Introduction

It is undeniable that healthcare professionals are increasingly under strain (LaDonna et al., 2022; Shanafelt & Noseworthy, 2017), with many healthcare professionals reporting excessive workloads and decision-making stress, challenges to work-life balance, and a lack of organizational support (Morgantini et al., 2020; Shanafelt et al., 2016). In addition, new technologies and an information explosion, accountability and efficiency mechanisms, and litigious workplace environments contribute to the tensions (Spence et al., 2017; Leicht et al., 2009; Taylor, 2014; Webster, 2014), fueling high levels of practitioner distress (Shechter et al., 2020) and burnout (Morgantini et al., 2020).

The consequences of work-related distress in the health professions are far-reaching, affecting personal well-being, patient care, and organizational effectiveness. Work-related distress has been documented to negatively impact interpersonal relationships, increase the risk of substance abuse and suicidal ideation, and contribute to diminished quality of care, higher rates of medical errors, lower patient satisfaction, and increased clinician attrition (LaDonna et al., 2022; Maslach & Leiter, 2016; Montgomery et al., 2019; Shanafelt et al., 2017; Shanafelt & Noseworthy, 2017).

Since the COVID-19 pandemic, symptoms of anxiety and depression have been documented in more than a third of frontline healthcare workers (Prasad et al., 2021; Shechter et al., 2020). Burnout, which is associated with stressors in the work environment is also a concern (LaDonna et al., 2022; Maslach & Leiter, 2016; Montgomery et al., 2019); with an estimated prevalence twice as high in health care as compared to other workplace sectors (Dyrbye & Shanafelt, 2016; Gutman et al., 2020). Clearly, many issues are impacting health care practitioners, with consequences for the next generation.

Health professions education

Health professions students are particularly under pressure. In addition to facing distressing situations in health care practice, students report distress related to the demands of their classroom education and clinical preparation, as well as with managing personal responsibilities amidst intense education-related expectations and demands (Johnson et al., 2020; Luberto et al., 2020; Obregon et al., 2020; Spadaro & Hunker, 2016). Anxiety and feelings of social isolation and apathy, which are correlated with burnout, are of significant concern in student populations (Obregon et al., 2020). Even prior to the Covid-19 pandemic, the prevalence of burnout among health professions students was estimated to be approximately 50% (Brazeau et al., 2014; Johnson et al., 2020; Luberto et al., 2020; Obregon et al., 2020); a significantly higher rate than for students in non-health professions majors (Baker & Sen, 2016; Johnson et al., 2020; Spadaro & Hunker, 2016).

It is well documented that stress-related anxiety negatively impacts academic performance in students studying to become health professionals (Eisenberg et al., 2009; Gutman et al., 2020; Luberto et al., 2020), and that burnout may be tied to decreases in both empathy and professionalism (Brazeau et al., 2014; Dyrbye et al., 2010; Dyrbye & Shanafelt, 2016; Thomas et al., 2007).

The challenges of the health care system for future practitioners are considerable (Maslach & Leiter, 2016; Montgomery et al., 2019), and the need for systemic reform is clear. However, such reforms have been slow to take shape. In the meantime, current and future health care practitioners are grappling with how to maintain their health and wellbeing amidst myriad challenges.

In short, health professions students are particularly at risk, with high levels of reported distress, and the dual stress of working within challenging health care environments and managing difficult academic requirements. While systemic changes are clearly required to our health care systems, and perhaps to our approaches to education, the question remains as to what we can do to support students in the current milieu.

Mindfulness

While not a panacea for the systemic issues facing health professions students, one approach that has received attention is the integration of mindfulness into health professions education programs (Gockel & Deng, 2016; Kinsella et al., 2020). Mindfulness has its roots in Eastern traditions dating back 3000–5000 years and has become popularized in the West over the last 40 years. It is important to acknowledge diverse perspectives and debates on the meanings, origins, and applications of mindfulness across traditions (See Williams & Kabat-Zinn, 2013 for an extended discussion). Although there are many approaches, one commonality is that mindfulness often focuses on ‘awareness’. In the Buddhist tradition this involves four foundations of ‘awareness’: mindfulness of body, mindfulness of feelings, mindfulness of mind, and mindfulness of phenomena (Goldstein, 2013). Kabat-Zinn (2003, 2013a, b), who popularized a secular approach to mindfulness widely adopted in health care, also focuses on ‘awareness’ in his definition. He defines mindfulness as the “the awareness that arises by paying attention on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn, 2013a, p.21). He describes mindful awareness as “cultivated by paying close attention to your moment-to-moment experience while, as best you can, not getting caught up in your ideas and opinions, likes and dislikes” (Kabat-Zinn, 2013a, p.21). Epstein (1999), a physician scholar who advocates for mindfulness in the health professions, writes about “the mindful practitioner” as one who “attends, in a nonjudgmental way, to his or her mental and physical processes during ordinary, everyday tasks to act with clarity and insight.” (p. 833). Kabat-Zinn (2013a) identified seven frequently cited attributes of mindfulness: non-judgement, patience, a beginner’s mind, trust, non-striving, acceptance and letting go. Mindfulness interventions in higher education are varied, and often involve a combination of three or four different practices, such as sitting meditation, mindful movement, attention to breath, body scan, guided meditation, mindful walking, reflective group dialogue, or other approaches (Kinsella et al., 2020). Recently, mindfulness apps for mobile devices have also become widely adopted (Creswell, 2017).

