Data were analyzed using a reflexive thematic analysis design with an inductive approach [44,50]. The steps followed were:

Ethical approval was obtained from Sunnybrook Health Science Centre Research Ethics Board (SUN-5492). All study participants provided prospective written informed consent.

Rehabilitation providers (n=20; see Multimedia Appendix 3 for participant demographics) who engaged in the SCHC course shared their experiences working in rehabilitation as well as their experiences with the course, thus resulting in 6 interconnected themes that portray HCPs’ intricate experiences. Only a subset of participants was interviewed, and we do not have information on the reasons why some individuals chose not to participate despite efforts to follow up after participation in the course (see Figure 1). This may have introduced self-selection bias, as those with more positive experiences may have been more likely to take part in interviews. The mean (SD) age of participants was 43.5 (10.5), the majority identified as women, almost one-third identified as White North American, and 96% worked in urban environments whereas one participant worked in both urban and rural areas. For an average of 13.6 years, HCPs worked primarily as occupational therapists and social workers, but there was indeed a vast spread of professions within specialist rehabilitation represented.

Participants spoke of (1) the nature of working in specialist rehabilitation, an interplay between longitudinal relationships and focus on adaptation, which heavily impacted (2) different perspectives on burnout in specialist rehabilitation and experiences with the course. Throughout the course, (3) a new perspective, less self-criticism, more self-compassion, was gained by many participants as they learned how to alter their self-deprecating attitudes. Once self-compassion was fostered using various techniques learned throughout course sessions, (4) growing recognition of the importance of compassion for oneself and others arose as participants learned how to extend their newfound sense of self-compassion to their patients, family members, and colleagues. Unfortunately, (5) challenges engaging with the SCHC course were inevitable as HCPs endured busy schedules and individuals varied in their comfortability being vulnerable in an online, group setting alongside their peers. Although it was reported by participants that the course helped cultivate self-compassion and enhanced their compassion for others, several factors limited the ability of HCPs to extend this compassion to their patients. These factors are described in the last theme: (6) challenges to sustaining self-compassion in specialist rehabilitation. Supplemental quotes categorized by theme are provided in Multimedia Appendix 4.

The first theme, the nature of working in rehabilitation, provides context into the aspects of working in rehabilitation that can render HCPs at risk of compassion fatigue, burnout, and STS and how these factors mirror and differ from those faced by HCPs that work in other settings. Reflecting on their experiences prior to taking the course, HCPs described how they are challenged with distinct stressors due to the nature of the specialty. Rather than curing, HCPs in this field are tasked with helping their patients adapt to new circumstances, often following life-changing illness or injury. Often, patients in rehabilitation are perceived by HCPs as initially resistant to adaptation as their expectations had not been addressed in acute care. Due to the nature of rehabilitation, HCPs build long-term relationships that can last from weeks to decades. HCPs may also connect with their patients on an emotional level, which can have positive and negative implications for well-being. Some HCPs endure long-term maltreatment from patients, and others are affected by the implications of difficult cases outside of working hours.

Like other HCPs, rehabilitation providers experience occupational stress from a lack of agency, large caseloads, staff shortages, time constraints, and excessive administrative work. Rehabilitation HCPs described how they often experienced moral distress when discharging patients to what were perceived to be unfit home environments, simply to meet organizational pressures around bed occupancy. Stress was accentuated for specialist rehabilitation HCPs when required to perform their duties, and sometimes colleagues’ duties, within an overwhelmed system.

These stressors, some of which may be unique to rehabilitation, some which are common throughout health care, made the SCHC course relevant for participants as they sought out strategies to manage burnout and build resilience.

Participants from different backgrounds and professional roles described the concept of burnout in various ways, whether they had learned about the concept from the course or elsewhere. Participants described experiences with burnout affecting numerous aspects of their lives, especially in relation to their work in rehabilitation.

