Drugs, indications, doses for achieving sedation and neuromuscular (NM) blockade during pediatric ETI.
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Endotracheal intubation (ETI) is one of the procedures that every physician attending critically ill pediatric patients must not only know but also getting the skills and experience necessaries to effectively perform.
In this chapter, we will summarize the most practical recommendations of ETI technique in children. In addition, we will discuss important anatomical particularities of the children’s airway. We include a section of devices that could help permeate the airway of pediatric patients with a difficult airway; and recent results of studies conducted regarding the association between the level of previous training in pediatric ETI and success rates.
Patient with an unstable airway. In this category, integrity of airway is affected by different infectious, anatomical and neurological diseases. Some examples are: (a) upper airway infectious (CROUP, bacterial tracheitis, etc.), (b) traumatisms, (c) congenital syndromes accompanied with macroglossia or micrognathia, (d) cystic hygroma, (e) branchial cleft cyst, (f) thyroglossal duct cyst, and (g) those patients with a large anterior mediastinal mass (non-Hodgkin lymphoma, acute leukemia, etc.). During childhood, the most common cause is infections [1].
Patient with neurological dysfunction secondary to trauma, seizures, metabolic disease, or toxic ingestion. Classically, we can find patients with a Glasgow Coma Scale (GCS) score of 8 or less, or a deterioration in the GCS score from 14 to 10.
Patient with impaired gas exchange:
Hypoxia. One of the most common indications of ETI. Clinically, the patient presents with respiratory distress, tachypnea, increased work of breathing, and an increase in alveolar-arterial gradient. Some causes of hypoxia are airway obstruction, hypoventilation, ventilation/perfusion mismatch, hemoglobinopathies, abnormal pulmonary diffusion, and intracardiac right to left shunt.
Hypercarbia. The pathophysiologic phenomenon consists of alteration in ventilation. There exists a reduced lung compliance and a V/Q mismatch increasing physiologic dead space. Alteration in ventilation can also be secondary to muscle weakness, altered mental status, exposure to toxins, or iatrogenic oversedation.
Patient with lower airway obstruction. Hypercarbia, tachypnea, increased work of breathing, wheezing, and a prolonged expiratory phase are characteristic. As lower obstruction progresses, dynamic hyperinflation and air trapping worsen, leading to a silent chest (inaudible breath sounds). This obstruction is common in asthma and bronchiolitis. We must remember that children can get intubated by this indication but it has been described an increase in mean airway pressure that may impede venous return. Therefore, under this indication children should only be intubated in EXTREME CIRCUMSTANCES [1].
Patient with a reduction of mechanical load, as seen in shock state and some patients with cardiovascular dysfunction.
By using rapid sequence intubation (RSI) method, a clinician can effectively achieve pediatric endotracheal intubation (ETI), however, we previously must identify if the patient has one or more of the following features related with a difficult airway [2]:
To have congenital abnormalities related with a difficult airway such as Pierre Robins Syndrome and/or Treacher Collins Syndrome.
A previous difficult ETI.
A poor mouth opening, large tongue or tonsils, small chin, short mandible, decreased neck mobility, and/or an evidence of partial upper airway obstruction.
Note: later in this chapter, you can find information about the causes, techniques, and a variety of devices a clinician may use for the management of children with difficult airway.
If it is not performed in an emergency setting (elective intubation), an informed consent must be obtained from the child’s parents explaining the technique, complications, and benefits of performing the procedure [3].
All the materials to be used should be functional.
Team should consist of three persons (at least).
Patient’s heart and respiratory rate, blood pressure, oxygen saturation, (capnography when available) must be monitored during the procedure.
Oxygen supply must be at least 10 l/min and suction equipment must be available and it must have pressures around 80–120 mm Hg.
An appropriate mask and bag for ventilation. We must select the mask size that fits the nasal bridge and the chin of the patient without covering the eyes (Figure 1). Bag used for infants and young children is named pediatric bag (which provides a tidal volume of approximately 400–500 ml); for older children and adolescents, an adult bag should be used (providing a tidal volume of 1000 ml) [3, 4, 5].
