This was a randomized, waitlist-controlled trial with a 1:1 allocation ratio, utilizing a simple random sampling method for recruiting eligible participants. The study commenced after obtaining due approval from the institutional ethics committee (AIIMS/IEC/20/733) and registration with the Clinical Trial Registry of India (CTRI/2020/11/029136).

The population for this study consisted of HCPs, including faculty members, resident doctors, medical students, nursing officers, and nursing staff posted at high dependency units, critical care units, intensive care units, and emergency departments of a tertiary care hospital in north India.

Infographic posters containing study procedures and contact details of the investigators were attached to the notice boards of the designated areas and circulated within the social media groups shared by HCPs. Interested candidates were contacted by phone after duty hours and briefed in detail about the study procedures.

Adult HCPs (18–60 years of age) employed at the host institute for the past six months were included after confirming free accessibility of mobile or a laptop device with good internet connectivity. Pregnant females and individuals already practicing yoga, meditation or any other stress reduction practice were not included. Participants were also excluded if reported having medical conditions like musculoskeletal disorders, uncontrolled hypertension, diabetes, cardiovascular disease, epilepsy, bipolar disorder, or schizophrenia.

A total of 124 individuals who showed interest were assessed for eligibility, and 98 participants were enrolled sequentially from March 2021 to November 2022. Figure 1 depicts the flow of events during enrollment (33).

Eligible participants were randomly allocated to the Experimental and Control groups in a 1:1 ratio using a computer-generated random sequence. Allocation concealment was implemented using sequentially numbered, opaque, sealed envelopes. Baseline outcomes were assessed after randomization.

A total of 62 males and 36 females were enrolled. There were 30 males and 19 females in the experimental group, while the control group had 32 males and 17 females. The average age for all the participants was 28.26 ± 3.547 years (age range: 21 to 39 years), for the experimental group it was 27.61 ± 3.610 years, and for the control group it was 28.90 ± 3.399 years. Both groups were comparable at baseline in terms of demographic variables like gender, age and job-role. See Table 1 and Figure 2 for details on the demographic distribution across the study population.

The mHealth-aided 12-week yoga-based meditation and breath Intervention was implemented using an online video conferencing application, “Zoom Meetings” (Version: 5.7.7 (1105) (zoom.us)). The intervention was based on Sudarshan Kriya, a comprehensive breathing technique that involves Ujjayi pranayama, Bhastrika pranayama, Om chanting, and rhythmic breathing, followed by resting in Shavasana. The entire 12-week intervention was divided into the following three main components:

Continuous variables were described using means and standard deviations. Counts and percentages were used to describe categorical variables. Continuous variables were checked for normal distribution using the Shapiro–Wilk test of normality, and parametric and non-parametric statistical tests were applied accordingly. An independent t test was used between two groups, and a paired t test was used within the same group for normally distributed outcome variables. For non-normally distributed outcome variables, the Wilcoxon Rank Sum test, also known as the Mann–Whitney u test, was used between two groups, while the Wilcoxon Signed Rank test was used within the same group. The Chi-square test was used to assess compliance within groups. A p value of ≤0.05 was considered as statistically significant. Effect size was estimated for all outcomes based on Cohen’s d using G*Power (Ver. 3.1.9.4) (36) and was interpreted as small (≥0.20), medium (≥0.50), and large (≥0.80) magnitudes (37). Post-hoc analysis of power was performed to check for type 2 error in primary endpoint outcomes between groups using OpenEpi (Version 3). All data was stored in “Microsoft Excel” (Version 2019) (Microsoft Corporation). Statistical tests were performed using “IBM-SPSS Statistics” (Version 26) (IBM Corporation, Armonk, New York). An ‘intention to treat’ analysis with a ‘last observed value carried forward’ approach was followed to minimize attrition bias. A sample size of 74 participants was determined using G*Power (36) based on findings from a previous study (38). An attrition rate of 20% was added to this, raising the total sample size to be 90, with 45 participants in each group.

A highly significant difference (p < 0.001) was observed after 12-weeks between the two groups for all the outcomes of MBI and PQL, depicting a large effect (Cohen’s d > 0.8) for EE, DP, PA, CS, BO, and ST (See Table 2).

Post-hoc analysis of primary endpoint outcomes depicted a power of 99.21, 99.38, 99.07% for EE, DP and PA, while a 100% for CS, BO and ST, respectively (See Table 3). No significant difference was observed after 12-weeks for the secondary outcomes of SBP (p 0.135), DBP (p 0.286), HR (p 0.117), Weight (p 0.207), Height (p 0.598), BMI (p 0.282), HC (p 0.137), and WHR (p 0.172) (See Table 4).

