International Journal of

Environmental Research
and Public Health

Article
Mindfulness-Based Intervention for the Reduction of
Compassion Fatigue and Burnout in Nurse Caregivers of
Institutionalized Older Persons with Dementia: A Randomized
Controlled Trial
Victoria Pérez 1 , Ernesto J. Menéndez-Crispín 2 , Carmen Sarabia-Cobo 3, * , Pablo de Lorena 1 ,
Angela Fernández-Rodríguez 4 and Julia González-Vaca 5

1 Institute CR Santa Lucía, 28001 Madrid, Spain

2 Centro Interdisdiplinar de Psicoterapia, 28001 Madrid, Spain
3 Facultad de Enfermería, IDIVAL, Universidad de Cantabria, Avda Valdecilla s/n, 39011 Santander, Spain
4 CAD Santander, IDIVAL, 39008 Santander, Spain
5 Nursing Research Group (GRIN) from the IDIBELL Translational Medicine Area, University of Barcelona,
08007 Barcelona, Spain
* Correspondence: carmen.sarabia@unican.es

Abstract: The recent COVID-19 pandemic has severely impacted the mental health of nurses caring
for institutionalized older people. Caring in this environment can be complex, with higher levels of
Citation: Pérez, V.; burnout and compassion fatigue in staff. It is therefore important to find interventions to increase the
Menéndez-Crispín, E.J.; well-being of staff. Mindfulness training is known to be effective in treating a variety of physical and
Sarabia-Cobo, C.; de Lorena, P.; mental health conditions. This study sought to conduct a direct evaluation of the effectiveness of a
Fernández-Rodríguez, A.; combined online training in two types of mindfulness-based therapies for the reduction of compassion
González-Vaca, J. Mindfulness-Based
fatigue and burnout in geriatric nurses caring for institutionalized elderly people with dementia.
Intervention for the Reduction of
In a randomized controlled trial (n = 39 experimental group, n = 35 control group), we explored
Compassion Fatigue and Burnout in
whether individuals with high levels of burnout and compassion fatigue would benefit more from an
Nurse Caregivers of Institutionalized
Older Persons with Dementia: A
online mindfulness training program. The outcome variable was the ProQoL professional quality of
Randomized Controlled Trial. Int. J. life scale, which was collected at baseline, at six weeks, and at three months after completion of the
Environ. Res. Public Health 2022, 19, intervention. Significant differences were found between both groups for the subscales Compassion
11441. https://doi.org/10.3390/ Fatigue and Burnout (p < 0.05), with a significant improvement in the experimental group (significant
ijerph191811441 effect size). These findings were maintained at three months after the end of the intervention for
both compassion fatigue (F1,28 = 18.14, p = 0.003) and burnout (F1,28 = 7.25, p = 0.040). However,
Academic Editors: Paul B.
Tchounwou and Yasushi Suwazono
there were no differences between groups for the satisfaction subscale. The effect of time and the
effects of comparing the two groups after controlling for time were statistically significant for all three
Received: 19 July 2022 subscales of the questionnaire (all p values < 0.001), with effect sizes ranging from small to large (R2
Accepted: 8 September 2022
change 0.10–0.47). These data indicate that the experimental condition was more effective, explaining
Published: 11 September 2022
between 10 and 18% more of the variance. A short, online intervention based on mindfulness
Publisher’s Note: MDPI stays neutral training appears to be effective for reducing compassion fatigue and burnout in geriatric nurses, with
with regard to jurisdictional claims in sustained effects over time.
published maps and institutional affil-
iations. Keywords: mindfulness-based intervention; nurse; dementia; burnout; compassion fatigue;
occupational stress

Copyright: © 2022 by the authors.

Licensee MDPI, Basel, Switzerland.
1. Introduction
This article is an open access article
distributed under the terms and Levels of occupational stress or burnout are higher in health professionals than in other
conditions of the Creative Commons workers [1]. The negative consequences of not having adequate stress-coping strategies
Attribution (CC BY) license (https:// to deal with the demands of professional life have an impact on the health and mental
creativecommons.org/licenses/by/ well-being of the individual, as well as on their professional performance [2]. This situation
4.0/). has clearly worsened with the COVID-19 pandemic [3].

