How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective

Meditation, an inward journey to explore profound levels of consciousness rooted in Buddhism, has significant physical and psychological benefits, including enhanced well-being, improved concentration, emotional stability, and positive cognitive shifts. This narrative review consolidates past two decades of research on the neurophysiological effects of Buddhist mindfulness meditation based on neuroimaging findings, and aims to examine the Buddhist view of mindfulness meditation in relation to the structural and functional changes in the brain areas in health and diseases. Meditation practices, such as Vipassana in Buddhism, emphasize mindfulness and non-judgmental awareness of oneself and surrounding. Neuroimaging studies have revealed its significant impact on brain regions including structural changes involving anterior cingulate cortex (ACC), temporal lobe, insula, hippocampus, amygdala, thalamus and other areas. Four fundamental mechanisms summarize the mindfulness meditation: attention regulation, body awareness, emotion regulation, and a transformed selfperspective. The scientific explanation of effects of meditation is challenging, and we are only beginning to understand in neurophysiological terms. Previous research on mindfulness meditation has employed diverse methodological approaches, including self-reported measures, behavioral tasks and neuroimaging techniques; but there lacks a standardization, making it difficult to compare the findings. However, the cognitive processes are thought to underlie the potential benefits of mindfulness meditation in promoting mental well-being on an individual and societal level. This review highlights the mechanisms of mindfulness meditation to improve cognitive flexibility and promote mental well-being, in relation to Buddhist philosophy, with implications for individual and societal benefits.

Interventions based on mindfulness have become increasingly popular. This article reviews the empirical literature on its effects on mental and physical health, discusses presumed mechanisms of action as well as its proposed neurobiological underpinning. Mindfulness is associated with increased well-being as well as reduced cognitive reactivity and behavioral avoidance. It seems to contribute to enhance immune functions, diminish inflammation, diminish the reactivity of the autonomic nervous system, increase telomerase activity, lead to higher levels of plasmatic melatonin and serotonin. It enhances the quality of life for patients suffering from chronic pain, fibromylagia and HIV infection. It facilitates adaptation to the diagnosis of cancer and diabetes. It seems to lead to symptomatic improvement in irritable bowel syndrome, chronic fatigue syndrome, hot flashes, insomnia, stress related hyperphagia. It diminishes craving in substance abuse. The proposed mechanism of action are enhanced metacognitive conscience, interoceptive exposure, experiential acceptance, self-management, attention control, memory, relaxation. Six mechanism of actions for which neurological underpinnings have been published are: attention regulation (anterior cingulate cortex), body awareness (insula, temporoparietal junction), emotion regulation (modulation of the amygdala by the lateral prefrontal cortex), cognitive re-evaluation (activation of the dorsal medial prefrontal cortex or diminished activity in prefrontal regions), exposure/extinction/reconsolidation (ventromedial prefrontal cortex, hippocampus, amygdala) and flexible self-concept (prefrontal median cortex, posterior cingulated cortex, insula, temporoparietal junction). The neurobiological effects of meditation are described. These are: (1) the deactivation of the default mode network that generates spontaneous thoughts, contributes to the maintenance of the autobiographical self and is associated with anxiety and depression; (2) the anterior cingulate cortex that underpins attention functions; (3) the anterior insula associated with the perception of visceral sensation, the detection of heartbeat and respiratory rate, and the affective response to pain; (4) the posterior cingulate cortex which helps to understand the context from which a stimulus emerges; (5) the temporoparietal junction which assumes a central role in empathy and compassion; (6) the amygdala implicated in fear responses. The article ends with a short review of the empirical basis supporting the efficacy for mindfulness based intervention and suggested directions for future research.

The Role of Frontolimbic Network in Suicide: A Descriptive Literature Review of Neuroimaging Studies.

Secular Mindfulness-Based Interventions: Efficacy and Neurobiology.