Endotracheal tubes (ETs). Uncuffed ETs are mainly indicated for neonates, infants, and young children (<8 years). The correct size of these ETs can be calculated according to the equation (child’s age/4) + 4. On the other hand, the formula (child’s age/2) + 3.5 might be used for cuffed ETs. Other methods to calculate ETs size include comparing the child’s fifth finger with the internal diameter of the ET or by using resuscitation tape such as the Broselow Luten tape, and it is recommendable to have one size larger and smaller of the selected tube.
Stylet. Adult sized for 5.5 tubes and beyond, pediatric ones for lower endotracheal tubes.
Laryngoscope handle and blade. The first one can be an adult or pediatric one, and the second can be straight or curved depending on the experience of the laryngoscopist. The blades used in pediatrics ranged from 00 (extremely premature neonates) to 4. Blades 0–1 are used for preterm and full-term neonates, size 1 for infants. At age 2, size 2 blade; at this age, a curved blade can be used. For ages 10 and above, a number 3 blade is recommended.
Colorimetric end tidal carbon dioxide devices or capnography monitors.
Tape or a commercial holder to secure the endotracheal tube.
Syringe for cuff inflation.
Nasogastric and orogastric tubes.
(A) The correct size for the child because it covers the area between nasal bridge and chin. (B) The mask elected is not correct, it covers part of the eyes of the patient. (C) The mask elected is not correct it covers the area far from the chin.
Tips and tricks
To remember all the preparatory equipment before starting intubation
You can use the STOP MAID mnemonic to remember all the preparatory equipment before starting ETI procedure:
Suction;
Tools for intubation;
Oxygen;
Positioning (sniffing position so that the external auditory canal is anterior to shoulder);
Monitors;
Assistant, Ambu bag with facemask, airway devices;
Intravenous access;
Drugs (sedation, neuromuscular blocking medications).
With all the necessary tools already prepared, next, we must position the patient for the denominated preoxygenation phase. This position consists in a sniffing situation avoiding hyperextension and/or hyperflexion of the neck. The correct sniffing position is the one with exterior auditory canal anterior to the shoulders (Figure 2).
(A) Correct sniffing position is shown the external auditory canal is anterior to the shoulders of the patient. (B) Incorrect position because neck is hyperextended. (C) Incorrect position because patient’s neck has hyperflexion.
Selection of ventilation technique relies on the number of persons available at preoxygenation phase:
One-person ventilation technique. The head must be positioned backwards, using the C-E technique and the chin must be elevated pressing and sealing the mask to the face. Sealing is very important. We may corroborate that ventilation technique is correct when elevation of the chest is observed (Figure 3).
Two-person ventilation technique. One member of the health care professional team will use the C-E technique but now with two hands while the other person will be pressing the bag (Figure 4).
One-person C-E ventilation technique is illustrated.
Two-person C-E ventilation technique. First person is doing a double hand C-E maneuver while a second person (not shown in the image) is pressing the bag.
After patient is positioned, then, ventilation must start with 100% inspired oxygen creating an oxygen reservoir. It is important to avoid hyperventilation. Therefore, a slow ventilation lasting around a second each must be applied being overall preoxygenation phase duration 3–5 min.
Premedication increases success rate of pediatric ETI independently from degree of previous training [6]. By using the rapid sequence intubation in children, success rate of 52% and a complication rate of 61% can be achieved [7], however, sedation can be omitted in obtunded or comatose patients and neuromuscular blockade must be avoided in patients with difficult airway. Table 1 summarizes the drugs, indications, and doses used for sedation and neuromuscular blockade during pediatric ETI procedure.
