Hsieh H-F, Shannon SE. Three Approaches to qualitative content analysis. Qual Health Res. 2005;2005(11/01):1277–88. Qualitative findings corroborate the quantitative results of increased mindfulness, self-reflection, and empathy, providing a narrative that relates these three outcome values. Students’ accounts of their course experience link their exposure to mindfulness and other MBM practices to increased self-reflection, empathy, and recognition of self in the other. An interdependence between individual and group experiences constitutes the core of these findings, present on three levels. (see Fig. 1): During 2012–2019, uncontrolled quantitative and qualitative data were gathered from 112 student participants. Outcomes including changes in perceived stress (PSS), mindfulness (FMI/MAAS), self-reflection (GRAS), self-efficacy (GSE), empathy (SPF), and health-related quality of life (SF-12) were measured between the first (T0) and last sessions (T1). Qualitative data were obtained in focus groups at course completion and triangulated with quantitative data.

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In her paper on problems with psychometric evaluation of health based QoL, Güthlin [ 15] expands on the confounding effect of “response shift”. Outcomes of QoL measurements may reflect real changes or they may be the consequence of “response shift” - a cognitive change in the reference system of the patient or changes in the values and concepts held about health and disease [ 15, 30]. After course participation students reported an increased awareness of the connection between stress, well-being, and self-care practices. However, they also described their difficulties to implement and sustain MBM practices both personally and in the face of a wider academic and medical system often perceived as largely uncaring about self-care practices. Thus, while both qualitative data and a reduction in quantitative stress measure (PSS) support a beneficial effect of course participation on students’ well-being, the overall experience may also have resulted in a shift of values and views that adversely affected QoL appraisal. This study’s qualitative results show that stress relief and self-regulation were primary motivations, but other motivations, such as professional interest in MBM as a future tool for patient care, have also been reported. It is possible that students motivated primarily by personal stress relief benefit from course participation in a different way from others. Divergent study outcomes may thus be a result of their respective group composition. Aukes LC, Geertsma J, Cohen-Schotanus J, et al. The development of a scale to measure personal reflection in medical practice and education. Med Teach. 2007;29(2–3):177–82.

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The qualitative and quantitative findings of this study suggest that an MBM course implemented at Charité may have been suitable for reducing stress and fostering self-care practices among medical students. These improvements were described qualitatively as both immediate benefits from practicing self-care and a gradually gained sense of empowerment, by acquiring a toolkit capable of sustainably self-regulating stress levels. Ann Dutton M, Arun P, Talley J, et al. Mind–body skills training for improving emotional well-being in medical students. Explore. 2013;9(5):328. Schwarzer R, Jerusalem M. Measures in Health psychology: a user’s portfolio. Causal and control beliefs. Causal and Control Beliefs. 1995;01(011):35–7. Güthlin C. Response shift: alte Probleme der Veränderungsmessung, neu angewendet auf gesundheitsbezogene Lebensqualität. Z für Medizinische Psychologie. 2004;13:165–74. Ware J, Kosinski M, Turner-Bowker D, et al. How to score version 2 of the SF-12 Health Survey. Lincoln, US: Quality Metric Incorporated; 2002.

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MBM courses have been evaluated in studies using various self-reported quantitative scores, qualitative surveys, and stress biomarkers. While it was generally found to reduce stress and promote empathy, self-care, and well-being [ 1, 13, 14, 22, 23, 29, 33], results for respective quantitative measures, such as the Perceived Stress Scale (PSS), were not always consistent across studies [ 7, 13, 33]. Esch T, Sonntag U, Esch SM, et al. Stress management and mind-body medicine: a randomized controlled longitudinal evaluation of students’ health and effects of a behavioral group intervention at a middle-size german university (SM-MESH). Forsch Komplementmed. 2013;20(2):129–37. Dyrbye LN, Thomas MR, Huntington JL, et al. Personal life events and medical student burnout: a multicenter study. Acad Med. 2006;81(4):374–84. At a relational level, students` descriptions of group discourse reflect qualities of individual mental states fostered by MBM mindfulness practices such as openness, non-discursiveness and non-judgemental attitude. This study included quantitative and qualitative data, each gathered from 11 MBM courses conducted between October 2012 and February 2019. However, between 2013 and 2014, quantitative and qualitative data collection was not upheld for two consecutive courses. Demographic characteristics and SF−12 scores were introduced from October 2015 onwards. A total of 112 medical students were included in the quantitative data analysis. Since the first evaluation of demographic characteristics in 2015, there were 48 female (70.1%) and 20 male (29.9%) participants with a mean age of 26.2 years (range = 19–42, SD = 4.9). Qualitative data were collected from 11 focus groups comprising 87 participants (62 females, 25 males), with an average interview duration of 52.8 min.Bullinger M, Kirchberger I, Ware J. Der deutsche SF-36 Health Survey Übersetzung und psychometrische Testung eines krankheitsübergreifenden Instruments zur Erfassung der gesundheitsbezogenen Lebensqualität. Zeitschrift für Gesundheitswissenschaften. J Public Health. 1995;3(1):21. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84(4):822–48.