ObjectivesRecent meta-analyses suggest that mindfulness meditation may enhance prosocial behavior, while evidence regarding moral behavior is still scarce. We combined a randomized controlled mindfulness training design with an ecologically valid moral decision-making task (Temptation to Lie Card Game; TLCG), in which participants were tempted to deceive an opponent to increase their monetary payoff.MethodTLCG and self-report measures (in the domains of attention regulation, body awareness, emotion regulation, and change in the perspective of the self) were administered to participants who underwent the mindfulness meditation training (experimental group, n = 44) or were waitlisted (control group, n = 25) twice: before and after the 8-week training.ResultsConcerning moral decision-making, we observed a significant effect involving condition, time, and group. Trained participants deceived significantly less in the post-training as compared with the pre-training phase (p = 0.03), while untrained ones showed no significant change (p = 0.58). In the self-reports, significant effects involving time and group were found for the Multidimensional Assessment of Interoceptive Awareness (MAIA-2) in Self-Regulation, Attention Regulation, Body Listening, and for the Five Facet Mindfulness Questionnaire (FFMQ) in Non-Reactivity to inner experience. Trained participants showed a time-related increase in all subscales scores, while untrained ones did not. Finally, a moderation analysis revealed a significant interaction between weekly mindfulness meditation training minutes and MAIA-2 Attention Regulation (post-training) on moral behavior change.ConclusionsOur preliminary results suggest that mindfulness meditation practice decreases self-serving dishonest behavior and increases awareness of one’s bodily and emotional state. In particular, the amount of mindfulness meditation practice predicted moral behavior change in practitioners who reported the highest regulation of attention towards internal bodily signals.PreregistrationThis study is not preregistered.

Anterior Cingulate Cortex: Unique Role in Cognition and Emotion

The scientific interest on mindfulness meditation (MM) has significantly increased in the last two decades probably because of the positive health effects that this practice exerts in a great variety of clinical and non-clinical conditions. Despite attention regulation, emotional regulation, and body awareness have been argued to be critical mechanisms through which MM improves well-being, much less is known on the effects of this practice on personality. Here we review the current state of knowledge about the role of MM in promoting changes in practitioners’ personality profiles and self-concepts. We first focus on studies that investigated the relations between mindfulness and personality using well-known self-report inventories such as the Five-Factor model of personality traits and the Temperament and Character Inventory. Second, based on the intrinsic limitations of these explicit personality measures, we review a key set of results showing effects of MM on implicit, as well as explicit, self-representations. Although the research on MM and personality is still in its infancy, it appears that this form of meditative practice may notably shape individuals’ personality and self-concept toward more healthy profiles.

Alterations in emotion generation and regulation neurocircuitry in depression and eating disorders: A comparative review of structural and functional neuroimaging studies

The brain structure correlates of individual differences in trait mindfulness: A voxel-based morphometry study

Attention and emotion: a clinical perspective: Adrian Wells and Gerald Mathews. Hardback, vii + 402 pp. £24.95. ISBN: 0-86377-339-7

Experienced meditators typically report that they experience time slowing down in meditation practice as well as in everyday life. Conceptually this phenomenon may be understood through functional states of mindfulness, i.e., by attention regulation, body awareness, emotion regulation, and enhanced memory. However, hardly any systematic empirical work exists regarding the experience of time in meditators. In the current cross-sectional study, we investigated whether 42 experienced mindfulness meditation practitioners (with on average 10 years of experience) showed differences in the experience of time as compared to 42 controls without any meditation experience matched for age, sex, and education. The perception of time was assessed with a battery of psychophysical tasks assessing the accuracy of prospective time judgments in duration discrimination, duration reproduction, and time estimation in the milliseconds to minutes range as well with several psychometric instruments related to subjective time such as the Zimbardo Time Perspective Inventory, the Barratt Impulsivity Scale and the Freiburg Mindfulness Inventory. In addition, subjective time judgments on the current passage of time and retrospective time ranges were assessed. While subjective judgements of time were found to be significantly different between the two groups on several scales, no differences in duration estimates in the psychophysical tasks were detected. Regarding subjective time, mindfulness meditators experienced less time pressure, more time dilation, and a general slower passage of time. Moreover, they felt that the last week and the last month passed more slowly. Overall, although no intergroup differences in psychophysical tasks were detected, the reported findings demonstrate a close association between mindfulness meditation and the subjective feeling of the passage of time captured by psychometric instruments.