Participant feedback suggested the SCHC course might help improve participants’ abilities to recognize and describe burnout and compassion fatigue, phenomena that were described as common. Indeed, burnout was described by participants as poorly functioning or performing at work. Accordingly, burnout was described as affecting more than one dimension of a person’s life, including emotionally and physically, which was seen to impact participants’ personal lives in an “…exponential downward spiral…” (Man, age 35 years).

Participants discussed burnout and compassion fatigue as distinct but related concepts. Specifically, participants described compassion fatigue as a concept constituting a precursor to burnout, which encompasses emotional exhaustion and limits the quality of compassionate care provided to patients.

Through attending the course, participants explained gaining a clearer vocabulary to describe burnout and compassion fatigue, enhancing their self-awareness and recognition of these phenomena in their daily practice.

The third theme speaks to gaining a new perspective when it came to teaching participants how to cultivate more self-compassion and less self-criticism. Participants recognized the importance of incorporating this new perspective to shape their attitudes about themselves and others in a positive way.

Following the completion of the course, most participants shared that the concept of self-compassion had been new to them. Most described being conscious of compassion for their patients, including the circumstances which would activate this way of being, but acknowledged not recognizing ever being compassionate to themselves. A common description across interviews was that self-compassion is more difficult to inculcate than compassion for others,

Frequently, providers described putting patient needs and work tasks before their own. Participants often recognized a tendency to self-criticize and be hard on themselves.

Despite this, participants described curiosity about the concept of self-compassion, seeming to recognize a clear need for self-care and lacking a resource to do so.

Participants reflected on gradually learning to recognize self-critical tendencies throughout the course and beginning to adopt new approaches over time, with deliberate attempts to incorporate compassionate responding to themselves. Recognizing the adverse effects of self-criticism, participants began to see self-compassion as humanizing how they responded to themselves.

Participants also noted that this had beneficial feed-forward effects in relation to others through common-humanity, with a renewed desire to alleviate the distress that all humans experience.

Participants described that recognizing the importance of compassion for oneself and others became more apparent throughout the course as they reflected on learning how to let go of their self-critical attitudes over time and focused on being kind to themselves, using the learned self-compassion practices, and listening to peers’ similar experiences.

Participants described that a fundamental premise to fostering self-compassion is recognizing it is okay be kind to oneself, even as an HCP “it’s okay sometimes to just step back and take care of yourself first, before other people,” (Woman, aged 53 years). Participants reflected on using self-compassion practices more naturalistically in their day-to-day lives as the course progressed while others described using what they had learned to incorporate in their clinical care of patients, or in their professional lives with students, or in their personal lives with family members.

Participants iterated a perceived importance of regularity of the self-compassion practice as a means of developing the skill and driving lasting change. In this regard, the course environment appeared to motivate continued engagement with the self-compassion practices, where participants described being inspired by others’ reflections on personal insights and use.

Indeed, the online nature allowing providers from otherwise separate rehabilitation sites reinforced a sense of camaraderie and solidarity.

Setting work-life boundaries, “not taking any work home” or “not looking at emails,” (Woman, aged 26 years) was also deemed a crucial element to self-compassion by participants, who described this as necessary to maintain their own well-being and ability to provide compassionate care to patients. According to HCPs, developing an understanding of cultivating inward compassion, through learning and applying specific strategies, played an integral role in fostering a grounded and clear mindset needed to extend compassion toward others.

Participants described several barriers to course participation from the method of course delivery to challenges with course content, as well as individual variation in level of readiness to engage in sensitive conversations. A striking insight shared was that to make time for course engagement, participants had to give up time spent charting during their lunch-hour (ie, investing time in themselves came at a cost, causing anxiety surrounding completing work later in the day.)

Other challenges noted included a sense of discomfort in connecting emotionally to others online and participants worried about how exposing oneself in this way might undermine their professional identity,

While some HCPs found aspects of the course to be conducive to engagement (eg, the diversity of attendees and the online format), there were many suggestions for improvement which primarily focused on timing, mode, and content. Suggestions did not follow a specific pattern and varied from implementing an asynchronous course to hosting the meetings before working hours to limiting the group to a smaller size. A persistent suggestion was tailoring content to typical challenging rehabilitation scenarios and implementing a follow-up course to reinforce new skills.