Medications | Indications | Doses (IV) | |
---|---|---|---|
Sedation | Etomidate | Hemodynamic instability, neuroprotective | 0.3 mg/kg |
Ketamine | Hemodynamic instability, patients with bronchospasm and septic shock | 1–2 mg/kg | |
Midazolam | It can cause hemodynamic instability | 0.2–0.3 mg/kg | |
Propofol | In hemodynamically stable patients | 1–1.5 mg/kg | |
Thiopental | Neuroprotection | 3–5 mg/kg | |
NM blockers | Rocuronium | For children in which succinylcholine is contraindicated | 0.6–1.2 mg/kg |
Succinylcholine | Do not use in extensive crush injury, chronic myopathy | 2 mg/kg |
Drugs, indications, doses for achieving sedation and neuromuscular (NM) blockade during pediatric ETI.
Clinician may most easily perform direct laryngoscopy by standing behind to the patient’s head and with height of the bed adjusted to the level of the laryngoscopist xiphoid appendix (Figure 5). After sedation and neuromuscular blocking, the clinician must perform a scissor maneuver to open mouth before laryngoscopy. Then, laryngoscope must be held in the left hand (regardless of dominance), inserting the blade in the right side of the patient’s mouth along the base of the tongue following the contour of the pharynx, and sweeping the tongue to the left.
Proper position of laryngoscopist and correct introduction of laryngoscope after opening patient’s mouth through a scissor maneuver (not shown).
Once the tongue and soft tissues are retracted, clinician must recognize the following anatomic structures: epiglottis, arytenoid cartilage, and esophagus (Figure 6). After identifying epiglottis, this must be elevated exposing the vocal cords by handling laryngoscope at a 45° angle. Next step, endotracheal tube (ET) must be inserted into the trachea by holding it (with right hand) like a pencil (Figure 7).
Tips and tricks
To identify epiglottis and/or glottic structures
If epiglottis and/or glottic structures are not visible, blade must be pulled back slowly until they are visible. Other useful technique for helping to identify epiglottis and/or glottic structures is the named “Sellick maneuver” or so known as “cricoid pressure” (Figure 8). To perform it, another member of the reanimation team slightly push the region of cricoid cartilage while laryngoscopist observes the structures and introduce ET.
To calculate ETT length insertion
ET length insertion can be determined by any of the following two formulas [5, 8, 9]:
#1- (Patient’s age (in years)/2) + 12
#2- ET internal diameter * 3
Note: we recommend first equation because it has been reported as more accurate.
A comparison between a real larynx and a model. Structures of the larynx must be identified before trying to insert ET. (A) Glottis, (B) Vocal cords. (C) Epiglottis.
ET is introduced like a pencil into the airway.
Sellick’s Maneuver (also known as cricoid pressure).
ET insertion in airway must be confirmed by the observation chest wall rise and down with ventilations, auscultation of breath sounds in both axillae and not heard over stomach, and, to observe an adequate oxygen saturation (>90%). Radiographically, a correct position of the tube is below the thoracic inlet and 3 cm above the carina (Figure 9). In case of ETT is located at esophagus or right bronchus, immediate measures must be taken to remove it and secure an adequate ventilation of patient (Figures 9 and 10).
In case of acute respiratory deterioration after intubation
Remember the mnemonic DONE which can help you to identify the probable causes:
Deviation of ETT to the main bronchus or misplacement during suction. Signs that can suggest this are asymmetric elevation of the thorax or asymmetric auscultation, specially the right hemithorax.
Obstruction due to secretions obstructing tube’s lumen.
Pneumothorax if are present signs as breath sounds diminished on the affected side, conduction of vocal vibrations to the surface of the chest may be increased, and hyperresonant at percussion.
Equipment, if problem is in the ventilator hardware or software.
X-ray on the left shows a misplaced endotracheal tube which is in the right bronchus. Right X-ray shows a correct placement of the endotracheal tube, where the tip is located above the carina.
ET located in esophagus.
ETI in neonates can be most commonly performed as an emergency procedure or as part of an elective or semi-elective treatment:
Emergency. When mask ventilation or non-invasive mechanical ventilation fails, in case of structural or congenital airway abnormalities, diaphragmatic hernia, prolonged cardiopulmonary resuscitation, if thoracic compressions are needed, surfactant administration and for direct tracheal aspirations if thick secretions exist [11].