Mindfulness and emotion regulation in clinically depressed youth

"Care for yourself so you can care for others" … an age-old adage that is easily forgotten in our jam-packed personal and professional lives. As caregivers, nurses have been socialized to care for others and thus often prioritize their needs as second. Self-care remains vital for nurses to ease the detrimental effects of stress in the constantly and rapidly changing health care environment and to prevent progression of those effects to burnout, which can have devastating consequences for nurses and those under their care.1–3 With the growing interest in whole-person–centered care, nursing leaders in health care organizations are paying more attention to cultivating practice environments that support similar person-centric principles for nursing staff, interprofessionals, and other employees.1,4,5Many integrative approaches support self-care and enhance resiliency. Mindfulness, one integrative approach, has demonstrably improved clinical outcomes in diverse patient populations, including healthy persons. As expert Jon Kabat-Zinn6 explains, mindfulness is "what arises when you pay attention, on purpose, in the present moment, non-judgmentally … And what arises is nothing more than the awareness itself." Thus, mindfulness involves developing an intentional awareness that is open and accepting, allowing oneself to respond rather than react to situations.7–9 To explore this integrative modality, the PICO (problem, intervention, comparison, outcome) question of interest for this evidence synthesis is, What effect do mindfulness programs have on whole-person (biopsychosocial) outcomes of nurses?The search strategy involved the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MED-LINE, supplemented by hand-searching bibliographies. Key words included mindfulness, mindfulness-based stress reduction (MBSR), nurses, and self-care. The search was limited to research in approximately the past 10 years.Eleven studies were retrieved (Table 1). Of these, 5 were randomized controlled trials, 1 was a nonrandomized trial, and 5 were observational studies. Mindfulness interventions ranged from 1- or 2-day workshops to 4- or 8-week programs with 30-minute to 2-hour sessions each week. Intervention components included (1) body scan: monitoring of body to increase awareness of sensations, (2) sitting meditation: mindful attention to breathing with nonjudgmental awareness of thoughts and distractions in the mind, (3) Hatha yoga: breathing with gentle stretching, and (4) intentional activation of loving kindness, gratitude, and self-compassion. Most MBSR programs incorporated daily home practice for 10 to 30 minutes a day. Two studies integrated mind-body interventions into the daily shift routine via a brief 5-minute MBSR session before the shift17 or a 1-hour weekly group session on the unit from 2 pm to 3 pm.20The nurse outcomes evaluated were focused on physiological states and symptoms, psychological symptoms, burnout, work or life satisfaction, mindfulness awareness, and sense of coherence (a psychological dimension that includes perceptions of comprehensibility, manageability, and meaningfulness). MBSR program feasibility was evaluated through participation rates, as well as qualitative reports of enablers and barriers. Overall, improvement in physiological and psychological well-being was evident. Physiologically, nurses reported increased relaxation states and fewer physical symptoms after MBSR.15,16 Stress reduction was noted in both physiological and psychological outcomes. Not only was the salivary amylase level lower at 8 weeks in 1 of the 2 studies that measured this biologic marker of stress, but nurses' self-reports of negative emotional reactivity to stress, anxiety, depression, or interference with social functioning were also lower at 4 and 8 weeks.12,14–18 In many studies, mindfulness increased attention awareness, self-compassion, and sense of coherence.10,12,13,15,16,19 These salutary effects of mindfulness led to less frequent reports of various components of burn out: secondary trauma, emotional