‘Mindfulness practices’ have been shown to contribute to a variety of positive outcomes for health professions students that may contribute to resilience. For instance, ‘mindfulness practices’ have been reported to improve health professions students ability to manage stress (Beck, 2017; Burger & Lockhart, 2017; Dobkin & Hutchinson, 2013; Goodman & Shorling, 2012; Gutman et al., 2020; Kang et al., 2009; Luberto et al., 2020; Schwarze & Gerler, 2015; Vogtmann & Provident, 2021) and cope with symptoms of depression and anxiety (Alsaraireh & Aloush, 2017; Chen et al., 2013; Dobkin & Hutchinson, 2013; Gockel et al., 2013; Goodman et al., 2019, Kinsella et al., 2020; Shapiro et al., 1998). Further, practicing mindfulness may help learners to cultivate empathy (Dobkin & Hutchinson, 2013; Goodman et al., 2019; Kinsella et al., 2020; Leppma & Young, 2016; Shapiro et al., 1998), compassion for others (Conversano et al., 2020; Decker et al., 2015; Tirch, 2010), self-compassion (Beck et al., 2017; Dobkin & Hutchinson, 2013; Felton et al., 2015; Gilbert & Choden, 2013; Jackman, 2014), clinical congruence in relationships (Hutchinson et al., 2024), and a more positive attitude toward people who are different than themselves (Akyurek et al., 2018). A number of reviews and reports suggest that ‘mindfulness practices’ may also contribute to an improved sense of well-being (Kinsella et al., 2020; Noble et al., 2019; van der Riet et al., 2015) and quality of life (Bonifas & Napoli, 2014; Kinsella et al., 2020).

The literature highlights potential affordances of mindfulness for helping students to mitigate and manage distress. At the same time, it is important to recognize the challenging workplace conditions, and structural and systemic issues, that create pressures and require redress (Caring-Lobel, 2016; Forbes, 2016; Kelly, 2022). Some authors have argued that mindfulness fails to adequately acknowledge such systemic issues and that it places the blame on individuals for the distress caused by neoliberal policies and structural issues (Forbes, 2019). Others have argued that ‘mindfulness practices’ can contribute to the compassionate transformation of structures and systems by changing the perspectives of those who work within them (Berila, 2016; Lemon & McDonough, 2018; Palmer & Zajonc, 2010; Stanley et al., 2018).

While there are growing reports about the potential affordances of mindfulness education in higher education, it is interesting to note that few investigations examine students’ lived experiences of learning about and practicing mindfulness in health professions education (Kinsella et al., 2020). This, despite longstanding calls by leading neuroscientists, cognitive scientists and philosophers of mind for more first-hand, lifeworld, and phenomenological investigations to complement advancements being made through experimental neuroscience in the field of mindfulness studies (Thompson, 2007; Varela et al., 1993).

Our team was interested in better understanding the experiences of ‘mindfulness practices’ from the perspectives of those who learn about and use them during their health professions education, and to consider what we can learn from students richly textured first-hand accounts that could help us think about the place of mindfulness education in the higher education health professions curriculum.

The research investigates health professional students’ phenomenological experiences of learning about and practicing mindfulness. This inquiry examines students’ reflective writing in a higher education setting and is situated in the context of one profession– occupational therapy. We propose however that the phenomenon of interest likely holds relevance to students in health and social care professions more broadly.

Methodology

Context

The study is situated in the context of an elective course on ‘Mindfulness and Professional Practice’ for professional students in a Canadian School of Occupational Therapy (MScOT clinical degree) that occurred over 4 years. Given that it was an elective course, participation varied from 10 to 14 students (out of 60) per year. The course included five weekly, three hour sessions, for a total of 15 hours of in-class mindfulness education. The curriculum was informed by Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR) curriculum (2003, 2013a). The course focused on the introduction of ‘mindfulness practices’ taught in MBSR including attention to breath, body scan, guided meditation, silent meditation, mindful walking, and mindful eating. Self-compassion mindfulness exercises drawing on the work of Neff (2011) were also incorporated. Mindful movement in the Sivananda Vedanta and Yogic style was facilitated for 45 minutes per session, with the rationale that mindful movement offers an accessible entry point for many beginners. Students read theory and research including scholarly literature on qualities of mindfulness, mindfulness-based stress reduction, mindfulness-based cognitive therapy, mindfulness and human occupation, and mindfulness in clinical practice. Additionally, students engaged in group reflection and dialogue in each session, and written reflections throughout the course. The students researched how to guide a mindfulness practice of their choosing (i.e., meditation, body scan, mindful movement, other), and led the class in a 10-minute guided facilitation on the last day of class.

The first author (EAK) designed and facilitated the course. As someone who has experienced the benefits of ‘mindfulness practices’ in personal and professional life, EAK was interested in what learning about ‘mindfulness practices’ might offer to health professions students, and what their experience would be. This interest fueled the development of the mindfulness elective course. The richness of students’ written reflections provided the impetus for the study. The first author (EAK) is an experienced mindfulness practitioner who has undertaken advanced training in MBSR. She has also practiced and studied across a range of mindfulness traditions including Sivananda Vedanta and Yoga; Vipassana Meditation (Theravada Buddhism); Tibetan Buddhism; and Zen Buddhism; for over 25 years. The instructor’s facilitation was guided by the MBSR approach and informed by knowledge derived from experiences across traditions. The second author (KSS) has had a personal mindfulness practice for more than 12 years and has formal training in mindfulness for children and youth. She has taught mindfulness courses for adult learners in university and clinical contexts and was a guest facilitator in the course. The third author (AC) has trained internationally in mindfulness and has developed and taught mindfulness education programs to health professions students and clinicians.