A highly significant difference (p < 0.001) was observed within the Experimental group for the outcomes of MBI and PQL, depicting a moderate effect (Cohen’s d 0.5–0.79) for EE, DP, PA, BO, and ST and a large effect for CS (Cohen’s d > 0.8). Within the control group, there was no significant difference observed for the outcomes of EE (p 0.51); CS (p 0.228); BO (p 0.294); and ST (p 0.533); however, DP (p 0.001) increased significantly and PA (p 0.018) reduced significantly (see Table 5). A significant reduction was also observed in HR within the experimental group (p < 0.001) but not in the control group (p 0.124). SBP (p 0.001) and DBP (p < 0.001) increased significantly within the control group, but no significant change was observed within the experimental group (SBP: p 0.289; DBP: p 0.109) (See Table 6).

EE involves energy drain, resulting in a feeling of being stressed and emotionally overwhelmed (34). Our results suggest that 12 weeks of yoga-based breath and meditation intervention significantly reduced EE among HCPs. This is supported by the findings of other yoga-based intervention studies (38, 39, 41–44). This decrease in EE can be attributed to the increase in parasympathetic drive due to regular practice of yoga, which helps calming down the stress response systems (32).

Yoga breathing modulates the hypothalamic–pituitary axis via hypothalamic and anterior pituitary vagal afferents (45, 46). Yoga practice brings about a state of calm alertness (32). Yoga also helps increase the production of well-being hormones like prolactin, oxytocin, and vasopressin (45, 46). It decreases production of stress hormones like cortisol and adrenocorticotropin while optimizing serum brain-derived neurotrophic factor levels (45, 46). Therefore, regular yoga practice might play a significant role in alleviating EE.

HCPs with high levels of EE are more likely to develop physical and mental health issues, further compromising patient care (1). Eventually, if EE is not managed, it may hinder patient care and decision-making (34). Our results add to the evidence that meditation and breathing practices can reduce both work-related exhaustion (47) and EE (48).

The present findings align with previous studies which have also reported a notable decrease in DP after participants underwent a yoga-based intervention. (38–41)

Yoga based practices have been shown to increase empathy (49–51), consciousness quotient (49), mindfulness (52–54), enhance prosocial behaviors (50, 55), and increase self-compassion (50, 54, 55). These benefits may also result in reducing DP.

HCPs with lower levels of DP and greater empathy can recognize and respond better to patient emotions and needs (56). On the contrary, when HCPs have high levels of DP, it can cause them to see patients as objects or tasks instead of individuals in need of care (1). This can lead to a decrease in patient-provider trust and rapport, ultimately compromising the delivery of healthcare (34).

Yoga based interventions have also been found to reduce interpersonal disengagement (47), cynicism (48), self-role distance (48), and improve social connectedness (57). These improvements can also be attributed to a reduction in DP. Whereas, high levels of DP can result in a lack of empathy, detachment from work, and work-related cynicism (34) and can add to lower job satisfaction, increased absenteeism, negligence, and even medical errors (1).

PA involves a sense of making an impact on one’s work and the people around them (34). In the current study, PA increased significantly for the yoga based intervention group, which is in line with the past findings (39, 42, 43). Literature also suggests that meditation and breathing practices increase professional fulfillment (47), professional efficacy (48), and have been associated with an increase in life satisfaction and self-esteem (58).

Yoga based practices have been shown to increase overall brain wave activity, increase gray matter, and enhance amygdala and prefrontal cortex activation (59). This increases interhemispheric brainwave synchronization, improves memory, attention, emotional control, and cognitive state (60).

Furthermore, yoga practice positively affects autonomic tone (61–63), improves heart rate variability (64), and enhances sleep parameters (64, 65), all of which are crucial for work-related productivity. Thus, regular yoga practices can help HCPs be more productive in their workplace and help achieve a sense of accomplishment and fulfillment.

When HCPs feel satisfied, it improves the quality of care they provide (34). This in turn improves organizational culture, increases job satisfaction, and reduces employee turnover (1, 6). On the other hand, low PA might cause HCPs to lose motivation (1), further hampering productivity, job satisfaction, and diminish patient care (1).

CS is about the pleasure one derives from being able to do one’s work well (12). Our study adds to past findings showing improvements in CS (40). Literature also suggests that yoga-based interventions can enhance professional fulfillment through self-worth, satisfaction, and a sense of contribution (47).