exhaustion, depersonalization, and low personal accomplishment.10,11,13,14,17,19 These mindfulness effects seemed to not only buffer nurses from burnout, but also promoted greater work and life satisfaction.13,20The majority of evidence for MBSR as a self-care modality for nurses represents level B evidence (Table 2). Although sample sizes were small, many studies demonstrated that a mindful practice is associated with holistic mind/body/spirit benefits for nurses that can begin after short-term use. The mechanism of action for mindfulness may be explained through a set of 4 interacting components.22 The first component, attention regulation, involves sustained attention, with returned attention on the main object of focus upon distraction. Body awareness is the second component, where attention is focused on subtle bodily sensations to enhance attunement with one's body. Emotional regulation, the third component, involves practicing nonjudgmental awareness of one's emotional responses in the moment. The last interlocking component, change in perspective of self, arises from detachment from the view of an unchanging self. Together these mechanisms enhance self-regulation, producing the favorable effects associated with mindfulness.Ongoing practice of mindfulness and integration of mindfulness into one's self-care routine is essential. The brief mindfulness interventions used in some studies in this synthesis may explain their lack of significant change in outcomes like burnout prevention or work satisfaction.17 Thus, the frequency of a nurse's mindfulness practice will most likely influence how effective this integrative approach will be in influencing his or her biopsychosocial outcomes. In other words, positive results are hinged on regular practice.9 One nurse expressed the catch-22 of incorporating mindfulness into everyday life: "You need it most at times when it is hardest to make it a priority."17(p121)A few studies in this synthesis examined feasibility outcomes for the MBSR programs. Participation rates ranged from a low of 13%4 to a high of 90%.20 Nurses in one study16 shared that their reason for participating was based on a conscious choice to find ways to reduce stress. Gauthier and colleagues17 commented that increased participation of nurses may have been due to the facilitation of MBSR in the workplace. This explanation is supported by nurses who expressed how helpful it would be for staff to be able to take 10 minutes for mindfulness when stressed in the moment at work.17 On the other hand, Shapiro and colleagues12 reported a 44% drop-out rate. Nurses in this latter study reported lack of time and increased responsibilities as the biggest barriers to incorporating an MBSR program into their lifestyle—a finding that further underscores the challenges nurses experience in prioritizing time for their own self-care. Finding ways to integrate mindfulness into the workplace, even if in brief segments, warrants further research and exploration in practice.By learning to quiet one's inner voice, mindfulness can increase resiliency that not only benefits nurses personally but also improves their effectiveness and safety in clinical practice. In one study, clinicians with higher mindfulness were more likely to use patient-centered patterns of communication such as building rapport, positive emotional tone, and discussion of psychosocial issues. Other studies have demonstrated that mindfulness of clinicians was associated with higher satisfaction among patients, specifically for overall satisfaction and patient-provider communication, as well as satisfaction with nurses and therapists.23,24 In addition to promoting patient-centeredness, mindfulness contributes to greater patient safety. Mindfulness enhances attentiveness and, thus, one's ability to identify patterns of thinking that can lead to diagnostic errors, as well as untoward patient events such as medication errors or falls.24–26 This evidence suggests that patients reap the benefits of nurses' self-care as well. So, go ahead, put on your oxygen mask first … so many patients are counting on you!