Elective/semi elective. Prematurity, positive pressure ventilation lasting more than 1-min, in case of ET must be changed, and in patients with an unstable airway [11].
In comparison to older children, adolescents and adults, anatomy of neonatal upper airway structures is different, being neonates a subpopulation where the ETI becomes a challenge. Some of these differences are the following: (a) a tongue proportionately larger, in consequence, trying to sweep it during ETI might be difficult and its backward movement might result in an airway obstruction; (b) epiglottis is longer, narrower, less flexible, and sometimes omega-shaped; (c) a cranial position of larynx can be an obstacle for observing the glottis during laryngoscopy, being this issue the reason why is preferable to use straight blades rather than curved ones in neonates; and (d) trachea is proportionally shorter and narrower [12, 13].
It is important to highlight, that neonates <1000 g, >4000 g, or those with congenital craniofacial abnormalities have less chance to be intubated at first attempt, representing a subgroup of neonates with a difficult airway which require special attention [14].
On the other hand, each attempt of intubation in neonates provokes injury of the mucosa which subsequently leads to an inflammation decreasing the caliber of the field of observation, and therefore, making the intubation less effective. Currently, it has been recommended a limit of 20 s for each intubation attempt in neonates, and if it fails, the ET must be removed and patient must be ventilated with a mask-bag reservoir until recovery [11, 15, 16].
Tips and tricks
Premedication phase in neonates is different from older children
In neonates, premedication phase must be only used as part of an elective ETI and not for emergency situations.
The American Academy of Pediatrics (AAP) and the Canadian Pediatric Society (CPS) recommend a combination of vagolytic agents and neuromuscular blockers for premedication phase in neonates. Also, the AAP recommends that muscular blockers and sedatives must not be used alone without analgesia [3].
Tips and tricks
ET size election for neonates
Election of ET size based on neonate’s weight and gestational age:
Weight (g) | Gestational age (weeks) | ET size (internal diameter in mm) |
<1000 | <28 | 2.5 |
1000–2000 | 28–34 | 3.0 |
>2000 | >34 | 3.4 |
Two methods may be used, and the objective is to place the tip of ET in the middle portion of trachea.
DNT method
We must add 1 cm to the distance (cm) between the newborn’s nasal septum and ear tragus (Figure 11) [17].
Gestational age method (Table 2)
“7-8-9 rule” method: in 1979, Tochen described a simple equation for the ET insertion length based on patient’s weight at birth.
Gestational age (weeks) | ET length insertion (cm) from the patient’s lips | Weight (g) |
---|---|---|
23–24 | 5.5 | 500–600 |
25–26 | 6.0 | 700–800 |
27–29 | 6.5 | 900–1000 |
30–32 | 7.0 | 1100–1400 |
33–34 | 7.5 | 1500–1800 |
35–37 | 8.0 | 1900–2400 |
38–40 | 8.5 | 2500–3100 |
41–43 | 9.0 | 3200–4200 |
Gestational age method to calculate ET length insertion [18].
DNT method.
Formula: 1.17 * weight at birth (kg) + 5.58.
This equation has been supported by the AAP and the American Heart Association (AHA), establishing ET insertion length can be calculated by adding 6 cm to the newborn weight (e.g., for a newborn weighing 1 kg = 1 + 6 = 7 cm), from the patient’s lip [14].
Tips and tricks
ET length insertion when nasotracheal intubation is used
When nasotracheal intubation is performed, the ET length must increase in 20% (e.g., for a newborn weighing 2 kg: (2 kg + 6) × 1.2 = 9.6 cm). We must also take in consideration that the 7-8-9 rule can overestimate the insertion length in newborns with a birth weight less than 1000 g. In consequence, it is preferred to use the gestational age method (Table 2) [18].