Int. J. Environ. Res. Public Health 2022, 19, 11441. https://doi.org/10.3390/ijerph191811441 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 11441 2 of 13

Staff providing long-term hospital care to older and geriatric patients are exposed
to numerous factors that can lead to the development of burnout syndrome [4]. Burnout
is associated with an increased risk of absence from work, low job satisfaction, and an
increased intention to quit [5]. Considering that the number of geriatric nursing staff is
already insufficient, research is needed on interventions aimed at reducing work-related
stress in inpatient care for older people [6].
Caring for patients with dementia generates significant job stress that can result in em-
ployee dissatisfaction and mental exhaustion [7]. Part of the stress stems from burnout, the
chronic psychological syndrome of perceived job demands exceeding perceived resources
in the work environment [4].

1.1. Theoretical Framework

The Cognitive Activation Theory of Stress [8] (CATS) defines stress neutrally, meaning
that stress in itself is neither good nor bad. However, Ursin and Eriksen [8] argue that
prolonged stress and/or excessive stress loads can be detrimental to the individual. The
starting theoretical framework is that staff working in nursing homes exhibit high levels
of compassion fatigue and burnout, marked by the characteristics of their work, as the
main elements of stress [9]. Many factors elevate caregiver stress, including the nature and
severity of the challenging behaviors of dementia patients, working conditions, degree of
support from staff management, working conditions, work overload, etc.

1.1.1. Compassion Fatigue

Researchers have also shown that compassion fatigue can affect the professional
caregiver as well as the workplace, causing decreased productivity, a greater number of
sick days, and increased turnover [10]. However, few validated reports have detailed the
incidence and prevalence of compassion fatigue in psychogeriatric nurses caring for older
people with dementia [5].
The condition of compassion fatigue was first identified by Joinson [11] in a study
of burnout in nurses working in an emergency department. The researcher identified
characteristic behaviors of compassion fatigue, including chronic fatigue, irritability, fear of
work, aggravation of physical ailments, and lack of joy in life. Later, Figley [12] defined
compassion fatigue as a state of tension and preoccupation with clients’ individual or
cumulative traumas. The phenomenon of compassion fatigue arises suddenly and without
warning and includes a sense of helplessness and confusion. Figley has described it
as the toll a caregiver experiences as a result of caring for others. Compassion fatigue
results from giving high levels of energy and compassion over a prolonged period to those
who are suffering, often without experiencing the positive outcomes of seeing patients
improve [12]. The term compassion fatigue has been applied to a disconnection or lack of
empathy on behalf of professional caregivers. Empathy and emotional investment have
been found to potentially cost caregivers, putting them at risk [13]. Compassion fatigue has
been equated with burnout, secondary traumatic stress disorder, vicarious traumatization,
secondary victimization or co-victimization, compassion stress, emotional contagion, and
countertransference. Numerous studies exist on nurses’ experiences of compassion fatigue
and burnout [10,13–15]. Most nurses who self-identified as having compassion fatigue
described a change in their practice whereby they began to protect and distance themselves
from the suffering of patients and their families [14,15]. Feelings of irritability, anger, and
negativity emerged, although participants described denying or ignoring these emotions
to try to overcome their workday. Difficulties with work carried over into the nurses’
personal lives, affecting their relationships with family and friends [15]. Such experiences
invariably challenged the participants’ identity, making them reflect on the type of nurse
they were. Participants’ compassion fatigue created a sense of hopelessness regarding
positive change, although some nurses described strategies that seemed to help alleviate
their compassion fatigue.
Int. J. Environ. Res. Public Health 2022, 19, 11441 3 of 13

Coping strategies can reduce nurse burnout and maintain effectiveness for six months
to one year [16]. Clearly, there is an increasing demand for wellness-support methods
at work [17]. Interventions based on mindfulness are gaining special relevance in recent
years, as they have the potential to improve the psychological wellbeing of nurses, a
result of the research carried out over the last 20 years in this regard [18]. Now, with the
situation generated by the COVID-19 pandemic, these interventions are more necessary
than ever [19].