Top-Down Control-Signal Dynamics in Anterior Cingulate and Prefrontal Cortex Neurons following Task Switching

INTRODUCTION Postgraduate Year 1 (PGY1) doctors face various challenges transiting from medical students to doctors. This period of steep learning curves and increased stress[1] can affect clinical performance and patient safety,[2] and lead to mental health issues.[3] Mindfulness and reflective practices have been shown to help equip junior doctors with coping mechanisms to reduce burnout and improve resilience.[4] Mindfulness involves paying attention to purpose, being in the present moment and doing so non-judgementally,[5] aiming to develop a greater understanding of oneself and the situation. Reflection is a meta-cognitive process that occurs before, during or after situations, similar to mindfulness in its purpose of developing a greater understanding of internal and external factors to gain new insight and learning for future improved practice.[6,7] Mindfulness practices have been associated with positive outcomes among doctors, including improved well-being,[8] reduced stress[9] and enhanced resilience.[4,10] Reflective practice is also well established in professional development.[11] As advocates for junior doctor well-being, we implemented a mindfulness and reflective practice pilot programme (MRPP) for our PGY1 doctors. We aimed to explore the impact of the MRPP using an outcomes-logic model. Recognising that the dynamic and stressful work environment with limited time and resources may be a barrier for successful implementation of this programme,[12] we also aimed to explore the barriers to and factors in sustaining our programme for future cohorts. METHODS This was a mixed-methods study with qualitative data obtained via group interviews and validated surveys completed by the participants. We adopted an exploratory research design as a broad-ranging, purposive, systematic, prearranged undertaking designed to maximise the discovery of generalisations leading to description and understanding of an area.[13] Group interviews were conducted to obtain and understand opinions in a natural setting.[14] Group interview was chosen over individual interview, as the nature of the topic was suited for discussion in a group setting (since all participants had undergone the same MRPP) and it saves time. This was a single-site study conducted from May 2019 to December 2019. The MRPP included elements from a validated programme, Mindfulness-Based Stress Reduction (MBSR) developed by Jon Kabat-Zinn.[5] The MRPP was led by a clinical psychologist trained in MBSR and reflection. Over each 4-month posting for PGY1 doctors, seven out of 12 weekly protected housemen teaching sessions were allocated for the MRPP. Sessions began with a short didactic teaching component (15 min), followed by interactive games or hands-on activities for concept demonstration (15 min). Significant time was allocated for in-depth reflection and exploration of real-life work scenarios facilitated by the psychologist (30 min). Senior doctors were invited to certain sessions to provide additional perspectives. The sessions were centred around a specific learning theme [see Supplemental Digital Appendix 1 at https://links.lww.com/SGMJ/A66].[15] Participants also learnt and applied different mindfulness techniques during the MRPP sessions. Ethics approval was obtained from National Healthcare Group Domain Specific Review Board (DSRB: 2020/00170). Group interviews were conducted by the same interviewer via the ZOOM video-conferencing platform. The authors jointly developed the interview guide [see Supplemental Digital Appendix 2 at https://links.lww.com/SGMJ/A67]. Interviews were audio-recorded. Discussion notes were jointly summarised by the interviewer after each interview. An independent party transcribed the recordings, after which any omissions or transcription errors were corrected. Maslach Burnout Inventory (MBI) and 25-item Connor–Davidson Resilience Scale (CD-RISC 25) were the validated scales used to measure burnout and resilience, respectively. An outcomes-logic model was utilised in this study, as this model pays critical attention to the relationships between programme components and the components’ relationships to the programme’s context.[16] Outcomes-logic model works best when the programme is a dynamic system; it allows the implementers to study the intended and unintended outcomes emerging from the programme.[17] There are four components in an outcomes-logic model: input, activities, outputs and outcomes [see Supplemental Digital Appendix 3 at https://links.lww.com/SGMJ/A68]. The input component comprises all relevant resources such as funding resources, facilities, faculty skills, staff time and relevant institutional culture. The second component, activity, is the set of ‘treatments’, strategies, innovations or changes planned for the educational programme. In our context, it will be the MRPP. This activity will require proper planning and underpinned educational theories for successful implementation. The third component, output, is defined as the indicator that one of the programme’s activities or parts of an activity is underway or completed, and that something (a ‘product’) had happened. This may include the number of participants attending, number of modules created or the number of experts produced. Lastly, the outcomes component consists of short-, medium- and long-term changes intended as a result of the programme’s activities. The outcomes that we anticipated after the participants went through the MRPP include demonstration of awareness in their own coping and wellness, implementation of reflection in their daily life, and reduction in burnout. In addition to these four components, context, such as social and cultural features, is crucial and will influence the success of the implementation.[17] Based on this model, we implemented the MRPP and explored whether the outcomes have been achieved. Data analysis was performed by two of the authors (SSL and YLL), who read each transcript thoroughly before thematic analysis.