Extracurricular, structurally equivalent, concurrent, 60-min, online programmes were facilitated via zoom. Emailed post-session summaries included a link to a daily home practice for MBI participants and an offer to provide extra support. Participants excused themselves if they were not able to attend a session. The virtual classroom remained open for 5–10 min post-session for participants who wished to ask questions or to seek individual assistance.

The 6-week MBI was adapted from Williams and Penman’s 8-week self-help programme.³³ Theme-based sessions consisted of practices, activities and enquiries. Early sessions focused on attention to internal and external experiences without judgement.³³

Shortened practices included body and breath, mindful movement and the body scan.³³ Practices provided opportunities to recognise mind habits, such as autopilot, mind wandering and dreaming. Mini meditations introduced the Three Step Breathing Space (3SBS) separately before including it in its entirety in week 3.^33,34 The remaining sessions focused on learning to view thoughts as mental events, with practices like sounds and thoughts and exploring difficulty.³³ Attitudes of kindness and curiosity for the self, personal experiences and other people were encouraged throughout the programme but were encapsulated within a Loving Kindness meditation in session 5.³³

The 6-week SC psychoeducational programme consisted of common, evidence-based stress reduction techniques used in psychotherapy. An introduction to stress included the use of a stress wheel and awareness triangle exercises.^35,36,37 Thereafter, sessions focused on the role of emotions in heightening stressful experiences in conjunction with the awareness triangle to explore such experiences.^{38,39,40,41,42} Progressive muscle relaxation, journaling, a communication genogram, and identification of goals and values are examples of skills, which were shared as additional stress management skills.^{43,44,45,46,47,48,49,50} This took place within an encouraging, supportive environment, where participants reflected on the previous, present and future challenges in conjunction with psychoeducation and skills’ practice.

Symptoms of distress were measured with the user-friendly, standardised, CORE-OM.⁵¹ The 34-item scale includes positive characteristics and symptoms of mental ill-health in areas of well-being, problems or symptoms, functioning and risk. Examples include ‘I have felt optimistic about my future’, ‘I have felt able to cope when things go wrong’ and ‘I have felt criticised by other people’.⁵¹ A mean score is assessed for total (range 0–40) and individual domain scores. Internal consistency is high (α = 0 > 0.75, < 0.95), test–retest reliability is good for all domains, except for risk (0.87–0.91, risk = 0.64). Sensitivity to change following an intervention is described as ‘good’.⁵⁷

Participants’ well-being during the past 2 weeks was measured with the self-assessed, 14-item, mental well-being monitoring instrument, WEMWBS.⁵² Positive statements about thoughts and feelings include ‘I’ve been dealing with problems well’ and ‘I’ve been feeling confident’, which are answered on a five-point Likert scale. Scores range from 14 (minimum) to 70 (highest) with item responses summed. Strengths include its simplicity, item clarity, sensitivity to change, good internal consistency (α = 0.89) and high test–retest reliability (0.83 at 1 week).⁵⁸ It corresponds closely with other mental well-being scales.

The clearly worded, widely used PSS was used to assess participants’ self-reported, perceived current level of stress during the last month.⁵³ A five-point Likert scale ranges from ‘0’ (never) to ‘4’ (very often), with higher scores reflecting more perceived stress. Of the 14 items, seven are positively worded and are reverse scored. An example of this include ‘In the last month, how often have you felt that things were going your way’. All items are summed for a total score with a minimum of 0 (no stress) and a maximum of 40 (highest stress level). It has adequate internal consistency (α = 0.84, 0.85 and 0.86 for three samples).⁵³

The SCS-sf’s 12 statements reflect Neff’s⁵⁹ proposed definition of self-compassion, including self-kindness, common humanity and mindfulness, as well the reverse: self-judgement, isolation and over-identification.⁵⁴ Statements like ‘When I feel inadequate in some way, I try to remind myself that feelings of inadequacy are shared by most people’, and ‘I’m disapproving and judgmental about my own flaws and inadequacies’ are rated from 1 to 5. The negative subscale items are reverse scored before calculating the mean total score.⁵⁴ Useful with time-constrained participants, the SCS-sf has adequate internal consistency (α = 0.86), correlates closely the Self-Compassion Scale (long form) (α = 0.97) and is reliable when assessing the overall self-compassion scores in time-constrained settings.⁵⁴

A post-course feedback form recorded participants’ perspectives of their experience, including their reasons for having volunteered and how the course was helpful to them. Four scales, two related to self-reported adherence to daily home practice (per week and per day of formal and informal practices) and two Likert scales (1 [poor] – 5 [excellent]) for programme and resource ratings, were included. The data were analysed using SPSS. In order to monitor attendance, a register was kept for each session.