1.1.2. Mindfulness-Based Interventions (MBIs)

Mindfulness-based interventions have experienced a remarkable increase in scientific
and popular interest over the last two decades [20,21]. Mindfulness can be defined as
an approach to experiencing everyday life by directing attention and awareness to the
present moment without judgment. Mindfulness encompasses the key therapeutic concepts
of acceptance, compassion, and detachment [22]. As a therapy, mindfulness practice
is predominantly based on a program that was originally established for mindfulness-
based stress reduction (MBSR). Since the 1979 debut of Jon Kabat Zinn’s Mindfulness-
Based Stress Reduction (MBSR) program [23,24], its structure and form have become
the model for subsequent mindfulness-based programs (MBP). A notable example is the
equally popular Mindfulness-Based Cognitive Therapy (MBCT) program developed two
decades ago [25,26]. Common features of these programs include (i) a standardized,
instructor-led experiential learning routine of about 2 to 2.5 h each week, (ii) a day of
silent mindfulness practice around the sixth week, and (iii) daily formal and informal
practices assigned each week that (iv) require approximately 45 min of daily dedication
for (v) six days a week. Admittedly, some programs may have a longer duration, such as
Mindful Self-Compassion (MSC), which lasts ten weeks [24], or the relatively simpler and
more abbreviated approaches such as the Finding Peace in a Frantic World program [27]
developed for companies or school settings, which usually lasts six weeks.
Sufficient evidence has accumulated over the last twenty years to indicate MBI’s effi-
cacy in addressing anxiety, burnout, and stress problems in both clinical and professional
populations [28]. MBIs are effective at improving many biopsychosocial conditions, such as
depression, anxiety, stress, insomnia, addiction, psychosis, pain, hypertension, weight man-
agement, cancer-related symptoms, and prosocial behaviors [29,30]. MBIs have been found
to be beneficial in healthcare settings, in schools, and in the workplace; however, further
research is warranted to examine its efficacy in relation to different problems [28]. A litera-
ture review included a total of 142 non-overlapping samples and 12,005 participants [31].
In posttreatment, mindfulness-based interventions were superior to no treatment, minimal
treatment, non-specific active controls, and specific active controls. Mindfulness conditions
did not differ from evidence-based treatments. The results of meta-analyses supported the
notion that there was evidence supporting mindfulness-based interventions as a treatment
for disorders associated with depression, anxiety, and stress.
In another systematic review, which focused on studies measuring the impact of
mindfulness-based interventions on physicians’ well-being and performance, the find-
ings suggested that physicians benefited positively from greater mental well-being after
mindfulness-based interventions [32].
Another recent systematic review included 85 randomized controlled trials [33], 79 of
which reported significant positive effects on at least one health-related outcome, and over
a quarter of these targeted a clinical population. Most studies focused on psychological
outcomes, such as reduced anxiety and depression, as well as emotional regulation, stress,
and cognitive outcomes. These were found in brief programs as short as 5 min.
In response to questions about the scientific basis of interventions based on MBI,
a recent investigation assessed their empirical status by systematically reviewing meta-
analyses of randomized controlled trials (RCTs) [34]. A total of 160 effect sizes were reported
in 44 meta-analyses (k = 336 RCTs, N = 30,483 participants). Intervention groups based on
the use of MBI showed superiority to control groups in most studies. The effects of MBIs
Int. J. Environ. Res. Public Health 2022, 19, 11441 4 of 13

were similar or superior to other intervention groups using conventional or evidence-based