[18] Given the exploratory nature of this research, we used inductive coding, interpreting the raw data towards generating codes. The two authors coded the data independently before gathering to obtain a consensus. Potential themes were then generated for similar codes, and the codes were clustered to form categories and eventually themes. The researchers came together again for discussion on the process of generation of themes to check if there was a good ‘fit’ between the themes and the coded data. This process was carried out until a definite set of themes were decided. Quantitative data was analysed using IBM SPSS Statistics version 23.0 (IBM Corp, Armonk, NY, USA). Comparative statistics were done using chi-square test for categorical data and t-test for continuous data. RESULTS Of the 18 participants who attended the MRPP over the study period, ten agreed to the interviews (55.6% response rate). Four themes emerged from the thematic analysis. The themes were integrated into the outcomes-logic model [Figure 1]. A summary of the themes and sub-themes is presented in Table 1.Figure 1: Diagram shows the overview of themes from qualitative data assessing our mindfulness and reflective practice pilot programme.Table 1: Themes and subthemes with selected quotes of interviewees from group interviews.Theme 1: Techniques applicable to learners In general, PGY1 doctors were able to learn and apply the techniques taught to them. The top three techniques included breathing exercises (40 coded phrases), reflection (20 coded words/phrases) and mindfulness practices (11 coded words/phrases). The mention of reflection related to in-session sharing activities and self-initiated reflections. Mindfulness was a term that encapsulated all the techniques taught in the programme. Other specific techniques such as body scan and relaxation exercises were also brought up. Another subtheme was the relational aspect where ‘specific stories’ allowed the participants to relate to the scenarios shared. Theme 2: Conditions for successful implementation Participants commented on tangible issues for implementation: practicality of the techniques, resources, timing, topics, duration and frequency of the sessions. Participants felt that they might not have energy left after work to practise what was taught, especially during busy workdays, and that it can be time consuming to practise. Participants also felt that more frequent and longer sessions would be useful in solidifying concepts and application. Regarding topics, participants felt that ‘personal life, relationships and spiritual’ topics were not ideal topics for discussion. The timing of the session was sometimes stressful due to workload in the mornings, when these sessions were scheduled. The ‘psychological atmosphere’ was another subtheme raised; some positive points highlighted included good support from peers and seniors, which was appreciated by the participants. The presence of seniors in some sessions made some feel less ‘open’ to share experiences; however, there were also those who felt confident in doing so in a psychologically safe environment. The role of attendees was the next subtheme; participants highlighted the role of the facilitator (psychologist) facilitating the session, particularly in picking up on issues and directing the discussions. The role of seniors was helpful, as their perspectives reassured the participants that their seniors also had similar experiences. Participants also aspired to be like their seniors. The department culture of allowing protected time for these sessions was well received by the participants. Theme 3: Short-term effects A major theme was the short-term effects of the MRPP. These included the ability for cognitive regulation, which helped participants in ‘thought process(ing)’ and thus, in decision-making. The MRPP also taught participants emotional awareness and ways to regulate emotion. Other positive short-term effects included nurturing values such as ‘patience’, ‘being kind’ and ‘empathy’. Additionally, participants reported being able to do reflections more proactively and share them more readily with other participants during the sessions. Theme 4: Potential long-term effects Long-term effects of the MRRP included participants having their own psychological strategy as part of their coping mechanism. Subthemes included the application of the MRPP in both clinical practice and daily life. Another subtheme was the challenges in continuation of practice after the programme ended, with heavy workload and difficulty in retention cited as the main factors. These main factors stemmed from the same reason, i.e., the participants felt less competent to practise techniques after having changed their clinical posting from the initial paediatric posting. This shift in posting resulted in a faster-paced environment with a heavier workload, which in turn reduced their free time and mental capacity to continue the practice of mindfulness and reflection. Significantly, the change in posting also meant cessation of the MRPP, which had acted as an efficient and constant reminder and an outlet for practice. Other innate factors cited included individual choice or personality traits. All 18 participants completed the study questionnaires. After the MRPP, the, prevalence of burnout on the MBI was significantly reduced (from 61.1% to 16.7%, P = 0.02). This improvement was most marked in the emotional exhaustion domain of the MBI (from 66.7% to 27.8%, P = 0.04). Mean resilience scores on CD-RISC 25 showed improvement from 66.2 to 70.8, although this was not statistically significant (P = 0.15) [Table 2].Table 2: Pre and post-intervention MBI outcomes and CDRISC 25 scores for participants of the MRPP.DISCUSSION We used the outcomes-logic model to evaluate the impact of the MRPP. While some outcomes we would like to achieve in the model (such as increased reflection process, staff wellness and reduced burnout) were put forward, we found that the participants gained more than the anticipated outcome. We found that PGY1 doctors were able to retain the key techniques taught (such as cognitive and emotional regulation, and reflection), allowing them to access these techniques even beyond the sessions. The ability to practise these in their daily lives translated to positive effects both in the short and long term. Our findings of the positive impact experienced are consistent with studies reporting that such programmes improved emotional stability, awareness and regulation[19] and also confirmed greater improvements in burnout with increased self-reflection and resilience.