Theme 1: Change in the initial stress reaction: A positive change in participants’ initial stress reaction was associated with the use of different practices like The Pause (1.1.1), or 3SBS (1.3.1), and/or the adoption of a self-compassionate attitude (1.2.1). Nine participants reported feelings of being calmer and grounded, while 14 participants reported use of the practices, which contributed to their changed response. Participants’ increased self-awareness made it possible to de-centre from unhelpful mind habits (1.2), which contributed to increased personal agency (1.3.1). One of the participants reported that:

Theme 2: Positive change in relationships: Mindfulness-based intervention participants perceived that the mindfulness training had positively affected their intra- and interpersonal relationships.

Fourteen participants observed that they had noticed that they were experiencing less self-judgment, self-blame, self-anger and self-disappointment. Instead, increased consciousness, self-care and self-compassion (2.1.1.) were reported. An example of this includes:

Some participants attributed their increased self-kindness and associated improved mood to the positive changes in interpersonal relationships. Such changes involved a willingness to listen, to offer support (2.2.3), to be more understanding, as well as improved conflict management (2.2.1.). One of the participants reported that:

Theme 3: Feeling of a sense of community through course interactions: While the programme was offered during the COVID-19 lockdown, 11 participants in the MBI group reported feeling a sense of community as they met weekly and listened to each other’s experiences (3.1.1; 3.1.2.). One of the participants described this as being on the same journey together, while another found that:

Twelve participants found that the supportive way the programme was facilitated had contributed to their appreciation of the mindfulness training. The online context was noted as safe, comfortable (3.2.1), unpressured (3.2.2), as well as kind and encouraging. The presence of a facilitator was helpful as noted by this participant:

Theme 4: Time as a barrier to practice: The medical students reported that time was the main barrier to daily formal practice but less so for the informal practices. It was found that for 17 participants, the latter could be included in daily life with more ease (4.3.1–4.3.4). Twenty-two participants reported having experienced difficulties with time management, a physical space in which to practice (4.1.1–4.1.4), as well as emotional challenges which arose during meditation (4.2.3). Regular practice was associated with flexibility in relation to time and space (4.2.2), as well as the choice of practice as can be observed in the following two participants’ comments:

This contrasts with the comment:

As presented in Table 3, the themes, subthemes and statements of the SC participants are discussed. For participants, the programme contributed to an increased awareness of emotions (theme 1), changes in the way that emotions were managed (theme 2) and an increased consciousness in relationships with others (theme 3). Like the MBI group participants, the SC group reported that there were barriers to their regular use of the tools. Four participants reported that their management of stress was unchanged at the programme’s conclusion.

Theme 1: Awareness of emotions and reactions: One of the themes identified from 11 of the SC participants’ responses was that there had been an improvement in the awareness of their emotions and associated reactions (1.2.). Increased self-awareness had contributed to increased self-agency and self-kindness (1.1.1.–1.3.2.). The technique, which nine participants reported was associated with this change, was the awareness triangle (1.1.1.). As one of the participants reported:

Theme 2: Change in approach to dealing with emotions: Do not be consumed: The SC participants reported feeling calmer, relieved and more effective in managing their emotions. This increased self-compassion and self-agency were associated with analysing a situation and identifying solutions (2.1.1 and 2.1.2.) and/or flexibility in tool selection and use. This is visible in the following responses:

In addition:

Theme 3: Increase in consciousness in relationships with others: Theme 3 observed an increased interpersonal interaction between SC participants and their family and friends. This was characterised by some reporting that they experienced comfort from others when self-disclosing about their challenging experiences and/or emotions (3.1.1) and others reporting that they had helped others with their stress management (3.1.2). Another reported an intention to:

Theme 4: Barriers to engaging with tools: The barriers to more frequent use of the techniques which SC participants reported they had experienced during the programme were the presence of challenging emotions, time constraints, relationship difficulties, family responsibilities, fatigue and daily life interruptions. Seven participants reported time constraints (4.2.1.) as their most significant barrier to technique usage, followed by emotional challenges (4.1.1.–4.1.2.). This resulted in an attitude of avoidance as was noted by one of the participants that: