Respondents' views are presented using the six core challenges in quality improvement (structural, political, cultural, educational, emotional and physical/technological) as a framework (Bate et al. 2008).
The Structural Challenge
Structuring Quality Improvement Efforts and Embedding Them Within the Organisational Fabric
Several workshop participants reported working to implement MBCT with little strategic support, with the provision of MBCT sometimes relying on a single clinician. Half of respondents reported that there was no managerial support to prepare or deliver classes within clinical time. Only 35 % reported that delivering MBCT classes was explicitly within their role. Many described how the UK Good Practice Guidelines for Mindfulness-based Teachers have been supportive in framing local governance criteria for running MBCT classes and facilitating communication to service managers (UK Network 2011).
The survey results indicated that MBCT services are currently developing equally in primary and secondary care. In some organisations, the focus on management of acute presentation rather than prevention presented a barrier to implementation. In other organisations, the NICE (2009) recommendations had given MBCT a natural place in service developments.
The Political Challenge
Negotiating the Politics of Change and Securing Agreement on Common Goals
In the UK, MBCT implementation is taking place within the current context of politically initiated restructuring and strong budgetary constraints. Workshop participants shared experiences of how challenging it was to develop high quality MBCT services alongside strong organisational agendas that pressured a focus on output, performance and outcomes, emphasising “quick wins”. In the words of one workshop participant: “It is difficult to hold ground with something that is steady, measured, and with the longer term in mind when surrounded by a quick culture.”
On the other hand, outcome evaluation has become routine, and 79 % of survey respondents indicated that emerging MBCT services collect outcome data. This was cited as an implementation facilitator because it enabled services to demonstrate MBCT's acceptability and efficacy in line with the emphasis on outcome-based commissioning.
The Cultural Challenge
Building Shared Understanding and Commitment to Quality Improvement
The upsurge in interest in mindfulness presents both a challenge and facilitator to the implementation process. On the plus side, service managers tend to be increasingly aware of mindfulness having potential for their organisation. However, respondents described that they frequently felt a lack of understanding from the organisation about what is involved in delivering MBCT classes and a tendency to perceive mindfulness as a panacea.
Workshop participants underlined that MBCT requires a strong personal commitment both to a mindfulness meditation practice and an in-depth training and development process. Some of the workshop participants' colleagues who are not involved in delivering MBCT find mindfulness-based interventions difficult to understand, and participants reported that this tended to result in their colleagues seeing MBCT as a lower priority for development. These tensions can create a cultural barrier to MBCT implementation. One workshop participant summarised her organisation's attitude as “it [mindfulness] is all very well but a bit of a luxury in these hard times.”
Conversely, mindfulness training appeals to health care staff because it can support them in “living well” both at home and at work. Several respondents reported that mindfulness training is offered as part of their organisation's strategy for staff wellbeing. This has positive effects on a number of levels, including developing a culture and “critical mass” of mindfulness within the organisation, which supports the development of clinical services. Mindfulness training for staff was seen as enabling them to “be a steady rock amidst so much change and challenge”.
Workshop participants spoke of the importance of challenging the prevailing culture that puts priority on addressing the “problem” of the acute presentation of anxiety and depression but does not invest in the development of long-term resilience.
The Educational Challenge
Developing Formal and Informal Learning
The survey indicated a chasm between published standards for MBCT training (Crane et al. 2010) and the reality of what training had been undertaken by practitioners offering MBCT: as many as 36 % reported delivering MBCT without any formal training, and a modal response was that teachers had participated in mindfulness teacher training retreats but had not undertaken a formal postgraduate training in MBCT (54 %). A significant number (17 %) indicated that their organisation saw professional training in a core profession as sufficient to teach MBCT, even though these trainings do not include MBCT within their curricula. The disparity between the widely recognised training standards and reality is probably because the financial support for training clinicians to deliver MBCT is low, with 67 % reporting no support and 66 % reporting no ongoing support to maintain good practice through attending continuing education or supervision.
When asked which professionals teach MBCT within their organisation, psychologists were the largest group (83 %), with occupational therapists (58 %), social workers (44 %) and psychiatric nurses (55 %) also delivering classes. Other professionals included CBT therapist, dietician, family therapist, psychiatrist and physiotherapist.
A theme in the workshop was the mismatch between the duration of time that it takes to cultivate MBCT teaching skills and the cultural tendency within the NHS to “get people trained quickly, get them delivering and then get them training and supervising others”. There was a strong theme in both the survey and workshop that mindfulness practice and teaching needs to be seen as a long-term investment.
Another aspect of the educational challenge is the level of knowledge that referrers have of MBCT; 60 % reported that referrers do not have a clear understanding of the intentions of MBCT and half reported that it is difficult to get sufficient and appropriate referrals.
The Emotional Challenge
Inspiring and Motivating Staff to Join and Sustain the Improvement Effort
A consistent theme from respondents and workshop participants was the importance of having a “champion” within their organisation who steers the process of change. Ideally, the champion(s) has training in MBCT and has strategic influence within the organisation.
The Physical and Technological Challenge
Developing a Physical and Technological Infrastructure that Enables Service Improvement
As a group-based intervention that involves teaching a range of mindfulness practices, there are a number of physical and technical requirements to be able to run MBCT classes well; 62 % of respondents reported that there is no fit for purpose room within their organisation in which to deliver classes, and 72 % reported a lack of administrative support for setting up and running MBCT classes. Workshop participants reported that clinicians in their organisation did all the photocopying, room booking and appointment scheduling for setting up MBCT classes.