Several barriers to being compassionate in rehabilitation beyond course completion were perceived, ranging from individual (eg, changing habits) to systemic (eg, heavy workload) in nature. However, following course completion, participants explained that by necessity they learned how to implement self-compassion practices from the SCHC spontaneously in their daily lives despite obstacles, such as stepping aside for a brief period to “ground” oneself during unbidden stress.

Perceived role stipulations were cited to challenge practices from the SCHC in specialist rehabilitation, where an explicit emphasis is placed on HCPs prioritizing physical function, and less attention paid to emotional distress which often underlies impairment and impedes functioning.

Participants also noted that implementing practices from the SCHC course could not address prevalent systemic issues directly, such as when patient and family expectations for rehabilitation were perceived as unrealistic due to not being addressed in the acute setting,

Systemic-level realities such as large caseloads, time constraints, and the fast pace of inpatient units were all seen as impediments to maintaining compassion, despite learnings from the course. Hinting at moral distress, there were clear depictions of the struggle to balance personal capacity (eg, energy) for delivering exceptional, compassionate care with the relentless demands of the work environment. This finding underscores the necessity of learning and implementing tools to foster self-compassion in an environment that may not inherently promote it.

In this exploratory qualitative study, specialist rehabilitation providers were provided with the opportunity to engage in the SCHC course online. Reflexive thematic analysis generated six prevalent and interconnected themes: (1) the nature of working in rehabilitation, (2) different perspectives on burnout in specialist rehabilitation, (3) a new perspective, less self-criticism, more self-compassion, (4) growing recognition of the importance of compassion for oneself and others, (5) challenges engaging with the SCHC course, and (6) challenges to sustaining compassion in specialist rehabilitation.

The nature of working in rehabilitation highlights the complexities of specialist rehabilitation that can render HCPs at risk of compassion fatigue, burnout, and STS. Not only does the focus of specialist rehabilitation—adaptation—contrast with the focus of acute care—treatment or cure, but also patient and families’ expectations of the goals of rehabilitation are rarely managed beforehand. Thus, managing expectations following a disabling life event becomes a daunting and burdensome task for HCPs to fulfill that extends beyond dealing with the emotional distress that may arise from completing their regular tasks. Additionally, the longitudinal nature of specialist rehabilitation affects HCPs in 2 capacities. On one hand, HCPs describe the value in getting to know their patients on a deeper level and the satisfaction of helping patients improve their functioning throughout time. On the other hand, HCPs may endure long-term maltreatment from their patients and their families if expectations are not managed properly and if functional improvements are not apparent. Further, these effects may persist outside of working hours, affecting HCPs in profound ways. Although familiar for specialist rehabilitation HCPs, these nuances may not be well understood among the general public [52,53], and effects on HCPs’ well-being are not always incorporated into organizational guidelines or well-documented in the literature [54,55].

The nuances that a specialist rehabilitation setting offers may expose HCPs to highly traumatizing experiences [8] which may contribute to a significant risk of burnout [56]. Most participants in this study were unclear about how to define or differentiate between compassion fatigue, burnout, and STS. Many had heard of the concept of burnout before the course and could speculate at its meaning based on personal or colleagues’ experiences. Most conveyed experiencing stress through providing patient care, some sounding personally traumatized. Participants discussed the course helping to grow their understanding of the concept of burnout and that it also provided a safe forum for discussing difficult experiences among peers who could understand, to the extent that this fed into suggestions for making the course even more relevant. Elsewhere, other self-compassion intervention studies have quantitatively reported reductions in symptoms of burnout among HCPs following participation or in comparison to a control group [57-60], and have also reported that HCPs developed an increased awareness of their own well-being [58]. In this exploratory qualitative reflexive thematic analysis, we did not assess quantitative changes in burnout pre- to postcourse, but participants did report that through participation in the SCHC course they became aware they may be experiencing burnout and also gained useful tools to combat these challenges. A better understanding among HCPs of how work in specialist rehabilitation can affect one’s occupational well-being may facilitate engagement with evidence-based self-care strategies and may feed into concerted efforts to change a culture in health care that raises the risk of burnout for many HCPs [61].