treatments, especially for stress management.
Mindfulness has therefore been shown to improve patient care and reduce work
stress and nursing staff turnover [35,36]. Improved awareness and the use of mindfulness
strategies have the potential to improve patient outcomes, reduce the cost of professional
turnover, and improve patients’ emotional well-being and job quality [37].
Therefore, we considered it important to carry out an effective, measurable, replicable,
and simple intervention to promote emotional self-care measures in nurses working with
older people with dementia in the current pandemic context. The aim of the present study
was to conduct a direct evaluation of the efficacy of a combined online training in two types
of mindfulness-based therapy for the reduction of compassion fatigue and burnout in
geriatric nurses caring for institutionalized older people with dementia in a randomized
controlled trial.

2. Materials and Methods

This study used a randomized controlled trial with a control group and an intervention
group.

2.1. Participants
Purposive sampling was used, based on a total sample of 82 nurses who were initially
recruited from twelve elderly care centers belonging to the same religious foundation in
six cities of Spain. A total of 74 nurses agreed to participate. The characteristics of the
nursing homes were similar in terms of the number of elderly people cared for, their degree
of dependency, staffing, and work shift characteristics. The participants who agreed to
participate in the study were randomly assigned to the experimental condition (n = 39)
and to the control condition (n = 35), with the reference that they had to belong to the
same center. Thus, six centers were considered the intervention group and six centers
were considered the control group to avoid contamination of the sample. There were no
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 5 of 13
dropouts, and all participants completed the study. The flow of participants through each
stage of the trial is represented in the CONSORT diagram (Figure 1).

Figure 1. CONSORT trial participation at baseline (T0) and three months (T2).

Figure 1. CONSORT trial participation at baseline (T0) and three months (T2).

The intervention was carried out between September and February 2021.
Int. J. Environ. Res. Public Health 2022, 19, 11441 5 of 13

The intervention was carried out between September and February 2021.

2.2. Variables
Sociodemographic variables such as age, sex, marital status, years of dedication to the
field of geriatrics, and hours of work per week were collected.

2.2.1. Dependent Variable

The dependent variable was the Professional Quality of Life Scale (ProQoL) in its Span-
ish adaptation [38,39]. This questionnaire contains 30 items that measure three constructs:
compassion satisfaction, burnout, and compassion fatigue [40]. Compassion satisfaction
is defined as pleasure derived from being able to do one’s job well; burnout is defined as
feelings of hopelessness and difficulty coping with work or doing a job effectively, as well
as trauma. Compassion fatigue is defined as secondary work-related exposure to extremely
stressful events. The scale has been shown to have good psychometric properties and has
been validated in different countries [41]. In this study, the α-reliability of each subscale
was 0.88, 0.76, and 0.81, respectively. Response options ranged from 0 (never) to 5 (always).
For scoring, five items belonging to the burnout subscale must be reversed. There is no total
score; the score for each construct is obtained from the sum of the values of the 10 items of
each subscale. Scores are interpreted as low (≤22), average (23–41), and high (≥42).

2.2.2. Independent Variables: Training Program

Participants were randomly assigned to one of two groups: (a) a six-week mindfulness
training program delivered through an online platform or (b) a three-month wait-list control
after completion of the intervention in the experimental group.

2.3. Outcome Measures

The ProQOL R-IV scale was collected at baseline, at six weeks of intervention (T1),
and at three months after the end of the intervention (T2).