Difficult airway can be defined as the clinical situation in which a conventionally trained physician has trouble for achieving an effective upper airway ventilation with a face mask, for tracheal intubation or both and where interact patient’s factors, setting conditions and operator skills [19]. First, we must evaluate child’s airway to identify those clinical, and/or laboratory factors that could make difficult to achieve ETI. Among the anatomical factors related with DA are the form and size of mouth, nose, mandible, neck, existence of masses or congenital malformations, and other childhood diseases that eventually could difficult ETI (Figure 12, Tables 3 and 4) [20, 21, 22, 23, 24].
Difficult airway for ETI based on modified Mallampati classification [25, 26].
|
Pediatric syndromes associated with DA.
Infectious | Traumatic | Neoplastic | Inflammatory | Neurologic | Other |
---|---|---|---|---|---|
|
|
|
|
|
|
Childhood diseases associated with DA.
DA devices can be classified according to the anatomical structure from where they will act and/or on their optical properties [27]:
It was developed in 1980 by Dr Archie Brain and forms part of the rescue devices in the ASA algorithm for the difficult airway management. It was designed to be situated in the hypopharynx, with an anterior aperture situated at the glottis entrance, the mask’s border is made of a silicone inflatable cuff, sealing the hypopharynx permitting positive pressure ventilation (less than 20 cm H2O). The mask is introduced using the index finger of the dominant hand as a guide towards the hypopharynx, following the palate’s curvature, until a resistance is felt, then the cuff must be inflated with a determined volume (the specific volume comes in a legend on the mask itself and depends of the number of the mask). Choosing the size mask depends on the weight of the patient. As complications of the procedure we can find aspiration of gastric contents, uvula, and pharyngeal pillars lesions (Figure 13).
Laryngeal mask.
In 2000 Brain published the description of a new laryngeal mask that tried to improve the airway’s protection against gastric aspiration. This was accomplished by including a second tube lateral to the airway’s tube and which in its distal end is located on the tip of the mask. This tube has the function of separating the digestive tract from the respiratory, and also Permits accessing the stomach with an orogastric probe (Figure 14) [28].
ProSeal laryngeal mask airway.
This type of laryngeal mask is designed with the objective of achieving intubation through the mask itself, it consists of an anatomically curved rigid tube, wide enough to accept in it endotracheal tubes this end is united to rigid metal loop that makes the insertion much easier, removal, and adjustment of the position with one hand only. Once installed, and ventilation achieved an ET is inserted, the mask is then removed maintaining the tube in place, with a specially designed stylet, so that after the mask is removed the ET remains in place (Figure 15).
FASTRACH or intubation laryngeal mask (ILMA).
Other type of Fastrach laryngeal mask (2005) with an incorporated camera, permits once it has been introduced into the hypopharynx, setting a monitor on the outer part of the mask so that it can be possible introducing an ET under direct vision (Figure 16).
New type of Fastrach laryngeal mask.
This device can only be used to ventilate in emergency situations. It was designed in Austria in the year 1980. Insertion is easy for any person and insertion is blindfold. It consists of a double lumen latex tube that combines the functions of an esophageal obturator and a conventional ET. Combitube has two balloons which inflate from the exterior. First one corresponds to an oropharyngeal balloon (85–100 ml of capacity) situated in a proximal position to the pharyngeal perforations with a function of serves as a sealing of the oral and nasal cavity; second one, is called traqueo-esophagic balloon, and needs a volume of 12–15 ml to seal the trachea or esophagus. Combitube can be placed either in the esophagus or in trachea, and in case of tube passes to the esophagus, the patient can still be ventilated because the perforations existing in combitube esophageal lumen, and the stomach can be aspirated from the tracheal lumen. In case of combitube is set in the trachea, the patient can also be ventilated from the trachea lumen (Figure 17) [29, 30].
Combitube.