HCPs have ethical duties to do no harm and to act in patients’ best interests (eg, [62,63]), even if this means doing so at the expense of their own well-being, which is a prevailing and problematic cultural norm in health care [32]. Therefore, it is not surprising that participants described having an easier time being compassionate to their patients than to themselves. Most HCPs recognized that they are regularly compassionate to their patients yet had never labeled their actions as such. Even fewer participants acknowledged intentionally being self-compassionate while reflecting on their lives prior to the course. While the course attempted to emphasize the opposite, for many participants, to identify professionally as a specialist rehabilitation HCP, one cannot also show humanistic qualities. Whether this belief was perpetuated by personal factors or systemic norms and the complex association between necessitates future research. Being a “human being” (eg, being exhausted or not performing your best at work) lends well to practicing self-compassion, but for HCPs, having self-compassion was not possible without compromising professional identity. Accordingly, it appeared to take time for HCPs to gain a new perspective, less self-criticism, and more self-compassion to challenge their beliefs. In line with the findings of Neff et al [32], the SCHC course may be more beneficial for HCPs who report having low self-compassion to begin with, although in this study, changes over time were described retrospectively and not formally assessed longitudinally.

Following the new perspective participants described, many discussed the course being helpful in growing recognition for the importance of compassion for oneself and others. Participants found being intentional about one’s thoughts, feelings, and actions important when seeking to cultivate compassion and debriefing about difficult situations as a health care team an important mechanism to bring compassion to bear on collective adverse experiences. Descriptions of growing compassion may align with current quantitative evidence that mindful self-compassion interventions are successful in minimizing HCPs’ self-criticism [59] and improving self-compassion [32,57-60]. This study is the first study to report participant experiences of growing self- and other-focused compassion in specialist rehabilitation HCPs, despite these constructs not being assessed quantitatively.

The “new” concepts covered in the SCHC course were well-received by HCPs who were open to learning about how to improve their well-being by increasing their self-awareness and engaging with self-compassion practices. Similarly, existing literature affirms the importance of practicing the techniques from the SCHC course in a health care setting for oneself and for one’s patients [58,59]. Accordingly, promoting common humanity [64] and fostering communities of support [58] continue to be useful tools to promote compassion in HCPs.

HCPs provided both positive feedback and constructive criticism based on the delivery of the SCHC course. The online format provided participants with the flexibility to join from several sites across a large metropolitan area, and the diversity of professional roles was appreciated and contributed to a sense of common humanity when peers discussed similar experiences in their duties even across sites. Additional advantages that supplement previous research [57] include saving travel time and facilitating joining from home. One of the most notable suggestions was to tailor the content to include rehab-specific examples. This suggestion was also reported in recent reviews. Emphasis on the importance of contextual adaptation underscores the need for tailoring digital interventions to the specific group of HCPs they intend to be delivered to [38] (eg, rehabilitation providers). A 2024 scoping review specific to the assessment of online MBIs primarily using audio-guided programs also suggested tailoring interventions for groups of HCPs [25]. This change is likely to enhance acceptability but would necessitate further feasibility testing.

Despite participants’ acknowledgment of the benefit of self-compassion practices they learned, many noted challenges engaging with the course such as scheduling challenges, expected with busy HCPs [32]. Interestingly, not being ready to share personal struggles in a group setting was a less common challenge. It is possible that those who were unwilling to share did not participate in interviews entirely. The fact that some HCPs disclosed these feelings still emphasizes participants’ curiosity about the self-compassion intervention and the importance of having trained facilitators to handle challenges that may arise. While the group format (eg, the presence of unfamiliar peers) hindered some participants’ willingness to share and reduced their ability to build rapport with other course participants and facilitators, the added benefit of accessibility must be weighed with the impracticalities of in-person sessions. However, most participants appeared to value the format of the course. Also noted was the impracticability of engaging in self-compassion practices and actions at work, in line with Crandall et al [58] and in contrast to Delaney’s [59] findings that most nurses found their self-compassion practices useful on the job. The lack of suitable work environments to practice self-compassion (eg, a quiet location to engage in the “hand on heart” practice) speaks to the need for leaders and organizations to understand the need to focus on employee well-being and appropriate infrastructure change (eg, staff “recovery” rooms; [4]).