2.4. Intervention
The intervention was a six-week group intervention based on the principles of
Mindfulness-Based Stress Reduction [23,24,42]. Kabat Zinn’s research has had a great
impact on the development of mindfulness programs applied to different settings, with
solid evidence regarding their effectiveness [43,44]. Our intervention was based on his
teachings and combines elements of MBCT [45]. The intervention was designed to decrease
or prevent compassion fatigue, to help learn to manage stressful situations, and to increase
compassion satisfaction, based on the literature and the training of the researchers who
designed it [16,46].
The main characteristics were: six recorded sessions of 60 min each, with videos and
interactive exercises led by a nurse and a psychologist trained in mindfulness. All sessions
followed the same structure: they began with a brief relaxation and breathing technique,
continued with the content of the session, and ended with a quote for personal reflection on
the topic covered and an individual reflective writing exercise. In addition to the sessions,
twelve assignments were also made available on the platform for participants to practice in
daily life with supporting emails (two per session). There were also five guided meditation
audio downloads. Participants could pause the course and repeat any part at any time.
There was also an email address and phone number for general and technical support.
The entire course was hosted on a free platform (Moodle), which each participant ac-
cessed with a username and password. Each week, the session was made available (on Mon-
days) along with the two tasks for the week, and every two weeks, an audio-guided medi-
tation was provided. The platform informed the user of their progress with notifications.
Int. J. Environ. Res. Public Health 2022, 19, 11441 6 of 13

2.5. Procedure
Participants were randomly assigned to one of two groups: (a) a six-week training
program or (b) a three-month wait-list control after completion of the intervention.
After signing the informed consent form, participants received a link by e-mail to
self-complete the study variables at three points in time: baseline, at six weeks (T1), and at
three months after completing the intervention (T2).

2.6. Ethical Considerations

All procedures were in accordance with the 1975 Declaration of Helsinki, revised in
2000. All participants gave written informed consent. The study was approved by the ethics
committee of the foundation (EC 09/2021) and the managements of the 12 participating
centers. All data were anonymized and treated according to the current legislation of the
country.

2.7. Statistical Analysis

IBM SPSS Statistics v.24 n.0. (INTERNATIONAL BUSINESS MACHINES CORPO-
RATION, Armonk, NY, USA) software was used for the statistical analysis. A bilateral
contrast and a 95% confidence level were adopted. A descriptive analysis of all the vari-
ables collected was performed for each group. Possible differences between the baseline
characteristics of the study groups were evaluated with t-tests for continuous variables and
χ2 tests for categorical variables. To examine differences in outcomes between the inter-
vention and control groups during the intervention period, a repeated-measures ANOVA
analysis of variance was performed to analyze differences between the experimental and
control groups between baseline and T1 and T2. Another repeated-measures ANOVA
was performed for the intervention group to test for intrasubject effects between baseline
and T1 and T2. The significance level was set at p < 0.05. Change over time within each
condition was examined by treating each group as an n of 1. Multiple linear regression
(MLR) was used to estimate the extent to which subject variables were predicted by the
type of intervention (experimental vs. control) after controlling for the effect of time. Ef-
fect size in the regression analysis is reflected by R2 (which is the percentage of variance
explained by the linear relationship between two variables), and specific effects were es-
timated by the change in R2, which is interpreted as R2 of 0.02 = small, 0.15 = medium,
and 0.26 = large. All study variables met the principles for applying MLR: skewness and
kurtosis values within ± 1, no significant outliers, and no evidence of multicollinearity
(variance inflation factor <5).

3. Results
The total sample analyzed consisted of 74 nurses (89.6% female and 10.4% male), with
a mean age of 37 years (SD = 9.13), and an age range of 25 to 56 years. Most of the sample
was married (70.2%), 8 were single, 19 were divorced, and 13 were domestic partners. The
mean years in practice were 11.52 (SD = 9.25), and most of the nurses worked 40 h per week
(79.8%).
Demographic characteristics of the participants in both groups were compared by
a series of chi-square and independent samples t-tests, which indicated no statistically
significant differences between the groups (p > 0.05). All subjects in the experimental group
completed the entire training program.
Table 1 shows the values for the baseline phase of both groups in the ProQoL question-
naire. There were no statistically significant differences in the variables between the groups
at baseline, nor were significant correlations established between the sociodemographic
variables and the subscales.
Int. J. Environ. Res. Public Health 2022, 19, 11441 7 of 13

Table 1. Subscales of the ProQoL questionnaire at baseline for the control and intervention groups.

