Mindfulness in the OR: A Pilot Study

Investigating the Efficacy of an

Abbreviated Mindfulness
Intervention on Improving
Performance in the Operating Room
Brian F Saway, MD,* Laurie W Seidel, MSN, RN,† Francis C Dane, PhD,‡ and Terri Wattsman, MD,
FACS†
*
Medical University of South Carolina, Department of Neurosurgery, Charleston, South Carolina; †Virginia
Tech Carilion School of Medicine and Fralin Biomedical Research Institute, Roanoke, Virgina; and ‡Radford
University, Radford, Virgina

BACKGROUND: Surgery requires operating room mindfulness skill employed prior to each postinterven-
physi- cians to succumb to unpredictable schedules, long tion surgery.
hours, and involved operations, which have led many to
RESULTS: The mindfulness intervention was
acquire maladaptive habits to attain focus in the OR.
associated with a significant increase in mindfulness (p
Research on mindfulness in the medical community has
= 0.006) and flow state (p = 0.009) and a significant
shown positive results on stress, burnout, and quality of
decrease in perceived stress (p = 0.033), particularly
life. However, due to the seemingly subjective nature of
during the com- plex routine cases (p = 0.024).
the benefits of mindfulness as well as the lengthy time
requirement by participants, researchers have had diffi- CONCLUSIONS: We have developed a brief mindfulness
culty conducting experiments with adequate sample intervention that is compatible with the busy workflow
sizes and controls in operating room specialties. of operating room physicians and can increase the mind-
ful state of participants as well as improve factors that
OBJECTIVE: We assessed the hypotheses that a brief
are associated with burnout and distractions. ( J Surg Ed
mindfulness intervention on physicians, residents, and
000:1 —7. © 2021 Association of Program Directors in
anesthesiologists can improve mindfulness, focus, and Surgery. Published by Elsevier Inc. All rights reserved.)
perceived stress in the operating room. Additionally, we
hypothesized that the improvement in scores are inde- KEY WORDS: mindfulness, surgery, wellness, burnout,
pendent of level of training and physician type. performance, operating room
METHODS: As part of a 3 (Physician Type) X 3 (Case) COMPETENCIES: Practice-Based Learning and Improve-
X 2(Timing) factorial design, 33 surgeons, anesthesiolo- ment, Interpersonal and Communication Skills, well-
gists, and surgical residents completed a pre- and postin- ness, Patient Care
tervention Mindfulness Awareness and Attention Scales
(MAAS) survey. Three categories of surgery cases, rou-
tine-elective, complex-elective, and add-on, were com-
pleted pre- and postintervention, along with measures
addressing focus and perceived stress. The intervention INTRODUCTION
included a 25-minute mindfulness training on the bene-
The acute and inherently complex nature of the operat-
fits of mindfulness and how to utilize a brief, 4-minute
ing room environment has been the subject of research
recently as the health care system seeks to find ways to
Funding: This research did not receive any specific grant from funding agencies optimize the workflow and efficiency of the operating
in the public, commercial, or not-for-profit sectors. room. While hospitals have historically focused on
Correspondence: Inquiries to Brian F Saway, MD, Medical University of South
Carolina, Department of Neurosurgery, 96 Jonathan Lucas St #306, Charleston, increasing patient outcomes by adjusting patient factors,
SC 29425; e-mail: saway@musc.edu only recently has medical research begin to explore and