To provide compassionate care to promote better patient satisfaction [1] and healing [4], both individual and systemic factors should be targeted. Participants spoke of their complex patient populations and difficulties managing patient expectations to limit the compassion they were able or willing to give. Patients undergoing specialist rehabilitation often exhibit distress in more than one area of their lives (eg, physical and emotional) as they typically experience life-altering diseases or catastrophic injuries [65,66]). HCPs should be aware that patients are frustrated with their new realities or the health care system more generally, which can be perceived as dehumanizing both by HCPs and patients alike [67]. Speculatively, increased awareness of shared distress and common humanity through participation in the SCHC course may limit HCPs’ internalization of patient frustration, to instead respond with compassion, and this in turn may limit their risk of feeling burnt out, although this remains speculative and would have to be tested quantitatively to map out processes and determine proponent causality. Regardless, HCP training in compassionate care should arguably include strategies for helping identify the source of patient frustration and provide tools for HCP emotional awareness and regulation. Although not only rehab-specific [68], systemic challenges that feature in HCPs’ day-to-day include being overwhelmed with case numbers and not having enough time to complete their duties. From participant accounts, the guilt that comes with wanting to be compassionate, but not being able to, may perpetuate specialist rehabilitation HCP moral distress and feelings related to burnout, and the cycle is likely to continue if changes are not made. Policy changes facilitated by leadership that foster a sense of shared humanity and a healthy workplace environment are likely to tackle barriers to compassion, such as implementing protected time with management to reflect on challenges as well as taking short breaks throughout the day [69,70].

Although rich data were gathered to portray HCPs’ diverse experiences with workplace-related stress and the SCHC course, this study comes with limitations. First, generalizability to the population of specialist rehabilitation providers is restricted. The sample all worked in the Greater Toronto Area, which limits applicability of findings to other populations across Canada or countries outside of Canada, especially those from rural areas. Fewer HCPs are employed in rural compared to urban environments, which can intensify workplace stress and increase the prevalence of role sharing among rehabilitation disciplines [71]. Such factors may intensify HCPs’ experiences with burnout and thus, the course may need tailored in relation to the needs of the population served. For instance, rural HCPs may find themselves experiencing more debilitating workplace stress that may or may not classify as burnout, as they may take on additional roles outside their scope of practice or work more hours than urban HCPs. Despite this limitation, the sample was heterogeneous, containing people of various ages and professional disciplines in rehabilitation who attended most sessions. This study recruited participants from a specific geographical area due to the nature of the research protocol. Future iterations should consider expanding the sample to increase generalizability and assess feasibility on a wider scale, something which offering an online SCHC, as opposed to in-person, can help facilitate.

Further, it is entirely possible that participants who did not interview had different experiences with the course than those who did interview, reflecting potential self-selection bias. Common barriers for participation in qualitative research include the time requirement (eg, more time intensive than survey-based research) and lack of incentives [72]. Noninterviewees could have been too busy at work to participate in an interview and thus, they may have described more severe workplace-related stresses than the group who interviewed. All participants were offered gift cards to interview. In addition to time and incentives factoring into one’s decision, those who did not interview may have had poorer experiences with the course than counterparts who interviewed. Alternatively, nonrespondents may have felt as though the course was not relevant to them, which may explain the lack of desire to provide feedback. These characteristics may or may not have altered the themes that arose from this analysis if the nonrespondents provided interview data. Ultimately, it was difficult to conclude why the 6 participants did not choose to interview as they did not respond to our interview invites even after following up. Positive findings, including the perceived growth of compassion and course accessibility, should be interpreted while considering the potential reasons why a subset of participants chose not to interview. Nevertheless, the number of participants who interviewed was high and motivation for participation was captured, important pieces of the puzzle when analyzing acceptability of a program in a specific setting.

