Table 6.

Reported outcomes: motives and central motives regarding the perceived effects of the training

Self-care Empowerment 1. Enhancing feelings of self-efficacy 2. Allowing self-care during leisure time. 3. Stepping out the hamster wheel	1. “Well, I just consciously brought the sole of my feet in contact with the ground, one by one, and this was instantaneously soothing, as if one is caressing oneself...It was such a sense of self-efficacy: I was able to easily do something good for myself.” (Person 14) 2. “I did some things more consciously, whether being out in the garden or doing sports. Just for myself. These things suddenly had a different quality to me.” (Person 01) 3. “I recognized this as a quality of its own, becoming aware of the fact that I need time and space in order to get in contact with myself and if I don’t find the time to just do a short mindful stop or to walk mindfully once in a while, then chances of establishing a good connection with the patients are low…and it doesn’t even take that much. Evidently, short time spans suffice.” (Person 21)
Mindful pauses in the midst of stress (Ger. Innehalten)*	1. “I stopped just for a short moment in very chaotic or critical situations and got myself out of that sort of vortex we can very quickly get in to here, where you start thinking all this is so horrible and awful and too much and when you take a step back, you notice it’s not necessary to take it upon you. And then the situation sort of widens and changes. I did that all the time.” (Person 05) *The name of this central motive poses a difficult translation situation. There is no English term that truly corresponds to the German expression of Innehalten. Innehalten implies shortly stopping in time in a conscious way. Participants referred to this skill as Innehalten in difficult or stressful situations which represent a specific training effect. Therefore we choose this descriptive translation as it transports better the quality of this effect.
Reduction of Rumination 1. Interrupting rumination spirals at work 2-3. Reduction of work-related thoughts after work (cognitive irritability).	1. “I′m a person who really worries an awful lot…and I am now more capable to interrupt this at an earlier stage: to say make a cut and see what good you can do in this very moment, and how you can change the situation towards something positive.” (Person 18) 2. “On my holiday I noticed very clearly that sending out compassion and practicing Tong-len for others, helped me to stop rumination on work. For 14 days I thought very little about it. Before, I often had difficulties to just call it a day and relax.” (Person 19) 3. “I tried the suggestion made in the training to formulate these, I would call them intercessions** for patients at home and this was great for me. I had the feeling, that in the moment I consciously went again into the problems of the people, wishing them well, I was liberated. That was rather surprising for me because when I first heard about it, my first thought was: in my free time I don’t want to deal with patients issues anymore, rather I want to distract myself. But then I noticed that distraction doesn’t really work. It is like a covering up. By doing this, I didn’t cover things up but handed them over.” (Person 10) ** means Metta -sentences
Reduction of empathic distress 1. Positive Re-appraisal of difficult care situations 2. Transforming difficult emotions 3. Reducing negative involvement with suffering	1. “I find dying situations less scary. I mean, nobody knows what is happening during death. It is something you cannot grasp and that can be frightening… I have had patients experiencing anxiety and unpleasant things. This [Metta] helps you to overcome those situations. It helps you to see the good and positive sides of it, to say O.K., accompanying them in such a situation can also be very beautiful.” (Person 18) 2. “We had, how should I put it, a very satisfied patient and a very overstrained wife, who was latently accusing every time she got in contact with the staff. Nothing we did was good enough for her…There is always a danger of taking these things personally: «you are not kind to my husband» or «you’re not doing a proper job ». In the past, I would have reacted defiantly, not towards the patient, but with the relatives. Now, before I drove to work, I consciously decided to encounter that with something positive, something warm. That allowed me to still create a warm atmosphere. This was very important for me.” (Person 09). 3. “I felt less responsible. I could be present with more equanimity. Well it wasn’t like calming down already but I didn’t feel like being called upon to change the situation by any means.” (Person 25)