Theoretical framework

This research is informed by practice theories. Practice theories, or epistemologies of practice, recognize reflection in and on practice as sites for the cultivation of embodied practical knowledge (Green, 2009; Kemmis, 2005, 2009; Kemmis et al., 2014; Kinsella, 2007, 2009, 2010, 2015; Kinsella & Pitman, 2012; Kinsella & Whiteford, 2009; Polkinghorne, 2004; Schatzki, 1996, 2001, 2012; Schön, 1983,1987; van Manen, 2014). Practices are viewed as “arrays of human activity” (Schatzki, 2001, p.2), and are recognized as taking place within situated intersubjective spaces (Lave & Wenger, 1991; Wenger, 1998) that include a variety of material, spatial, and temporal arrangements (Kemmis et al., 2014; Schatzki, 2010, 2012). This research attends to practices as sites for the cultivation of knowledge and adopts practice theories as a lens through which to attend to reflective accounts of ‘mindfulness practices’. Practice theory was integrated into the study in a number of ways. First, the course was designed to move beyond studying ‘theories’ and ‘research’ to incorporate experiential ‘mindfulness practices’ as a primary focus in the classroom activities. Second, students were encouraged to continue to engage in ‘mindfulness practices’ outside of the classroom. Third, students were invited to engage in ongoing reflection in and on their experiences of the ‘mindfulness practices’ throughout the course. Finally, written reflections on experiences of the ‘mindfulness practices’ (described in the methods section below) served as data for the study.

Hermeneutic phenomenology

This research adopts hermeneutic phenomenology as its methodology (Gadamer, 1975, 1996; Heidegger, 1927/2008). This approach was chosen as it responds to a gap in research that examines first-hand ‘lifeworld’ perspectives of health professions students’ experiences of mindfulness. Hermeneutic phenomenology has been increasingly recognized as a generative methodology for health and health professions education research (Benner, 1994; Bynum & Varpio, 2018; Carel, 2011; de Witt & Ploeg, 2006; Dowling, 2007; Kelly et al., 2020; Laverty, 2003, Merleau-Ponty, 1945/2006; Neubauer et al., 2019; Park Lala & Kinsella, 2011; van Manen, 1997, 2014; Wilding & Whiteford, 2005; Wright-St.Clair, 2015; Wright-St. Clair & Kinsella, 2021). It examines phenomena “in the living world where people find themselves” (Smythe et al., 2008, p. 1392), and aims to elicit richly textured, first-hand accounts, as a means to contribute to nuanced understandings of phenomena. In his work on ‘phenomenologies of practice’, van Manen (2014) points to the richness of phenomenological approaches for inquiring into the practices of professional practitioners, noting the affordances of phenomenology for engaging deep reflection in and on practices. Given that the phenomena of interest in this study were students’ experiences of learning about and practicing mindfulness, hermeneutic phenomenology was thought to align well with the research aims.

Methods

Students in the mindfulness course maintained a reflective journal, in which they were invited to write about past experiences with mindfulness, responses to ‘mindfulness practices’ during the course, key insights arising through dialogue in the class, and their engagement with the course materials. Students were asked to engage in daily ‘mindfulness practices’ outside of class time, ideally for 20 minutes in the morning and evening. However if this was not possible they were invited to practice for whatever time they could manage. The principle of non-judgement was emphasized, drawing on the metaphor that if you ‘fall off the meditation cushion’ it is ‘no big deal’!; simply get back on and begin again.

At the end of the course, students submitted an 8-page reflective paper drawing on their journal reflections. For this paper, students were asked to reflect on their experiences and perspectives about mindfulness and its place in various domains such as everyday life, professional practice, human occupation, and with clients/patients.

This study received approval from the University Research Ethics Board prior to participant recruitment. After students completed their coursework, and final grades were submitted to the registrar’s office, a research assistant contacted students by email to request consent to include their papers in the study. This occurred immediately following course completion for years 2, 3, and 4, and one year later for the first group. Written consent was obtained from 31 students across the four years. 30 students were recruited across years two (12 out of 14), three (9 out of 12) and four (9 out of 10). Only one out of 10 students from the initial cohort participated, due to difficulty contacting this group retrospectively. The research assistant anonymized the papers of consenting participants and assigned each participant a pseudonym to ensure confidentiality.

Data analysis

The reflective papers were analyzed using hermeneutic interpretation (Gadamer, 1975, 1996; Kinsella, 2006), and informed by van Manen’s (1997, 2016) analytic framework. Data analysis utilized a four-step process, including: (1) reading for a sense of the whole; (2) descriptive analysis to identify meaningful words and phrases; (3) selective analysis to identify thematic patterns within and across participants through mind-mapping approaches (Buzan & Buzan, 2003, Davies, 2011; Northcott, 1996); and (4) holistic analysis to identify overall patterns emerging across the data. Throughout the analysis the researchers focused on students’ descriptions of their lived experiences of learning about and practicing mindfulness, while remaining attuned to the phenomenological existentials (Merleau-Ponty, 1945/2006; Heidegger, 1927/2008; van Manen, 2014) of lived time (temporality), lived body (corporeality), lived space (spaciality), and lived relations (relationality) in the data. Each member of the research team conducted an independent analysis of the transcripts, with the research team meeting regularly to identify themes. Once the four core themes were identified, the data was revisited and extractions from the data were clustered thematically and reviewed. This extracted data served as a basis for writing up the thematic representations of the data.