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address provider factors such as focus, burnout, and the during performance, the concept of measuring and
interaction with the operating room environment. As increasing
the operating room has been found to be a source of
adverse events for patients, there has been a vested
inter- est in elucidating the cognitive, interpersonal, and
physi- cal factors that are causing these adverse events.1
What is currently understood is that adverse events
are often triggered by a combination of factors such as
demanding caseloads, pressure to perform complex
tasks, and conflicting priorities.2 As the workload
surpasses the resources available, the ensuing stress
experienced by the operating team makes them
increasingly susceptible to dis- tractions and more
prone to making errors. Distractions are a particular
area of concern as one study found that the prevalence
of distraction in the operating room was observed in
98% of cases, and the number of distractions was found
to positively correlate with length of case, stress level of
the operating team, and impaired teamwork.3 Alto-
gether, stress and distractions in the operating room
have been associated with decreased efficiency and
closely linked to poorer patient outcomes.2—4 While
these factors have been well defined, there appears to
be a paucity of lit- erature on how to effectively
decrease the amount of stress and number of
distractions in the operating room or how to alleviate
their effects on the operating team.
Mindfulness has been at the center of recent research as
a mechanism to decrease stress and burnout in the health-
care profession and has been associated with increased
focus in areas outside of medicine.5—7 Mindfulness is a
type of mental training that fosters moment to moment
awareness of one’s experience in a way that generates a
greater sense of emotional balance and well-being. This
ultimately allows for the development of helpful and crea-
tive ways of responding to difficult situations.8—11 Multiple
studies have demonstrated the benefits of mindfulness in
the health care fields. For example, one study with nurses
and psychologists using a 2.5 hour-per-week mindfulness
education session for 8 weeks and an additional 7-hour
retreat session found a significant decrease in reported
burnout amongst the participants.12 A more recent study,
which utilized an abbreviated mindfulness education
method to overcome the attrition rate seen in previous
research, found significantly decreased burnout symptoms
reported among primary care physicians.13
One other outcome of mindfulness training is
achieve- ment of flow,14 which has been linked to
improvement in performance among athletes, airline
pilots, and per- forming artists.6,7,15—18 Flow is a
cognitive state that is characterized by a present-
moment focus and complete absorption in the task at
hand and is associated with an increase in skill
performance.19 As the high intensity and stress
experienced in the operating room has been paral-
leled to that experienced by professional athletes

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flow in the operating room has been a growing interest
for those vested in surgical patient outcomes.5
While previous research has repeatedly backed the
effi- cacy of mindfulness in various health care
fields,11,12,20,21 there is still a large gap in knowledge on
whether it can significantly decrease burnout and stress
symptoms in the physician specialty with the highest
reported burnout rate, surgeons.22 Because stress and
burnout have been linked to poorer patient outcomes, it
is important that this gap is filled.23 It may be that some
of the same causes for stress and burnout, long
operations and shifts, also prevent adherence to involved
mindfulness practices and education sessions. A
mindfulness practice for surgeons, therefore, would
require modification in such a way as to be performed
efficiently and easily integrated into a com- plex
workflow. Therefore, we tested the hypothesis that a
modified mindfulness practice would increase the mind-
fulness state, increase focus, and decrease perceived
stress among physicians in the operating room.

MATERIAL AND METHODS

Recruitment
The study was powered at 80% (nQuery, Statistical
Solu- tions, Cork, Ireland) to include 60 participants, but
was closed early due to the COVID-19 pandemic. The
inclu- sion criteria included any physician working in the
oper- ating room, general surgery, surgical
subspecialties, and anesthesiologists. Residents were
included in the study, but PGY-1s were excluded as it
was believed they might not have enough experience in
surgery/OR environment to be able to answer the
surveys in a thoughtful way. Par- ticipants were offered
$40 compensation for completing the project. The study
was approved by the hospital IRB.

Project Outline
The project was divided into pre-training, training, and
post-training phases. At the start, participants completed a
demographics questionnaire and the Mindful Attention
and Awareness Scale (MAAS). During the pre-intervention
phase, participants completed electronic surveys (Flow and
perceived stress) before and after three cases: a sched-
uled-routine case, a scheduled-complex case, and an add-
on case. Case definitions were provided to participants
dur- ing the consenting process (Table 1). The training
phase included a face-to-face 25-minute mindfulness class
devel- oped by a certified mindfulness teacher who
provided evi- dence-based instruction on mindfulness
including a guided 4-minute mindfulness practice. Each
study participant downloaded the audio recording of the
mindfulness prac- ticed to their phone at the end of the
class. After training, participants again completed the
MAAS. In the

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one feels involved, in control, focused, as if nothing else

TABLE 1. Table Presenting the Various Cases Performed by mattered, etc. regarding the
Par- ticipants and the Description of Each Case That Was
Provided to Participants
Case Type Case Description

Scheduled Routine A case/procedure YOU more

com-
monly perform/provide anesthesia
for, without great complexity, in
a patient that is physiologically
stable. Involves a patient
population that you commonly
care for. Not an emergency or
add on case
Scheduled Complex A demanding procedure OR case
that
involves challenging patient
physiology or an unstable
patient. A type of case that is
less commonly done and is of
greater complexity. Not an
emergency or add on case
Add On A non-elective case that was placed
on the add-on list.

post-training phase, participants again completed surveys

before and after three cases of the same categories and lis-
tened to the 4-minute mindfulness intervention between
completing the pre-case survey and entering the operating
room. REDCap® software was used for data collection.
Mindfulness Intervention and Practice
The 25-minute mindfulness training was held at a
conve- nient time and location for each individual
physician and included the guided mindfulness practice.
The interven- tion was based on the psycho-educational
model of Kras- ner et al.24 The mindfulness practice for
our study was the 4-minute audio recording of a brief
breath awareness practice where participants pay
attention to the sensa- tions of breathing in the present
moment. Breath aware- ness serves as one of the first
objects of attention for beginning students in
mindfulness.