Experimental (n = 39) Control (n = 35)

Variables p*
M (SD) Range M (SD) Range
Professional Quality of Life ProQoL (0–50)
Satisfaction 40.49 (7.22) 29–50 41.25 (5.02) 11–50 0.087
Compassion fatigue 16.44 (4.45) 2–30 17.45 (7.12) 2–47 0.065
Burnout 17.88 (7.33) 8–28 18.38 (4.05) 4–34 0.074
* Student’s t test (significance p < 0.05).

To measure the effectiveness of the intervention, a repeated-measures ANOVA was

performed. At six weeks, immediately after the intervention, the level of compassion
fatigue decreased significantly in the experimental group (M 9.21, SD 11.24) compared
to the control group (M 18.23, SD 6.23) (F1,65 = 8.15, p = 0.011). The same phenomenon
occurred in the burnout subscale (F1,65 = 11.05, p = 0.02), with scores of 11.23 (SD 6.10) for
the experimental group and 19.21 (SD 8.32) for the control group. However, satisfaction
values remained similar for both groups, with no statistically significant differences.
Longitudinal measurement at three months after completion of the intervention
showed that the initial decrease in the level of compassion fatigue remained significant
(F1,28 = 18.14, p = 0.003), which was also the case for the burnout subscale (F1,28 = 7.25,
p = 0.040). Levels of compassion satisfaction remained similar to the baseline for both
groups, with no statistically significant differences.
The effect size also increased from the baseline to the final phase (T2) for both the
compassion fatigue subscale (baseline Cohen’s d = 0.32; T2 Cohen’s d = 2.34) and the
burnout subscale (baseline Cohen’s d = 0.12; T2 Cohen’s d = 2.48). However, it remained
stable for the satisfaction subscale.
In Table 2, we can see the multiple linear regression analyses predicting subject
variables, including the three subscales (ProQOL). The effect of time and the effects of
comparing the two groups after controlling for time were statistically significant for all
three subscales of the questionnaire (all p’s < 0.001), with effect sizes ranging from small to
large (R2 change 0.10–0.47). These data indicate that the experimental condition was more
effective, explaining between 10 and 18% of the variance in the psychological data, with all
coefficients being β-significant and greater than 0.31, reflecting substantial psychological
improvement in the experimental subjects.

Table 2. Summary of multiple linear regression analyses predicting subject variables, including the
three subscales (ProQOL). Controlling for the effect of comparing the experimental group with the
control group after controlling for time.

Model R2 R2 Change Variable Standardized β p

ProQOL: Compassion satisfaction
1 0.45 0.45 <0.001
Time 0.62 <0.001
2 0.50 0.11 <0.001
Exp. vs. control 0.31 <0.001
ProQOL: Compassion fatigue
1 0.40 0.40 <0.001
Time −0.61 <0.001
2 0.61 0.16 <0.001
Exp. vs. control −0.69 <0.001
ProQOL: Burnout
1 0.38 0.37 <0.001
Time −0.60 <0.001
2 0.44 0.11 <0.001
Exp. vs. control −0.32 <0.001
Int. J. Environ. Res. Public Health 2022, 19, 11441 8 of 13

