dye; ThermoFisher) used were tumor necrosis factor (TNF)-a
(Hs01113624_g1).
2.6.2. Salivary cortisol
Saliva (1 mL) was obtained from control and intervention group
participants (morning assessments only; 8 a.m. to 11 a.m.) on T1
and T2, using 1 mL saliva collection tubes (Salimetrics). Salivary
cortisol (hydrocortisone, compound F) was measured by enzyme-
linked immunosorbent assay (Salimetrics).
2.6.3. 24-hour ABP measurements
Participants wore 24-hour ABP monitors for a 24-hour period at
T1 and T2.
2.7. Statistical assessment
IBM SPSS V22 (IBM, US) and GraphPad Prism 5 (GrpahPad Soft-
ware, US) statistical software packages were used to analyze data
175
from the psychological and biological measures, respectively.
Single imputation replaced missing values. Mean and standard
deviation values are denoted as follows: (x = x[y]). Paired and
unpaired t-tests (denoted as P values) were used to examine
intra- and inter-group differences. One- and two-way mixed anal-
yses of variance were used to compare multiple datasets with
independent variables of group and time. Linear regression analy-
sis was used to examine changes in either group over time. Cohen’s
d and associated effect size calculations (U3) were applied to mean
and standard deviation results (0.2 is considered a small effect size,
0.5 represents a medium effect size and 0.8 a large effect size).
Probability of superiority was subsequently calculated using effect
size values. The reader should note that the term ‘‘effect size” used
throughout this manuscript is employed to determine the
probability of superiority of the intervention, compared to the
no-treatment control for a specific parameter, and does not refer
to absolute decreases or increases in values.
Although this is a preference-based study, intervention partici-
pants achieving home ABT practice greater than 10% of the recom-
mended weekly target were regarded as ‘‘adherent” and
subsequently compared to the control group using per-protocol
analysis. The same statistical approaches applied to the no-
treatment control vs the total intervention group, were applied
when the no-treatment control group was compared to the adher-
ent group of participants.
3. Results
3.1. Retention
Of the 29 participants allocated to the wait-list control group, 4
dropped out prior to program commencement, while 25 completed
the project. Of the 22 intervention group participants who started,
90%, 72%, 54% and 31% attended session 1, 2, 3 and 4, respectively.
Four withdrew during the study, with reasons for withdrawal
including family commitments (n = 1), relocation (n = 1), unavail-
ability (n = 1) and difficulty engaging with the practice (n = 1).
One participant was lost to follow-up (Fig. 1). There was no
significant difference between study completers and withdrawers.
3.2. Adherence to ABT practice
Total minutes spent meditating peaked on week 6 (n = 17 total
1510 min; individual participant weekly x = 137[140] min) with
the lowest number of minutes on week 7 (n = 17 total 576 min;
individual participant weekly x = 58[62] min). The percentage of
participants achieving the weekly target decreased over time, with
13% of participants reaching target (280 min, weekly) by the final
session. Adherence data for the week following week 1 were not
recorded due to issues relating to syncing of data. Seven interven-
tion group participants who were considered ‘‘adherent” practi-
tioners, those who practiced ABT for greater than 10% of the set
weekly targets, were examined to determine whether length of
time spent practicing had any impact on other measured parame-
ters. This cut-off value was chosen after study completion, when
improvements in secondary outcome parameters were detected
for those participants practicing for a minimum of 10% of the daily
recommended time.
3.3. Psychological questionnaires
Changes to individual components of burnout as defined by
Maslach [1]: the assessment of burnout using the MBI instrument
revealed a significant decrease in EE between T1 (x = 26[12]) and
176 P.J. Dunne et al. / Journal of Integrative Medicine 17 (2019) 173–180
Fig. 1. CONSORT flow diagram of study. T: time point; CONSORT: Consolidated Standards of Reporting Trials.
T3 (follow-up at two months after intervention; x=22[12]) for the
intervention group (n = 17; P < 0.05; effect size = 0.63; 95% confi-
dence interval [CI] = –0.3 to 8.5) (Fig. 2A). No significant changes
were observed for either DP or PA scores when compered over time
or between groups. There was a significant decrease in stress
scores over time between T1 (x = 7.7[4]) and T2 (x = 5[4]) for
the intervention group (n = 17; P < 0.05; effect size = 0.75; 95%
CI = –0.8 to 3.8) with a significant difference between the groups
for stress scores at T2 (P < 0.05; effect size = 0.64) (Fig. 2B). A signif-
icant decrease was also observed for anxiety scores between
T1 (x = 4[3]) and T2 (x = 2[1.7]) for the intervention group
(n = 17; P < 0.05; effect size = 0.79; 95% CI = 0.14 to 3.4) (Fig. 2B).
3.4. Biological investigations
3.4.1. Pro-inflammatory cytokine analysis
Gene expression for TNF-a was increased at T2 for intervention
participants, and TNF-a relative gene expression was significantly
increased (P = 0.03; effect size = 0.69; 95% CI = –1.3 to 0.1) for the
intervention group (n = 17) on T2 (x = 1.7[1.5]) compared with
T1 (x = 1.1[0.7]) (Fig. 3A).
3.4.2. Sleep
There was a significant difference (P = 0.02; effect size = 0.83;
95% CI = –1.746 to –0.154) in sleeping time (mean daily minutes
asleep; normalized units to account for significant variance) when
adherent ABT practitioners (n = 6; x = 0.99[0.0098]) were com-
pared with control participants (n = 25; x = 1.9[1.27]) over time
(Fig. 3B). Adherent practitioners slept for longer on average each
day.
3.4.3. Heart rate and 24-hour ABP
There was a significant difference in slope values (mean, daily,
resting heart rate metrics; measured over 45 days) between no-
treatment control (slope = 0.0035; P = 0.4) and intervention
(slope = –0.02; P = 0.006) groups; mean daily resting heart rate
 P.J. Dunne et al. / Journal of Integrative Medicine 17 (2019) 173–180 177

Fig. 2. Impact of ABT on MBI and DASS scores. A: Emotional exhaustion, depersonalization and personal accomplishment scores of MBI on time points (T) 1, 2 and 3 for
control (n = 25) and intervention (n = 17) groups. B: Stress and anxiety scores of DASS questionnaires on time points (T) 1, 2 and 3 for control (n = 25) and intervention (n = 17)
groups. MBI: Maslach Burnout Inventory; DASS: Depression, Anxiety and Stress Scale; ABT: attention-based training. T1: one week before intervention; T2: one week after
intervention; T3: two months after T2.

measurements for intervention group participants decreased over 3.4.4. HRV

time by comparison to their no-treatment control counterparts,
which actually increased over the same time period. Although
there have been reports showing that transcendental meditation
(with an emphasis on focused attention training) can reduce blood
pressure [22], we did not find any significant impact of our ABT
program on 24-hour measurements for individual intervention
group members.
Healthy individuals have high variability in the duration of their
R-R intervals (HRV; miliseconds), which is regulated by the auto-
nomic nervous system (ANS). Mental stress reduces the ability of
the ANS to respond to stimuli, which is reflected by reductions in
HRV [23]. In addition, lower HRV has been associated with sup-
pressed parasympathetic tone, in response to work-related stress
[24]. There was a significant increase (P = 0.06; effect size = 0.86;
178 P.J. Dunne et al. / Journal of Integrative Medicine 17 (2019) 173–180

P 50

45

HRV-HF (nu)
40

35

30

10 20 30 40
Time point (d)

Fig. 3. Impact of ABT program on HRV, sleep parameters, TNF-a mRNA from peripheral blood cells and salivary cortisol for control (n = 25) and intervention (n = 17) groups.
A: TNF-a relative gene for intervention group between T1 and T2. B: time spent sleeping (total mean daily minutes asleep over time; normalized units) between control and
intervention groups. C: total mean time domain SD2 HRV values between control and intervention groups. D: HRV-HF (normalized units) between control and intervention
groups over time. E: log10 salivary cortisol concentration and TNF-a relative gene expression for intervention participants on T1 and T2. ABT: attention-based training; HRV-
HF: high-frequency heart rate variability; TNF: tumor necrosis factor; SD2: standard deviation of R-R intervals; T1: one week before intervention; T2: one week after
intervention.

95% CI = –24 to –4.3) in the total mean time domain SD2 (standard
deviation of R-R intervals) HRV values for the adherent ABT practi-
tioner group (n = 7; x = 69[14]) compared with the no-treatment
control group (n = 23; x = 55[10]) over time (Fig. 3C). High-
frequency heart rate variability (HRV-HF) values (normalized unit,
nu) from total intervention group participants (n = 18) were signif-
icantly higher on T2, when compared with T1 (P = 0.02; effect
size = 0.77; 95% CI = –57.65 to –6.61). Furthermore, there was a
significant increase in HRV-HF slope values for intervention group
participants (slope = 0.17; P = 0.01) over time, compared with the
control group (slope = 0.008; P = 0.5) (Fig. 3D).
3.4.5. Salivary cortisol concentration and comparison with TNF-a
Significant inverse correlations were noted between salivary
cortisol concentrations and TNF-a relative gene expression for
 P.J. Dunne et al. / Journal of Integrative Medicine 17 (2019) 173–180
intervention participants on T1 (Pearson’s r = –0.81; P = 0.0002;
r2 = 0.5) and T2 (Pearson’s r = –0.67; P = 0.005; r2 = 0.47) (Fig. 3E).
3.5. Adverse event reporting
No adverse responses were reported as a direct result of the
intervention.
4. Discussion
Burnout among healthcare professionals and its subsequent
deleterious impact on individuals (psychological, physiological,
and social), patients and organizations, remain a global concern
that requires immediate attention. To our knowledge this is the
first ABT program evaluated for efficacy on reducing burnout
among emergency staff. Our results indicated a very significant
reduction in EE, a principle component of the MBI. The resultant
effect size (probability of superiority) for EE was 59%, implying that
greater than 1 out of every 2 individuals receiving ABT will experi-
ence a reduction in EE. Unfortunately, no significant changes were
detected for the other two components of burnout (DP and PA),
implying that overall burnout as measured by the MBI was not
reduced in ABT participants. However, significant positive changes
were observed for secondary outcome measures: anxiety, stress,
resting heart rate and HRV, and increased TNF-a mRNA for the
intervention group, as well as total sleep time for adherent ABT
practitioners. An inverse correlation between salivary cortisol
and TNF-a mRNA was also observed.
Reliable recording of meditation practice has been an issue in
studies on mind–body interventions [25]. As far as we are aware,
this is the first study to employ a smart phone app in conjunction
with a wearable device to accurately measure practice adherence.
We suggest that the adherence data published here represent a
more valid estimate of home practice than self-reported adher-
ence, which has been reported as high as 90% [26].
Our results are consistent with recent research, which indicated
that meditation-based interventions improve biological markers of
wellness in the HRV metrics, which cannot be subjectively manip-
ulated, a potential criticism of questionnaires or interviews.
Increases in HRV, specifically, time domain parameters and HRV-
HF, have been demonstrated among meditators [27]. In our study,
non-linear SD2 values of high-frequency domain analysis, another
measure of HRV, increased in adherent meditators. It is likely that
these improvements in HRV are due to participation in the ABT
program, rather than a placebo effect. The increased HRV-HF val-
ues observed for the intervention group are also in agreement with
other work [28]. The wearable device used in this study to charac-
terize HRV, employs technology that is based on the detection of
individual R-R peaks in the optical photoplethysmogram (PPG) sig-
nal, obtained at the wrist. Previous research has shown a high
degree of agreement between HRV derived from electrocardiogra-
phy and optical PPG [29].
Pro-inflammatory cytokine expression was low for study
participants prior to the program start. The increase in TNF-a
expression among intervention group members after ABT program,
runs counter to studies on pro-inflammatory cytokine production,
in response to stress; reports in the literature have proposed that
stress actually increases pro-inflammatory responses [30]. On the
other hand, in agreement with the findings presented here, Cahn
et al. [31] described recently that peripheral blood TNF-a concen-
trations were significantly increased among participants following
a 3-month yoga retreat. The discrepancies between some pub-
lished studies and those described here, might be due to differ-
ences in the nature of stress and burnout. Acute stress, such as
that induced by exam pressure, might induce a temporary pro-
179
inflammatory response. Conversely, chronic stress, associated with
burnout, might ultimately lead to a reduction in pro-inflammatory
responses, as indicated here.
The inverse relationship between salivary cortisol and peripheral
blood cell TNF-a mRNA among intervention group participants
reported here, is in line with previous research [32]. Cortisol and
pro-inflammatory cytokines exist in a tightly regulated system,
whereby circulating TNF-a can downregulate cortisol production
and vice versa, through various intermediaries [33]. Since interven-
tion group participants experienced increases in peripheral blood
cell TNF-a mRNA over a 7-week period, it might be reasonable to
propose that this is partially due to corresponding decreases in sys-
temic cortisol concentration. Further research is required in this area
to better understand the factors impacting on biomarker responses.
Total sleep time measured by Fitbit devices correlates well with
polysomnography [34,35]. Only adherent ABT practitioners
showed improved sleep quality in this study, which (along with
SD2 results described earlier) might lend credence to the possibil-
ity that these improvements are due to ABT and not placebo.
There are a number of limitations to this study. Power calcula-
tions carried out prior to the study suggested a minimum of 51 pairs
were required to achieve significance for burnout, specifically EE as a
principle burnout component. The results here show a 59% probabil-
ity of improvement in EE scores for intervention group members
(n = 17) versus control counterparts (n = 25). Regardless, studies
with larger numbers should be carried out to confirm these results.
Future studies should also include an active control group to account
for the Hawthorne effect (the awareness of being studied and possi-
ble impact on behaviour and subsequent study results) [36].
Additionally, long-term follow-up is required in subsequent studies
to examine impact and help develop sustainable ABT programs.
Contamination between groups in terms of performance bias
remains a possibility. In terms of salivary cortisol measurements,
we acknowledge that 8 to 11 a.m. is a significantly large window
for measuring this hormone. Unfortunately, it was not possible to
have participants return on the same time (within the 8–11 a.m.
window) for T2 measurements. Therefore, significant variations
between T1 and T2 salivary cortisol concentrations are expected.
Furthermore, additional environmental stressors (unrelated to
work-related burnout) can confound morning salivary cortisol
readings, especially with only two time points measured. In terms
of adherence, the weekly home meditation practice target for this
study was set too high and impacted negatively on adherence and
retention rates. Future larger studies are also required to examine
differences in adherence and the subsequent impact of the ABT
program between gender, work role and age. Finally, we note the
presence of outliers in our data, which might distort the differences
between experimental groups, especially in relation to HRV metrics,
which have a high degree of inter-individual variability.
5. Conclusion
The results described in this study suggest that an ABT program
represents a viable option to limit burnout (specifically EE) among
emergency staff. We believe a 59% chance (probability of superior-
ity) of an improvement in EE for ABT participants is a significant
result. We acknowledge that ABT might not be suitable for all staff
and represents one of a suite of potential alleviating practices,
which can contribute to self-management of burnout. Further
research is warranted in this area.
Acknowledgements
We have received written permission from the following indi-
viduals and groups in this acknowledgement section. We would
180 P.J. Dunne et al. / Journal of Integrative Medicine 17 (2019) 173–180
like to acknowledge Laurence Freeman (OSB; BA) for facilitating
the ABT program described here and for all his support and advice
throughout the study, including development of the ABT instruc-
tion manual. We would also like to acknowledge the Health
Research Board of Ireland/Wellcome Clinical Research Facility at
St. James’ Hospital (Dublin) for their professional support. Finally,
we acknowledge the staff at the Emergency Department, St. James’
Hospital (Dublin) for their time and co-operation throughout.
Conflict of interest
Authors received Charge 2 devices from Fitbit Inc. for all
participants in the study. Otherwise, none.
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