Measures
The MAAS is a 15-item unidimensional scale that
measures mindfulness attention, a sensitive awareness of
what is occurring in the present. 25 and is widely accepted
as a reliable and valid assessment of the mindful state of
partic- ipants after an intervention.26,27 Perceived stress
was mea- sured with a single-item rating on a 1-5 scale
ranging from no stress to extreme stress. Flow was
measured with the Core Flow State Scale,16,17,28 a
unidimensional scale con- taining 10-items describing
what it feels like to be in flow during a target activity
with which respondents indicate agreement ranging from
strongly disagree to strongly agree along a five-point
range. Items ask for ratings about the extent to which
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event under consideration The scale has demonstrated
acceptable reliability and validity.29 Supplementary
Figure 1 displays the surveys included in this study
except the copyrighted items on the Flow survey,
which can be obtained from MindGarden.com.

Statistical Analysis
Descriptive statistics appropriate to the variable were
utilized; mean SD for continuous variables and per- §
centages for categorical variables. Reliability for the
MAAS and Flow scales was assessed with Cronbach’s
alpha. Changes in MAAS were examined with a 3
(Phy- sician Type) X 2 (Intervention Timing: pre
versus post) mixed model Analysis of Variance
(ANOVA). Changes in perceived stress and Flow were
assessed with sepa- rate 3 (Physician Type) X 3 Case
Type) X 2 (Interven- tion Timing) mixed model
ANOVAs. Tukey b tests or single-df contrasts were
used for post hoc examination of main effects and
interactions. A significance level of a = 0.05 was used.
All analyses were completed using SPSS version 25.

RESULTS
The attenuated sample included 11 attendings, 16 resi-
dents, and 6 anesthesiologists. The mean age was 38.06
8.459. Table 2 provides the sample demographics §
for each physician category. Cronbach’s alpha for
Flow and MAAS were 0.723 and 0.767, respectively,
indicat- ing acceptable internal consistency. The
ANOVA for MAAS indicated a marginal effect for
intervention (p = 0.064, hp2 = 0.11) for the
Intervention and a stron- ger effect for Physician Type
(p = 0.034, hp2 = 0.20). Inspection of the means
revealed that the anesthesiolo- gists as a group were
unaffected by the intervention which, combined with
the small number of them included before cessation of
data collection, resulted in their being excluded from
further data analyses. After exclusion, mindfulness was §
much higher after (62.7 9.96) than before (57.1 §
10.32) the intervention §
(p = 0.006, hp2 = 0.267). Overall, attendings (65.0 §
7.38) were more mindful than residents (65.5
8.74, p = 0.014, hp2 =
22).
Regardless of case and physician type, flow was
much greater after the intervention (42.5 2.0) than §
before (38.6 1.98, p = 0.009, hp2 = 0.24). Also, §
regardless of physician type, perceived stress was
lower after the intervention (2.19 0.63) than § §
before (2.40 0.61, p = 0.049, hp2 = 0.15) (Fig. 1).
As would be expected,
complicated cases (2.54 § 0.73) were perceived as
more stressful than either routine (2.15 § 0.66) or add-
on (2.19 § 0.65) cases (p = 0.003, hp2 = 0.32).

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TABLE 2. Sample Demographics (Mean §SD or Percentage Within Category)

All Participants Residents Attendings Anesthesiologists

Participants 33 16 11 6
Age 38.06 § 8.459 31.38 § 4.303 45.27 § 6.482 42.67 § 5.955
Gender Male: 23 (69.7%) Male: 3 (50%)
Male: 11 Male: 2 (18.2%)
Female: 10
(68.7%) Female: 9 Female: 3 (50%)
(30.3%)
Female: 5 (81.8%)
(31.3%)
Weekly Work Hours 66.21 § 12.185 73.13 § 10.626 64.09 § 9.439 51.67 §
4.082 Years in Role 7.41 § 6.514 3.31 § 1.702 12.14 § 7.457 9.67 § 6.532
Specialty n/a General: 5 General: 5 (45.5%) n/a
(31.3%) Neuro: 5 Neurosurgery: 3 (27.3%)
(31.3%) ENT: 1 (9.1%)
Plastic: 1 (6.3%) Orthopedic: 2
OBGYN: 3 (18.8%) (18.2%)
Podiatry: 2 (12.5%)