[4,10] We believe that our programme can help with cognitive regulation and equip PGY1 doctors with the ability to manage the risk of burnout and improve resilience as they continue to negotiate challenges throughout their career. In addition, they were able to bond better with their colleagues through these sessions, which improved their peer relationships even outside of work. While the short-term benefits accrued from attending the MRPP are apparent from our interviews, we believe the ability to change practice — in which mindfulness and reflective thinking become a natural part of coping — would be a true reflection of the success of this programme. To ensure better retention of the skills learnt in the sessions, we recognise that seven sessions may not be sufficient to allow for adequate application. Increasing the frequency of sessions and continuing these throughout the PGY1 year may lead to more opportunities for practical application (duration of the sessions was also brought up by the participants). The curriculum for the programme, including specific topics for discussion, needs to be planned carefully. Participants preferred to discuss matters confined to work and professional relationships instead of their personal life, relationships and spiritual topics. In addition, while there was openness in sharing about work-related topics, the people present in the sessions made a difference; the presence of seniors may pose a challenge to more open sharing. This finding is not surprising and echoes sentiments from published literature.[20] We believe that a fine balance is needed in this aspect; while confidentiality and psychological safety are important in sharing, there are benefits to having certain faculty members in the sessions to receive feedback and clarify any issues pertaining to the workplace that the participants may have. Another benefit of seniors’ participation is that the sharing of their personal journeys and challenges may promote solidarity, empathy and inter-rank collegiality, which may in turn enhance workplace well-being.[21] Our results have also highlighted aspects that educators and administrators can improve on when planning and continuing such programmes, particularly to ensure sustainability in supporting junior doctor well-being. Tangible issues such as practicality of techniques and timings should be addressed. We recognise that PGY1 doctors are busy with the stressful demands of clinical work and must balance work schedules with attendance at these sessions. Work commitments have been cited as a significant barrier to attending such programmes.[22] Protected time and a culture that prioritises junior doctor well-being are helpful in enabling PGY1 doctors to attend sessions without feeling that they are compromising clinical work. Support from leadership and seniors is thus essential and has been shown to enhance the effectiveness of such courses.[23] Importantly, our experience highlights that the structured delivery of a mindfulness and reflection-based curriculum for junior doctors can be feasible and potentially beneficial for participants. A particular strength of our MRPP is that the programme had been curated specifically to cater to the needs of our PGY1 participants locally, with topics and practices that are applicable and culturally relevant for the local context. We hope that our positive experience with the MRPP will be a catalyst that initiates conversations about the potential implementation of similar programmes locally or in the wider community. We recognise several limitations of our study, which may prevent a wider adoption of the MRPP. The programme was conducted during a paediatric posting that has different clinical demands from other postings, potentially affecting the participants’ mindset. However, PGY1 duties tend to be similar regardless of discipline. Our pilot programme was conducted in a small group, which may limit the overall perspectives shared. Nonetheless, the three group interviews achieved data saturation from the thematic analysis. As the interview was voluntary, those who agreed to participate may be a self-selected group who might have positive inherent traits and thus, higher positive perceptions of the programme. As we wanted to ensure anonymity, we did not collate reasons for those not willing to participate in the study. We recognise the use of interviews is subject to recall bias, and the responses may be affected by their current situation at work or in their personal lives. While there were potential ‘long-term’ effects gathered from the participants, the interviews were conducted within 4 months after completion of the posting. This and the lack of repeat of the objective validated measures (MBI and CD-RISC 25) after a longer period since leaving the posting precluded confirmatory findings on sustained benefits of the MRPP. Overall, our PGY1 doctors had positive perceptions of the impact of the MRPP and were able to adopt techniques that benefitted them, at least in the short term. Our exploratory research identified tangible issues in the implementation of this programme. These issues need to be taken into consideration when implementing the MRPP on a wider scale, for the benefit of junior doctors. Financial support and sponsorship This research received funding from the National University Hospital Education Fund. Conflicts of interest There are no conflicts of interest.