4. Discussion
The present study aimed to conduct a direct evaluation of the efficacy of a combined
online training in two types of mindfulness-based therapies for the reduction of compassion
fatigue and burnout in geriatric nurses caring for institutionalized older people with
dementia in a randomized controlled trial. Very few studies have investigated effective
ways to reduce stress in staff caring for people with dementia in nursing homes in relation
to compassion fatigue and caregiving satisfaction during this period [47–49]. This trial will
extend our knowledge by evaluating whether online mindfulness training reduces stress
and improves job satisfaction in this professional group.
In view of the high rate of completion and attendance, the findings of our study
suggest that our combined intervention, based on MBSR and MBCT, is a feasible and ac-
ceptable psychosocial program for the target population. The results obtained in achieving
the main objective show that online mindfulness-based training effectively decreased levels
of compassion fatigue and burnout up to three months after the end of the intervention
compared to a control group with similar characteristics. Although such a conclusion
may be somewhat premature given the heterogeneity of mindfulness-based interventions
and the lack of independent research groups replicating specific mindfulness-based inter-
ventions, the field clearly indicates that engaging in mindfulness-based practices helps
caregivers improve their well-being [18,50,51]. Furthermore, when caregivers engage in
mindfulness-based practices, they improve their clients’ quality of life by reducing or
eliminating the use of restrictive procedures, such as physical restraints and emergency
psychotropic medications [52].
Our findings suggest that these processes mediate some of the effects of MBI on nurses’
psychological functioning. We found that changes in compassion fatigue and burnout were
reasonably predicted by the intervention, although satisfaction with care remained stable. In
addition, the passage of time was also a modulating variable for intervention effectiveness.
Our findings are similar to other studies that employed similar interventions and conducted
a longitudinal follow-up [53–55]. Baseline levels of compassion fatigue and stress in both
groups are average values, comparable to those found in other similar studies [5,10,56]. In
a recent and interesting study in Italian healthcare professionals evaluating baseline stress
levels before and after the pandemic and the effect of Mindfulness-Based Stress Reduction
(MBSR) training on well-being (PGWBI), stress (PSS), and burnout (MBI), the authors
concluded that MBSR training may represent an effective strategy to reduce distress in an
emergency period [57]. Although the type of intervention used in this study had a different
approach, the results are similar to our study. Although we did not specifically look at
stress levels before and after the pandemic, we did conduct the intervention during the
pandemic. The stress levels are similar to those achieved in the Italian study, although the
latter did not specifically examine geriatric nurses.
Regarding the compassion satisfaction variable, there was no significant change when
comparing the two groups, though there was a significant change at the follow-up of the
experimental group at three months post-intervention. The lack of a significant initial
change could be because the study sample reported average to high satisfaction at the
beginning of the study, which is relevant in this professional group, especially when they
have been doing this work for years [58,59].
Dementia tends to progress slowly, and the average time from the onset of overt
symptoms to death is about 8–10 years. Symptoms usually develop slowly and worsen
over time, and, therefore, the demands on the daily caregivers of people with dementia
increase progressively [60]. Therefore, interventions tailored to healthcare professionals
should be sustainable, while empowering them to cope with daily challenges [5]. Our
results showed that the beneficial effect of the combined program based on MBSR and
MBCT could last at least three months after the intervention. This finding may be related
to the benefits of the regular practice of mindfulness among nurses [33,61]. This program
provided five audio recordings (MP3) of guided mindfulness exercises for the nurses
in the experimental group to use as practice, plus two assignments per week, and we
Int. J. Environ. Res. Public Health 2022, 19, 11441 9 of 13