Enhancing interpersonal connection skills 1. Being present with suffering 2. Connecting to the patient as a person. 3. Taking a bold step onto closeness 4-5. Embodying compassionate feelings	1. “I can recount some emotionally loaded situations, either because it was a difficult topic or because the other person was sad, or they were difficult for me, because of how stressed I felt, by having this feeling, I just can’t engage in the situation because there are so many other things that I have to do. Then, I brought my attention to the breath and tried the heart visualization and in two occasions I could strongly experience how relieving this was. I mean, I could develop compassion then, and stay in the situation. This was very beautiful for me.” (Person 23) 2. “I had one situation with a patient who is strongly anxiety-affected because she is leaving her youngest son and she is not sure yet how things will unfold, who is going to take care of him and so on. And although she took care of everything there is nothing there she can rely on with absolute certainty. I found that was a challenging setting of conversation. Then I tried to practice Tong-len… And I left the conversation more satisfied. I had the feeling I gave everything I got. I mean not only on a counseling level, but also on an interpersonal level.” (Person 25) 3. “There was a patient who was already in the dying phase…His family was also there. Somehow they were already waiting for him to die and remained quite distant and tense. I had the feeling something was wrong, that he needed something else. He didn’t need people sitting around and watching him in awe. In that moment I put my hand in his heart area and then it came out of me. This warmth, a feeling which I can’t really describe and which I could give to the patient. It was like saying to him: - everybody is here, everything is fine … you can let go. I expressed my gratitude to him and there was so much pouring out of me which I sent out to him. I said it is fine, you can let go and then he died…The relatives came to me afterwards asking –“what was that? Everything happened so quietly and it was a wonderful atmosphere.” (Person 18) 4. “That is the practice [Metta] I liked the most… because it was very concrete and I could visualize it here [touches the heart area]. This really did me very good. I find it interesting how this area immediately gets very warm…it was thrilling for me, to see my source of strength. I mean this is something I already know. I know the sources of my strength, but with the meditation I could localize them and give them a name.” (Person 22) 5. “During one interaction in particular I could realize how good this works. Simply by knowing, that through being present in my body, through becoming aware of my body I can irradiate so much and on the same time be able of receiving suffering. That just felt so good.” (Person 14)
Team Communication 1. Speaking openly about distress 2. Finding common ground on self-care issues 3. Dealing with conflicts in team	1. “I didn’t anticipate such openness, that everyone would participate so open mindedly. I wouldn’t have expected that so many people here have the same kind of problems... To realize, that ultimately all feel very similar to oneself. I found that very impressing, surprising and beautiful, to realize that one is not alone.” (Person 19) 2. “During one supervision session we agreed on the fact that our lunch break is not really a break. We declared that during this half an hour we don’t want to talk about patients. This certainly was an aspect fostered by the training. Otherwise it wouldn’t have been brought to light in this way.” (Person 19) 3. “I recently witnessed a tense situation between two team members. I thought, well this is going to be the usual old fighting and I perceived, that at some point they looked at each other smiling, saying ok let’s breathe deeply for a moment and there was a change of outlook and somehow the whole energy changed.” (Person 15)
Self-positioning as compassionate 1-2. Referring to professional expertise 3. Offering examples of compassionate work 4. Setting Ingroup /Outgroup boundaries to other areas in health care	1. “Being compassionate to the patients, conveying compassion and being there for them, is very clearly our task here. However, seeing this task from the perspective of those meditations made it easier for me.” (Person 14) 2. “I just finished my education as a grief counselor 1 year ago…As I just said, communication skills are integral part of our work.” (Person 27) 3. “I believe this is a capability to love you carry within you, in terms of loving not others, but persons. That doesn’t mean you must like everything they do. Love is the strongest among all positive feelings that we can have in ourselves. To come to the point where it can flow freely and you can stand up for it, is a process. Eventually this became natural for me. Not only to feel it but to show it. I mean, that’s what people confirm to me, and this touches me so deeply when patients say, Thank you very much! You did that very well! and I think to myself, I just washed them and bedded them, but there was probably something else beyond that, that caused them to notice: somebody is there for me, radiating calmness and presence…and that’s somehow compassion too.” (Person 01) 4. “I internalized this attitude only until I started working at the palliative care center. At the intensive care unit, when relatives were irritated, one just used to say they are annoying. Here you handle this in a total different way. You think to yourself they are worried or they feel insecure.” (Person 24)