Findings

Four predominant themes were identified in the analysis: reframing perspectives, being while doing, witnessing the struggle, and compassion for self and others. While other insights of importance were also present in the data, these themes were the most robust across the transcripts. Although the themes are presented separately here, many of them are interwoven, with some exemplars of data that cross themes.

Reframing perspectives

A major theme was reframing one’s thinking or perspectives in ways that were less stress inducing. Students regularly noted changes in perspectives about everyday life through the process of engaging in ‘mindfulness practices’. For instance, Chris described reframing worry and anxiety through the practice of dwelling in the present moment as follows:

I had recognized in myself… a super-charged tendency to worry about the future, to dwell in hypotheticals, and to over-scrutinize my own performance…I recognized…the stifling anxiety that it produced but couldn’t seem to do anything about it. I tried to tell myself to ‘just relax’, but this felt impossible. Mindfulness offered a new suggestion: a method not for stopping worry, but for cultivating its opposite - the direct practice of dwelling non-judgmentally in the present moment…I seemed calmer, clearer, and better able to react to challenging situations.

Pauline expressed astonishment at “what a difference” the ‘mindfulness practices’ made especially in her sense of “resilience and ability to cope”. Similarly, Camille described how reframing her perspectives allowed her to begin “to feel more well-equipped to combat… ‘typical’ and chronic stresses”. And Adeline wrote about changing perspectives toward anxious thoughts: “as I began meditating more, I was able to come to a place of acceptance, let go of my anxiety, come out of my head and be in the present moment.” For Layla, transformations in her perspective on school demands were notable:

Mindfulness has brought a sense of levity and calmness to my life. Over the course of the semester, rather than becoming more anxious about the increased load of the semester, I have become more calm. In the face of long to-do-lists, I have felt that I have the resources I need (both within and outside of myself) in order to manage the stresses.

Two participants described how ‘mindfulness practices’ fostered new perspectives on grief following the loss of a loved one. Hannah noted that mindfulness “has been a catalyst to remember that my well-being is on the other side of grief-work, not through avoiding it”. Layla wrote about the idea of “coming to terms with things as they are” as prompting a shift in her “understanding of grief.”

Some students described reframed perspectives related to becoming more appreciative of taken-for-granted aspects of life. Emily wrote;

I, like most people, frequently fail to acknowledge the beauty and potential of goodness in ordinary items and activities. By learning about and practicing mindfulness, I’ve gained a greater appreciation for life and see that I am truly privileged to be able to participate in a variety of activities.

Jody reflected about how she never consciously paused to “think about the good things in life…what I am grateful for, or what brings joy.” She noted “it was astonishing…how something so small could impact and enhance my positive emotions throughout the remainder of the day. It is so powerful.” Zoe described a similar positive change of perception: “I find myself experiencing gratitude for my life experiences and every emotion or feeling that I have.”

Being while doing

For many participants, the value of mindfulness while doing was a key insight. Several participants noted that mindfulness offered a counterbalance to societal pressures to achieve, whereby mindfulness appeared to offer openness to “being” in the midst of doing. Kathryn notes of her mindfulness practice: “while I clearly was ‘doing’ something, this doing was intrinsically different from other occupationsFootnote 1 I engage in. Mindfulness, for me, has been more about ‘being’; being present, being open, and being aware, as well as the sheer joy of just being.”

Emily described bringing mindfulness to art:

It did not take long for me to get in the zone. I was fully absorbed in the activity despite being in a loud and busy environment. It was almost like I was a sponge, my senses absorbed every aspect of the activity. As I colored I sipped my coffee. My taste buds were delighted by the rich flavor and added to the experience. The variety of colors was a treat to the eyes. I enjoyed seeing the lines on the page twist and turn to make something beautiful. I even admired my “errors” and how occasionally I would color outside the lines and how quickly the paper absorbed the ink and bled into another color to make an entirely new color, something beautiful.

Sarah described how mindfulness allowed her to see her daily occupations afresh:

Encompassing mindfulness into my daily occupations enabled me to experience these mundane occupations through a new lens. I focused on how my food tasted, the shape, the smell and the colour, the sensations of the water falling onto my body when showering, and how my body felt when walking including my breath, the feeling of the natural elements such as, the wind on my face and the emotional experiences.

Anaya wrote about how mindful attention while doing enhanced her experience of everyday activities. She wrote, “the walking meditation was very powerful for me. I felt every part of my body interacting with each other and the ground beneath my feet. It made me realize how walking can become a more mindful occupation with a shift of your attention to the occupation itself.” Constance echoed this idea, noting that mindful attention in her daily walks facilitated a deeper appreciation:

I was able to enjoy these already meaningful occupations in a different kind of way; by noticing more beauty and detail in my natural surroundings, feeling the wind and sun on my face, and sensing my feet as they made contact with the ground.

Kathryn described how uniting occupations and mindfulness offered new levels of awareness:

For me, uniting my occupations and mindfulness practice meant that I was open to and aware of sensations I hadn’t previously experienced. It also encouraged me to be mindful during occupations when I allow my mind to linger in the past and future. The moments have brought new meanings to and knowledge of mundane occupations as well as clarity during periods that usually pass in the blink of an eye.

