Mindfulness, as defined by Ronald Epstein in his aptly titled paper Mindful practice, is simply the manner of ‘attending to the ordinary, the obvious, and the present‘. He conceived mindfulness as ‘a quality of the physician as a person‘ which encompasses the ‘technical, cognitive, emotional, and spiritual aspects of practice’, and he identified its key feature as the ability to make health practitioners ‘act with principles and compassion‘.
Mindfulness has five major hallmarks, and these were explored by Karl Weick and Kathleen Sutcliffe in their paper titled Managing the unexpected: assuring high performance in an age of complexity. These five attributes of mindfulness are:
- A constant concern about the possibility of failure
- The ability to adapt when the unexpected occurs
- The ability to concentrate on a task while having a sense of the big picture
- The ability to alter and flatten the hierarchy to fit a specific situation
- Deference to expertise regardless of rank or status
One of the main ways by which mindfulness improves clinical practice, according to Epstein, is by fostering critical self-reflection during ‘ordinary, everyday tasks’. This capacity of mindfulness serves many clinical functions for physicians, and Epstein identified the following:
- It enables them ‘to become more aware of their own mental processes
- It enables them to listen more attentively to their patients’ distress
- It helps them to ‘recognize their own errors‘;
- It helps them to ‘refine their technical skills‘
- It helps them to ‘make evidence-based decisions‘
- It helps them to act more flexibly
- It enables them to ‘clarify their values so that they can act with compassion, technical competence, presence, and insight‘.
Beyond these, Epstein went further to demonstrate how the critical self-reflection that is engendered by mindful practice protects the physician from the deviations, the multitasking, and the technical and judgmental errors that characterise mindless practice.
Epstein explored another mechanism by which mindfulness improves clinical practice, and this is its ability to inculcate fluidity of mind in the practitioner. This is an open mind which he likened to the ‘beginner’s mind‘, and which he contrasted with the mind of the expert whose previous experiences may ‘delimit and confine observations‘ and thereby narrow the scope of ‘new diagnostic and therapeutic possibilities‘. The fluid mind, Epstein argues, enables the practitioner to welcome uncertainty, to conceive of difficult patients as interesting, and to see complex problems as questions for research. Mindful practice, he also added, alerts physicians to ‘the factors that cloud the decision-making process’, and it enables them to be ‘mentally and technically better prepared for the next situation’.
Erica Sibinga also explored the benefits of mindful practice in her paper titled Clinician mindfulness and patient safety. Apart from heightening the empathy and patience of practitioners, Sibinga showed that mindfulness also improves their mood and thereby reduces their risk of burnout. Mindful practice, she added, also opens physicians up to new experience, and makes them better able to trust themselves and others. Perhaps more importantly is the benefit of mindful practice on the patients of mindful practitioners who she said have an enhanced experience. Sibinga also argued that mindful practice improves patient safety by serving as an effective debiasing strategy against diagnostic error, and she said it does this by heightening clinicians’ awareness of their experiences, thoughts, emotions, and bodily sensations.
Unfortunately there are several barriers to the attainment of mindfulness, and Epstein listed the following:
- Unexamined negative emotions
- Failure of imagination
To overcome these obstacles to mindful practice, Epstein recommended such activities as keeping a journal, practicing meditation, reviewing recordings of patient sessions, using self-evaluation forms, undergoing peer evaluations, writing critical incident reports highlighting clinical and ethical dilemmas, and sharing family or illness narratives.
We have now completed our exploration of the clinical foundations of human error. We will next look at the systemic foundations of human error starting with organisational safety.