DISCUSSION increases the flow state of physicians in the operating

A brief mindfulness intervention can increase mindful room may be particularly useful as the care OR physi-
awareness among attending surgical physicians and resi- cians provide patients has been shown to be negatively
dents as well as improve flow and reduce stress during affected by distractions and decreased focus.
surgery. Stress reduction is important as stress not only While this study is very much a proof of concept
study, there may be far reaching implications for the
predisposes physicians to burnout, it also has been cor-
results. To date, there have been no studies assessing the
related with an increase in medical errors. 30—32 Addition-
effect of a mindfulness intervention on physicians in the
ally, high stress in the operating room has been linked to
operating room nor has a study been performed with an
emotion liability, interpersonal conflict, and increased abbreviated intervention of this length. Accomplishing
operating time.33,34 those 2 tasks assures the healthcare community that this
An increase in flow state may have considerable paucity is being addressed for this vulnerable population
impli- cations for surgeons as distractions have been and a suc- cessful intervention that can be implemented
found to be a significant factor negatively affecting the into the busy workflow of this population has been
efficiency and outcomes in the operating room. While designed and tested. Additionally, this study
many other system-based interventions have attempted demonstrates the utility of this very abbreviated
to modify the workflow of the operating room to mindfulness intervention for this population and
decrease distrac- tions from occurring, the demanding provides merit for further investigation of its utility in
and complex nature of the operating room makes it other fields of healthcare.
nearly impossible to remove all distractions. A brief There are several limitations to this study that are
intervention that worth noting. Primarily, because the postintervention

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FIGURE 1. Effects of brief mindfulness intervention on MAAS score, flow state, and perceived stress in the operating room for surgeons and
surgical residents.

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measurements of flow and stress are taken after each distraction in the operating room. Lastly, and most
case, and because surgeons are likely to experience importantly, future directions will assess the
less stress and increased flow following a successful
case, the effect of the intervention may be confounded
by the timing of our measurements. While we
attempted to mit- igate this confounder through
comparison of flow and stress measurements for pre-
and postintervention cases by the same participant, it
is a limitation that must be addressed in future. In
addition to the attenuated sample size, the study was
relatively brief—about one month generally separated
the intervention from the last sur- gery—and other
studies of mindfulness healthcare often assess 6
months postintervention.12 Perceived stress was
measured instead of physiological stress, and future
research should address this shortcoming.
Additionally, while we found a decrease in perceived
stress in partici- pants, we believe it is important to
further assess whether or not mindfulness can
improve team dynamics and interpersonal
communication. Another bias that needs to be
explored in future studies that may impact the
external validity of our results is acceptance bias.
While MAAS baseline scores were calculated for
each participant to attribute for differences in baseline
mind- fulness amongst participants, it is possible that
the par- ticipants that enrolled in the study are unique
in regard to their acceptance of mindfulness as an
intervention for surgeons. This bias may influence the
results as a cohort more acceptive of mindfulness may
be primed to elicit a positive response from the
intervention. This could be addressed in a future study
by assessing perception and acceptance of a
mindfulness intervention by participants prior to
intervention. To this point, there were a high
proportion of female attending surgeons (81.8%) that
does not reflect the proportion of female attendings at
the institution this study was performed at. While no
study to our knowledge has assessed gender
preferences for a mindfulness intervention, it is
possible that females are more accepting of
mindfulness and willing to partici- pate in this study
and may provide evidence of accep- tance bias
playing a role in this study. There is also the inherent
bias of participants being aware of the objective of
the study as both the consent process and interven-
tion stated that this study was assessing the efficacy
of this mindfulness intervention. Lastly, as we found
an increase in flow state, it would be astute to design
a study that was able to assess whether this
mindfulness training and intervention lead to a
decrease in perceived distractions while
simultaneously measuring the number of distractions
that actually occur in the operating room. This would
provide evidence as to whether or not increasing flow
state actually leads to a decrease in the burden of

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implications of this mindfulness training and interven-
tion on patient outcomes.

ACKNOWLEDGMENTS
We would like to acknowledge Nikki Sood, MD for their
assistance in this research endeavor.

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SUPPLEMENTARY INFORMATION
Supplementary material associated with this article can
be found in the online version at doi:10.1016/j.
jsurg.2021.03.013.

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