also monitored their progress by email to encourage the nurses to cultivate the habit of
practicing mindfulness and to apply a mindful attitude to their daily activities. We believe
that this is the main reason for the sustainable effects we found in our study, supported by
the systematic reviews conducted on the influence of mindfulness training [34,61].
Understanding the effects of caring for institutionalized patients with dementia on
nurses is a responsibility of the institution. Although concepts such as compassion fa-
tigue and burnout are multifactorial [62], studies suggest that the social environment of a
workplace and its organizational structure are particularly relevant contributors to these
conditions [16,62]. The results of this study suggest the need for an intervention for at-risk
staff, since modifying the organizational structure is often more complex. If we provide
professionals with personal tools that favor their self-care and emotional self-regulation,
we will contribute to improving their health, and thus the quality of their work [52,63].
This will have a relevant impact on the care of the older people they attend, supported by
multiple studies [64,65].
Similar studies, as well as systematic reviews, point to the effectiveness of mindfulness
training-based interventions (either for stress reduction or within cognitive therapy, com-
bined in our study) for enabling caregivers to self-manage their stress under adverse work
conditions with a high care overload [66,67]. These results are of great importance because
they suggest that decreasing compassion fatigue and burnout may prevent emotional prob-
lems and symptomatology [36,68]. The longitudinal study design is also relevant, because
the development of brief, online interventions that are easy to implement and follow, with
sustained long-term effects that promote training, is highly applicable [69]. Further, the
online nature of the training, which favors self-paced training, makes it highly replicable.
Thus, organizations with these characteristics can implement this approach to prevent or
reduce the levels of compassion fatigue and burnout of their professionals [13,70,71].
However, although the mindfulness-based interventions developed over the last
30 years are increasingly used by healthcare professionals to reduce the risk of burnout,
they have had varying results [55]. A recent review of the literature on mindfulness-based
interventions for stress reduction in professionals concluded that there is still a lack of
evidence regarding the effectiveness of these interventions [36]. A possible explanation may
be the heterogeneity of the numerous intervention types (approach, content, methodology,
and duration) [18]. Another recent systematic review of 44 meta-analyses of RCTs clearly
suggested that more rigorous studies are needed, using randomized and controlled trials
that highlight longitudinal effects, as is the case in our study [34].
Therefore, three relevant aspects of our study are worth highlighting: (1) this was a
RCT with a control group, meaning that the variables have been rigorously controlled and
a random selection has been made; (2) the intervention was online, which can be replicated
and implemented at a low cost, which demonstrates its effectiveness; (3) it has shown
a longitudinal benefit according to the regression model, with a six-week intervention
lasting 120 min, which, compared to the literature, makes it a short intervention, which
also enhances its applicability and effectiveness. The advantage of using online training in
this environment is that staff can access the course when convenient and at their own pace,
and they can immediately use the techniques learned in their practice.
Although our findings, despite being a RCT, must be taken with caution, and given
the heterogeneity of mindfulness-based interventions and the lack of independent research
groups replicating specific mindfulness-based interventions, research in this field clearly
indicates that engaging in mindfulness-based practices helps healthcare professionals
improve their well-being.
Despite the usefulness of our findings, this study is not exempt from limitations. We
cannot generalize these findings to other settings such as the public sector, which would
be interesting, since working conditions and professional ratios may have an influence.
Another limitation is that, despite the difficulties of access to change and the fact that it is
an RCT, the sample (74 nurses) is too small to draw generalizable conclusions. Another
limitation—although in this study, it is seen as an advantage—is the fact that the interven-
Int. J. Environ. Res. Public Health 2022, 19, 11441 10 of 13

tion was not conducted face-to-face, but via an online format. Several studies suggest that
this approach makes it less effective, since in the literature, training tends to be face-to-face
and led by an instructor.

5. Conclusions
Future research could replicate this intervention in a sample of professionals from
public institutions and caregivers with high compassion fatigue, high burnout, and low
satisfaction, as well as in larger samples and in different sectors to determine whether these
findings can be generalized. It would also be worthwhile to test the intervention with
family caregivers outside the scope of institutionalized care. Further research is needed
on online mindfulness training and interventions to improve the biopsychosocial health
of nurses during the COVID-19 pandemic. If it is known that these interventions are
effective when applied to work environments with high fatigue and stress load, it would
be worthwhile to replicate them during this pandemic and post-pandemic era.

Author Contributions: Conceptualization, C.S.-C., E.J.M.-C.; methodology, C.S.-C.; formal analysis,

C.S.-C.; investigation, C.S.-C. and P.d.L.; writing—original draft preparation, C.S.-C., V.P., P.d.L.,
A.F.-R. and J.G.-V.; writing—review and editing, C.S.-C., V.P. and P.d.L.; supervision, C.S.-C.; project
administration, E.J.M.-C. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declara-
tion of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of H.A.D.
(CE 09/2021, 2 July 2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study. Written informed consent has been obtained from the participants to publish this paper.
Data Availability Statement: Not applicable.
Acknowledgments: We would like to thank all the participants for their disinterested contribution,
as well as the centers and the religious foundation that has made this project possible.
Conflicts of Interest: The authors declare no conflict of interest.

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