Witnessing the struggle

Another major theme highlighted the struggle to learn and practice mindfulness. For some, this struggle related to the time involved. Andrew wrote, “I have had a hard time justifying mindfulness breaks with a busy school schedule.” For Whitney, the fullness of student life made it difficult to maintaining concentration during the practice: “On busy mornings in my own meditation I found it very difficult to observe my thoughts and often found myself planning my day.”

For other participants, the struggle related to a sense of self-judgement or a desire to practice mindfulness ‘correctly.’ Camille, wrote, of an inner resistance that emerged due to “an internal tension of wanting to do mindfulness ‘right’”. She noted how she “struggled with… incorporating” ‘mindfulness practices’ into everyday life, and “grappled with a tendency see mindfulness as an ‘all or nothing’ commitment.”

Jody echoed similar concerns, writing of finding the practices challenging and wondering, “Why can’t I be good at this?” Kathryn, described the battle to stop her ‘thoughts’, and high expectations of herself, as her greatest challenge: “My racing thoughts seemed uncontrollable, so each time I meditated I felt an internal battle to stop my thoughts and achieve an unachievable standard.” Some participants identified specific practices as more challenging than others. Emily wrote that when she was told to close her eyes, she struggled with “twitching, blinking and consequently being distracted and frustrated. Andrew described struggles with yoga: “I found yoga to be difficult…physical pain and fatigue made it difficult to focus on my breathing during yoga.” Jody indicated a similar challenge with breathing exercises, stating, “I found it awkward and challenging”, writing that she “recognized it created more stress rather than calming and relaxing me.”

Participants also wrote of self-judgement and internal dialogue as a challenge. Jody noted of yoga practice:

I found it challenging to remember to try to continue to breathe when focusing on a physical pose. Rather than just naturally trying the pose I found myself looking around the room comparing myself to others. Why can’t I be more flexible? Why can’t I look like them?

Kathryn echoed these concerns, writing: “At yoga, I consistently compared my practice, my body, and my ability to other people…Even though the instructors would encourage the class… to embrace whatever our practices were when we came to the mat, I couldn’t quiet the voice in my head that demeaned my efforts.”

For some participants, these struggles were mitigated, in part, by the presence of a supportive community. For Sophia, meditation was observed to be easier when done in community. She wrote, “I found it easier when meditating in community with other people.” Anaya noted, “The mindfulness class also created an environment that was supportive, and each person felt like their struggles were being given a little more attention.” Kathryn echoed this sentiment, writing, “One of my favourite parts of the course (and most helpful) was the safe, supportive community within our class. I have found it helpful to discuss these struggles in and outside of class.”

Compassion for self and others

Despite the challenges in developing a mindfulness practice noted by participants, many reported a new-found sense of compassion for self and others. Emily noted a sense of enhanced self-compassion, “It was as if I was being accepted for who I am and allowed to participate with a new sense of comfort.” Hannah wrote of her mindfulness practice as, “a remedy to harshness and anger, and a tangible pathway to self-love and resilience. Jody, described a transformation from self-criticism to acceptance, writing:

At first I was frustrated because I was not good at it, but I have now come to learn and accept myself. It is okay. I do not have to be perfect…Everyone is different and I accept and will not judge myself.

Many students also wrote about how mindfulness helped to enhance a sense of compassion toward others. Constance discussed her belief that cultivating self-compassion would translate to compassion for others:

I have started the process of cultivating self-compassion by practicing being kinder, as well as more gentle, and loving with myself, even the messy and imperfect parts. With continued practice, this undoubtedly will continue to grow and transfer to my capacity to feel compassion and empathy for others.

Andrew noted that his experiences with mindfulness would enhance his empathy for clients: “experiencing anxiety and mindfulness first-hand has been very beneficial, as it gives me more insight into how my clients may be experiencing anxiety.” Pauline envisioned mindfulness as fueling empathy: “I think my own mindfulness practice will be an extremely valuable resource to help me develop emotional intelligence and empathy.”

Discussion

The findings from our study suggest that there may be generative outcomes and affordances for health professions students who learn about and practice mindfulness. As the benefits of ‘mindfulness practices’ have become more widely recognized, scholars and advocates have called for mindfulness education as a fruitful approach to the mitigation of practitioner distress and burnout (Shanafelt et al., 2017;), while highlighting that change at the systemic level is also essential (Caring-Lobel, 2016; Forbes, 2016).

Many students in our study described how engaging in ‘mindfulness practices’ enabled them to better manage and reframe persistent negative or anxiety producing thoughts (referred to in some mindfulness traditions as suffering) and their consequent perceptions of being “calmer” and “more centered.” The capacity to work with and reframe negative and anxiety producing thoughts (suffering) may be productive in supporting health professions students to be resilient in navigating challenging academic demands and health care contexts.

In the mindfulness tradition, ‘suffering’ is viewed as the result of the tendency of the human mind to focus on elements of experience that are uncomfortable or problematic (Teasdale & Chaskalson, 2011). From this perspective, negative thoughts are viewed as largely unconscious, habitual, and self-perpetuating (Teasdale & Chaskalson, 2011). Drawing on different approaches and traditions, some ‘mindfulness practices’ aim to disrupt these patterns of thought by retraining the focus of attention (Teasdale & Chaskalson, 2011). Some practices encourage a focus on bodily experiences, using the breath or other sensations as anchors for attention. Other approaches encourage practitioners to direct non-judgmental attention to the thoughts themselves; simply watching as thoughts arise and dissipate across the screen of the mind. By resisting the urge to push negative thoughts away or ruminate on them, and instead regarding them with a sense of curiosity and compassion, thoughts may become less burdensome.