High levels of CS can make HCPs feel happier and more fulfilled with their work (12). This results in job satisfaction, motivation, better engagement, productivity, and quality care (40). Whereas, low CS can leave HCPs feeling exhausted, unfulfilled, and disconnected from their positive work (13). It adversely affects job satisfaction, care, and motivation (13). Eventually, HCPs may lose purpose and meaning in their work, decreasing their commitment and increasing turnover (1).

BO is one of the two prime components of compassion fatigue (12). BO is generally associated with a high workload and a non-supportive environment (40). The present results are in line with previous findings suggesting that yoga-based interventions can help improve BO (40, 57) Yoga also improves parameters of sleep, life satisfaction, and resilience (65), all three of which are inversely related to Burnout.

Yoga improves emotional awareness, which increases resilience by enhancing self-awareness and empathy for others (66). Yoga-based practices help increase interoception (67) and develop emotional self-regulation and awareness. Their regular practice improves selective intentional attention and helps develop a non-judgmental attitude toward one’s own experiences (65). This insight helps combat negative self-perceptions and help reduce self-criticism, negative reappraisal, emotional reactivity, and rumination (65) which play a crucial role in overcoming BO.

Since BO causes a gradual onset of hopelessness and a decline in job performance, it gets reflected by self-criticism and a feeling of lack of efficacy (12). Thus, yoga-based interventions might help HCPs to be self-aware and avoid self criticism. Simultaneously, it can help enhance their psychological resilience and enable them to better manage workload, even in challenging circumstances like viral outbreaks (65, 68).

ST refers to the second component of compassion fatigue and involves secondary exposure to traumatic experiences at work (12). Our results of a significant reduction in ST for the experimental group are novel when compared to past studies (40).

Evidence suggests Meditation and yoga breathing practices as effective tools in reducing anxiety and post-traumatic stress (68–70). Patients with post-traumatic stress disorder (PTSD) benefit from yoga-based practices in terms of emotional and physical resilience, stress, and energy (71–78). Yoga helps reduce PTSD symptoms by reducing stress-induced allostatic load and increases parasympathetic activity, leading to a decrease in physiological arousal (71).

Additionally, yoga reduces physical tension, increasing relaxation, attenuating automatic thoughts and behaviors associated with hyperarousal (72), thus enabling practitioners to achieve a state of calm and restfulness (55).

HCPs tend to face ST on a more regular basis in comparison to other occupational professionals (40). If unhandled, ST may cause fear, intrusive images and sleep problems (1). ST can impair an HCP’s well-being, increase their risk of mental health disorders, and reduce their ability to provide empathetic and effective care (1).

Considering yoga’s beneficial effects on psychological trauma, HCPs can benefit from yoga-based practices to overcome the negative effects of working as a caregiver, thereby preventing compassion fatigue and protecting one’s mental health.

Our study showed a significant reduction in HR within the meditation and yoga breathing group. This is a common finding for yoga based interventional studies (32, 45, 46, 64). Since all the participants were healthy adults, anthropometrics did not vary significantly post-intervention. However, a significant change in DP, PA, SBP, and DBP was observed within the waitlist-control group participants. These could be due to the stressful and demanding nature of participants’ jobs (1, 4, 5, 9–11, 79), as DP and PA are both components of Burnout, while stress is identified as a significant risk factor for increase in BP.

Yoga-based research studies suffer from shorter interventions and low compliance rates. This impacts the treatment effect of yoga, ultimately diminishing the overall evidence on yoga’s efficacy. However, our study used a longer intervention of 12-weeks, in comparison to past studies which ranged from four to eight weeks of intervention (38–44).

Longer interventions are associated with greater improvements in outcomes of psychological well-being and behavioral functions (80). This might be the reason for a greater effect on outcomes of our study, when compared to past research (38–44).

The mHealth-aided intervention allowed HCPs to choose their preferred time and space for practice, enabling them to incorporate it into their busy schedules. Further research can help establish the treatment fidelity of mHealth-aided yoga-based interventions.

Our study utilized a unique and thoroughly-researched yoga-based technique called Sudarshan Kriya (32, 45–47, 61–63, 70, 75). It follows a specific sequence of procedures that can be taught by trained individuals and implemented at home using simple and easy to follow instructions, therefore, making it suitable for prescription purposes. Since this was an online based intervention, the long-term effects of offline or in-person Sudarshan kriya practice also need to be explored in the context of Burnout and PQL.

Our study lacked blinding among the two groups and an active intervention for the comparator group. Future research can be strengthened by implementing blinding of participants and employing an active or sham intervention for the control group.

Researchers are also encouraged to utilize objective psychological, physiological, neurological, endocrine, and immunological outcome measures for deriving possible correlations with the domains of MBI and PQL. Further research is warranted to generalize our findings.