Social desirability bias, the tendency to respond in accordance with perceived socially acceptable characteristics or favorable outcomes [73], may have influenced interviewee responses. The more engagement with researchers students in a learning setting experience and the more stress in one’s life (eg, being overworked or experiencing burnout), the more likely participants are to respond to questions favorably, without responses reflecting their true experiences [74,75]. Social desirability bias may explain the tendency for participants to report that the SCHC course was helpful in growing their understanding of the concept of self-compassion or limiting feelings associated with burnout or workplace stress. Additionally, HCPs may fear disclosing burnout-related feelings due to stigma surrounding mental health issues, worries about it impacting their employment [76], or privacy concerns [77]. While semistructured interviews were used to gather responses, which may increase the effects of social desirability bias, the study coordinator limited her involvement during the trial to limit potential influence, being on camera only when necessary to solve technical issues or answer logistical questions. Furthermore, the purpose of the study was communicated to participants as not to solely provide tools to improve emotional well-being, but rather to gain insights into the experiences of engagement with the course. Questions were phrased from both sides (eg, in which ways was the course helpful or unhelpful?) or as neutral as possible, and participants were assured their responses would remain anonymous. Social desirability bias has been shown to be minimized in these ways (eg, [73]) and the mix of positive and negative responses, including suggestions for course improvement, help demonstrate this. Aside from the risk of socially desirable responding, online interviewing is liked by participants, easy to use by researchers and facilitators, and conveys perceptions of empathy and rapport well when used for qualitative research [40,41,78].

Participation in the online SCHC course appeared to help improve HCPs’ knowledge of the concept of burnout, validate common struggles with their peers, and teach them tools to foster self-compassion and compassion for others. Some participants experienced challenges feeling connected to the course and fellow participants because of the online synchronous format, course timing, and other barriers described. Accordingly, participants described program strengths and areas for improvement. Both positive feedback and constructive criticism provided by HCPs can inform the development of knowledge translation tools (eg, a website), educational sessions, organizational strategies to better support staff well-being.

This is the first study exploring HCPs’ experiences with the SCHC course in a specialist rehabilitation context. Variations of the course should be tested iteratively for acceptability, accessibility, and efficacy by adjusting course timing (eg, time of day), format (eg, synchronous), and class size in line with suggestions provided by our participants. The most prominent suggestion was to make content rehabilitation specific. Future trials should include concrete examples of stressors that may arise in rehabilitation when discussing the need for self-compassion so that participants can relate. Course delivery conditions also matter; protected learning time and continuing education credits may be required.

Accordingly, to better understand potential mechanisms of action and effectiveness (eg, by measuring pre- and postburnout, compassion fatigue, and STS scores), the next phase of research will compare the SCHC course and a matched comparator, such as a Health Enhancement Program. The Health Enhancement Program is an intervention specifically designed to match MBIs in terms of group context, instructor time and attention, education on health behaviors, but not on any content on mindfulness or self-compassion [79]. This would constitute a phase 2 randomized controlled trial design [80]. Additional future studies, such as one that gathers perspectives from health leaders (eg, Division heads) can provide valuable insights into organizational structures that may facilitate participation (eg, the availability of quiet spaces) and clarify responsibility for participation.

An online SCHC course appears relatively acceptable and accessible to some specialist rehabilitation providers, who noted gaining a deeper understanding of the concepts of self-compassion and burnout and discussed a desire to extend more compassion to themselves, their patients, and colleagues. Barriers to participation, such as difficulties making the time to join sessions and challenges with being vulnerable online were also discussed by participants, which may limit relevance for some busy HCPs. Self-compassion interventions like this one may be a useful strategy for improving HCPs’ well-being in a postpandemic context; however, optimization changes appear necessary to maximize relevance and use for all specialist rehabilitation HCPs, and this should be the focus of future research.