‘Mindfulness practices’ are said to help foster ‘awareness’, described by Williams and Kabat-Zinn (2013), as the elements of clear comprehension and discernment. Williams and Kabat-Zinn contend that through mindfulness it is possible to systematically explore and refine our relationship with awareness itself. Students’ written reflections were consistent with this claim, and the idea that mindfulness can help to see the ways that thoughts are often misaligned with reality which in turn, enables the transformation or reframing of perspectives, and reduces the destructive power of negative thinking (Teasdale & Chaskalson, 2011).

Students frequently wrote about difficult emotions and grief. For some, ‘mindfulness practices’ appeared to foster an awareness of the benefits of witnessing and working with grief and other difficult emotions rather than avoiding them. This aligns with Epstein’s (1999) contention that the ability to integrate one’s emotions and thoughts in a way that promotes good patient care is a core characteristic of the ‘mindful practitioner’.

Some participants recounted how practicing mindfulness helped them to reframe their thoughts to cultivate more gratitude in everyday experiences or allow for greater appreciation of the present moment. These findings are interesting given other studies of mindfulness education in health professions students that point to the potential of gratitude and appreciation to support student resiliency (Dobkin & Hutchinson, 2013; Noble et al., 2019). In the psychology literature, gratitude has been reported to provide protection against burnout and contribute to overall job satisfaction (Guan & Jepsen, 2020; Lanham et al., 2012). Additionally, positive emotions are reported to give rise to more positive thoughts (Fredrickson, 2004; Guan & Jepsen, 2020; Lanham et al., 2012) and may help to neutralilze the residue of negative emotions (Fredrickson, 2004). Theories of positive emotion suggests that gratitude helps to develop personal resources which can be drawn upon when one feels stressed, and which encourages ‘outside-the-box’ thinking, enabling a broader view of available options (Fredrickson, 2004; Lanham et al., 2012). This suggests that mindfulness education that focuses on the cultivation of gratitude and appreciation, may be generative in building resiliency in future students.

Some of the findings from our study align with Epstein’s (1999) assertion that mindfulness education may encourage critical self-reflection that in turn can foster the development of practitioners. As an example, one student described an intention to cultivate ‘beginner’s mind’, bringing critical self-reflection and curiosity to routine activities. In the clinical context, Epstein (1999) suggests that this type of inquiry may cultivate mindful practitioners who are attentive, curious, non-judgmental, and compassionate.

Another important theme was “Being while doing,” whereby participants identified the value of mindfulness as a way of ‘being’ amidst the ‘doing’ of their daily activities or ‘occupations’. Of interest, in the occupational science literature with which these students are familiar, occupations are broadly defined as “all that people need, want, or are obliged to do” (Wilcock, 2006, p.9).

Students described how they engaged in mindfulness through engagement in a range of everyday activities such as brushing their teeth, showering, sipping tea, walking a dog, riding a bike, walking in nature, crocheting, and other activities. This is a particularly interesting theme as often mindfulness conjures an image of trying to find time away from everyday life to make time for ‘mindfulness practices’. This theme however suggests something quite different - the idea that mindfulness can be engaged within active life, while carrying out everyday occupations, while ‘doing’. This potential to engage in mindfulness while doing may have greater appeal to busy health professions students as a more realistic entry point into mindfulness.

The promise of mindfulness and occupation is an emerging area of attention in the field of occupational science. A review by Goodman et al. (2019) highlighted that mindfulness may be realized through focused attention during occupational engagement, and that mindfulness may also shape the quality of occupational engagement. Elliot (2011) has argued that “mindful engagement in occupation” can provide “a means to enrich the quality and fullness of this life” (p. 369). And Reid (2008) highlights how “tuning into ‘doing’ moments” through mindfulness has the potential to enhance well-being and quality of life.

Participants discussed the ways mindfulness supported them in being more present in their daily occupations. This aligns with what Reid (2008) describes as “occupational presence” - the process of “being aware of the self” while “engaged in occupation” (p. 43). Reid (2011) contends that engagement in occupation offers opportunities to develop presence and suggests that occupational presence may support well-being. Expanding on Reid’s work, Elliot (2011), brings the concepts of presence and occupation together, suggesting “presence is occupation, the active participation in one’s life” (p. 372). This raises interesting considerations for how mindfulness may be taught in higher education contexts, and for considerations regarding how mindful engagement in occupations may be a productive way for health professions students to integrate mindfulness into daily life.

A number of participants highlighted the ways in which mindfulness brought new insight and perspectives to their daily occupations. Reid (2008) argued that mindful engagement in occupation held potential for change or transformation and that this was a powerful tool for reflection and self-awareness. Elliot (2011) elaborated on this idea suggesting that “becoming more mindful during occupational engagement” could “allow and facilitate greater awareness of deeper layers of meaning inherent in those occupations” (p. 371). Elliot argues that mindfulness offers opportunities to deepen understanding of “the process of doing occupation and being in daily life” (Elliot, 2011, p. 373). This raises questions about how mindfulness may potentially offer space for health professions students to reflect more deeply on the various daily activities and occupations they engage in, as well as the deeper layers of meaning within.

In addition, the incorporation of mindfulness into daily activity may reduce the time burdens associated with traditional ‘mindfulness practices’ (Goodman et al., 2019; Reid, 2008). This may be an important consideration given time pressures many health professionals and students encounter. Furthermore, it has been suggested that embedding mindfulness into daily occupations may enhance the accessibility and frequency of mindfulness practice (Goodman et al., 2019; White, 2020). The findings suggest that everyday occupation may be a fruitful place to develop and sustain the practice of mindfulness.

Another salient finding highlighted the challenges students encountered in developing their ‘mindfulness practices’. A major difficulty identified by participants was the self-judgement or criticism that arose when participants struggled with the practices or didn’t perform to their own expectations. This echoes findings from previous research into mindfulness with health care providers (Langdon et al., 2011; Irving et al., 2014). Taking students’ struggles into account has potential implications for the design of mindfulness education. It may for instance, be important to ‘normalize’ challenging experiences in the mindfulness classroom, so that expectations are more realistic. Students may find support in instructors who acknowledge the struggle, and share their own challenging experiences or report on other students’ documented experiences of challenge. It may also be important to prioritize approaches to mindfulness that explicitly focus on self-compassion as a means to mitigate or counterbalance the excessive self-criticism that may arise.

The role of community in supporting novice mindfulness practitioners to manage their self-criticism is another important factor to consider. Irving et al. (2014) reported that health care providers participating in a Mindfulness Based Cognitive Therapy (MBCT) program highlighted that a group format offered a forum for sharing insights into “ways to navigate challenges inherent to practice” (p. 5). Consistent with these findings, some participants in our study indicated that the group nature of the course offered a place to discuss their struggles and receive support, particularly around the challenges they were experiencing with ‘mindfulness practices’. Attention to the creation of ‘safe’ spaces for the cultivation of trust and supportive relationships may be an important consideration in educational design.

The time commitment required to participate in ‘mindfulness practices’ was identified as a challenge. This is consistent with literature which identifies time as a barrier to developing a practice across a range of populations (Demarzo et al., 2015; Hartley, Due & Dorstyn, 2022; Irving et al., 2014, Langdon et al., 2011). Creating opportunities for protected time within the educational curriculum may be one approach to mediating this issue. Overtly recognizing time as a constraint and inviting students to share ways in which they have negotiated the challenge of finding time may also be useful. Within the course some students shared experiences of the ways in which the ‘quality’ or their use of time, changed through engagement in ‘mindfulness practices’. The study of mindfulness and health care practitioners’ perception of and use of time, and the study of students or practitioners who adopt a daily practice and their insights about time, would be interesting future work.

Further, as discussed above mindful engagement in occupations, may reduce time demands by allowing for the integration of mindfulness into daily routines. For example, mindfulness can be integrated into daily activities like washing dishes, or walking to work, or listening to music, sipping a cup of tea, eating one’s meals, and more. Thinking about how mindfulness can be integrated into everyday activities is particularly salient given research that indicates that novice mindfulness practitioners often struggle to balance their contemplative practices with their desire to “do.” (Irving et al., 2014, Langdon et al., 2011).

Another finding of our study related to students’ descriptions of compassion toward self and others. A leading mindfulness scholar, Kristen Neff defines self-compassion as “being touched by and open to one’s own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one’s suffering and to heal oneself with kindness” (p. 87, 2003). Neff highlights three elements: extending kindness to oneself during periods of hardship or suffering; viewing one’s own imperfections as part of the common human experience; and cultivating awareness of one’s own emotions (Neff, 2003; Neff et al., 2007). This aligns with descriptions by participants in our study who variously described processes of self-compassion and compassion for others as arising from the mindfulness practice. Participants wrote of compassion as “a remedy to harshness and anger, and a tangible pathway to self-love and resilience”, and as “the process of cultivating self-compassion by practicing being kinder, as well as more gentle, and loving with myself, even the messy and imperfect parts.” Another suggested this will “undoubtedly…continue to grow and transfer to my capacity to feel compassion and empathy for others.”

In two studies of undergraduate students, Neff and colleagues (2005,2007) found that self-compassion was negatively associated with anxiety and fear of failure: “By not harshly judging the self or blowing one’s failures out of proportion, self-compassion is associated with greater self-confidence in one’s ability to learn and less trepidation concerning possible failure” (2005, p.275). They found that students who practice self-compassion are more likely to see experiences of failure as opportunities for growth and to set more adaptive ‘mastery goals’ (Neff, Hsieh, & Dejitterat, 2007). Other studies have demonstrated a connection between self-compassion and improved well-being among students (Neely et al., 2009), including a negative association with anxiety, depression, and self-criticism and a positive association with life satisfaction, social connectedness, and emotional intelligence (Neff et al., 2007). Some of our participants pointed to this when they reported that practicing mindfulness improved their ability to accept themselves and their imperfections.

The cultivation of compassion may also have value for working with others in health care settings. A recent study found that compassion cultivated through ‘mindfulness practices’ reduced rates of perceived burnout in student nurses (Cheli et al., 2020), suggesting the potential of ‘mindfulness practices’ for both developing compassion and reducing burnout. While our findings primarily revealed perceived changes to self-compassion, Gustin and Wagner (2013) suggest that self-compassion is the starting point for delivering compassionate care, leading the caregiver to adopt a relationship characterized by giving and receiving. Although empathic health professionals may feel their patients’ suffering as their own (Neff et al., 2020), practicing self-compassion may enable practitioners to open themselves to their emotions and to those of their patients, and to regard them without judgment (Gustin & Wagner, 2013). Gustin and Wagner (2013) argue that with self-acceptance and compassion, practitioners are better positioned to recognize mutual vulnerability and honour others’ perspectives. Further, Neff and colleagues (2020) suggest that the resultant interconnectedness may also contribute to a sense of fulfillment for practitioners. Thus, the self-compassion that arises through mindfulness may enable practitioners to be more present to another’s suffering (Neff et al., 2020), and to go the extra mile without compromising their own well-being (Gustin & Wagner, 2013).

In short, the findings of this study into health professions’ students lived experiences of learning about and practicing mindfulness in a higher education setting raise interesting conversations about the potential promise of mindfulness in the education of future health professions students. The findings suggest that such education may support students to develop ‘mindfulness practices’ that may offer affordances in: (a) reframing negative thoughts and working with difficult emotions in more productive ways; (b) identifying the value of mindfulness as a way of ‘being’ amidst the ‘doing’ of their daily activities or ‘occupations; (c) recognizing and potentially normalizing the challenges inherent in such practices; and (d) supporting the cultivation of self-compassion and compassion for others. While not a panacea, these types of experiences may be supportive of students’ capacities to become more resilient and to cultivate a sense of well-being in the midst of complex challenges.

Interestingly, a growing body of literature highlights the potential of mindfulness to contribute to systemic change by supporting the cultivation of deep reflection and ethical deliberation, compassionate relationships, acknowledgement of human suffering, mindful communities, and mindsets that align with work for social justice (Berila, 2016; Lemon & McDonough, 2018; Palmer & Zajonc, 2010; Purser & Milillo, 2015; Stanley et al., 2018). While an investigation of this dimension is beyond the scope of the current study, these insights open reflection about how the transformations that occur through ‘mindfulness practices’, may inform the perspectives of future health care practitioners’ and their participation in shaping the systems of the future.

Strengths and limitations

There are four primary strengths of this study. The first is the use of practice theories as a theoretical framework for the study. The course focused not only on cognitive learning, but on the regular ‘practice’ of mindfulness. Students were encouraged to engage in ‘mindfulness practices’ and prompted to write and reflect on these ‘practices’ in their journals, which shaped the quality of the data available for analysis. A second strength is the hermeneutic phenomenological methodology and the methods of written reflection which provided a means to inquire deeply into students’ experiences and inner thoughts about the phenomena of learning about and practicing mindfulness. Third, the students’ reflective journals were completed in real time across participants’ tenure in the course; the students then used these journals to write their final reflective papers, which served as the data sources for this study. This contributed to our capacity to elicit thick descriptions and in-depth first-person accounts of students’ experience. Fourth, regular team meetings, reflexive dialogue about the findings, and iterative processes of analysis, enhanced the depth of the research teams’ engagement with the work and consequently the representation of the findings.

Limitations include that the data was generated within a course, and students may write in a constrained or less authentic way when they know that an instructor will be reading and grading their writing. Despite this risk, the accounts shared by students were largely resonant with the ‘phenomenological nod,’ conceptualized by Buytendijk and popularized by van Manen (1997, 2014). The phenomenological nod refers to the ability of a reader to ‘nod’ to a phenomenological work as revealing “an experience they have had or could have had” (van Manen, 1997, p. 27). Another limitation was the self-selected nature of participation in the elective course; the course may have attracted students with a predisposition to be open to the practice of mindfulness or to view it in a favourable manner. Further, while the majority of the students across the last 3 years opted to participate, a few students chose not to participate. Additionally, there were challenges retrospectively locating many students from the first year. As a result, it is possible that other experiences of learning and practicing mindfulness are not represented in the findings. While it is not the aim of a phenomenological study to be representative, diversity in viewpoints and experiences are important to generating nuanced understandings of phenomena.

Conclusion

The aim of this hermeneutic phenomenological study was to examine health professions students’ experiences of learning and practicing mindfulness as part of their professional education. While this study is focused on one group of health professions students– occupational therapists - the findings encourage consideration of the potential of mindfulness education for students in health professions more broadly and highlight the need for further research in this field. In a time where health professionals are increasingly under strain, and systemic reform to improve the conditions of professional education and practice are clearly needed, the findings of this study reveal potential affordances of mindfulness for helping students to navigate the tsunami of challenges they face. The findings are unique in their in-depth exploration of health professions students written reflections on the experience of engaging in ‘mindfulness practices’ in a higher education context. The findings show how students wrote about reframing perspectives in new ways that were less stress inducing; experienced mindfulness while ‘doing’ everyday activities pointing to ways it could be integrated in busy student life; witnessed the struggle of developing ‘mindfulness practices’ suggesting the need for educators to ‘normalize’ this struggle in mindfulness education; and noted a growing sense of compassion for themselves and others which is a desired outcome toward building practitioner resilience and supporting patient centred care in the health professions. Some considerations for the design of mindfulness courses for health professions students were also highlighted, including the importance of recognizing the challenges students may encounter while developing a mindfulness practice. The findings of this study contribute first-hand lived experience perspectives to the evolving field of mindfulness research and generate new conversations about mindfulness education in the health professions curriculum.