Eschman Guide or Gum Elastic Bougie (GEB) is a semi-flexible guide of polyester covered in resin (to avoid laryngeal trauma). GEB has a 15-Fr diameter and can be introduced in 6 mm internal diameter tubes. Insertion technique consists of sliding the angulated tip underneath the epiglottis, then, dragging at the tracheal cartilages must be perceived (Figure 18) [31].
Gum Elastic Bougie (GEB).
In some countries, a lighted stylet is used for ETI, this is the called Trachlight. It is based on transillumination of the soft tissue of the neck with a high effectivity for achieving intubation in an approximate time of 25 s (Figure 19) [32].
Lightwand device (Trachlight).
They are laryngoscopes that carry in its distal blade’s end a high-resolution video camera to visualize the glottis and to introduce an ET without the need of observing the glottis directly but through a high-resolution screen which can be located in the same device or at the patient’s side. Among the main complications reported are the soft palate lesions (Figure 20).
Video laryngoscope.
Learning curve (LC) in the case of the direct laryngoscopy requires of approximately of 45–50 previous intubations [33], while LC for video laryngoscopy is around 5 attempts. ETI using a video laryngoscopy is possible with little training, due to transmitted image from the blade’s distal tip makes easier the visualization of the larynx entrance. When intubation attempts using Miller or Macintosh laryngoscopes or video laryngoscopy fail other methods to secure pediatric airway are recommended to be used (i.e. supraglottic devices). Recent studies have reported that ETI with video laryngoscopy even performed by less experienced medical personnel, increases significantly the success rate in the first attempt in comparison with direct laryngoscopy [34]; moreover, it has been reported that video laryngoscopy decreases the intubation time with less desaturation and less failure rate when it is compared with conventional laryngoscopy [35, 36]. Nevertheless, other video laryngoscope methods (GlideScope) implying other type of learning (mainly based on exploration), have resulted to be inferior to direct laryngoscopy regarding the time required for ETI [37].
Until date there is no standard definition for the term proficiency in pediatric/neonatal airway ETI. In a recent study, defined a formal training in pediatric airway management as having received at least 2 weeks of training by pediatric anesthesiology teachers. In that study was reported that after formal training, intubation success rate increased from 65.1 to 75.7% (p = 0.01), and it was observed a significant decreasing in the number of intubation attempts (p = 0.01). However, they did not find statistically significant differences in the time for achieving Intubation nor for the frequency of complications [38].
In a study conducted by Kerrey et al., where rapid sequence intubation technique was used, pediatricians in emergency departments and anesthesiologist had higher success rates (88–91%) in comparison to physicians in formation (45%) [7]. These results were similar to the reported by Goto et al. where intubation success was higher at the first attempt in pediatricians (OR 2.36; CI 95% 1.11–4.97) and in emergency room physicians (OR 3.2; CI 95% 1.78–5.83) in comparison to pediatric residents of the first and second year [39].
It has also been evaluated the skills for neonatal ETI between residents. Interestingly, skills significantly improved with a success rate from 27% during the first year of formation to 79% for the second year. Number of attempts also improved decreasing from 3.6 to 1.2 from the first to the second year, respectively [38]. This and other study results highlight the relevance of implementing training strategies from early stages of education in medicine to effectively achieve ETI in children with the less number of attempts and complications [6, 40, 41].
Recently, it has been mentioned that there are no differences in the learning curve or the skills for performing neonatal intubation by comparing live models versus ETI training models. Retention curves with a follow-up of 6, 18 and 52 weeks remain constant after 6 weeks and get lost after 18 and 52 weeks; although, retention is higher when skill levels are higher too [42, 43]. Additionally, it has been reported that educational interventions such as training sessions using didactic and simulation components have not been related with an improvement in intubation success rate; even, performance points decrease after 8 weeks of the intervention [44]. Importantly, other studies have not found differences in pediatric ETI success rate at first attempt by comparing groups with and without training [45].
It is important to highlight, that clinicians who attend critically ill pediatric patients requiring airway management know the rapid sequence intubation procedure, identify a patient with difficult airway, know the devices and techniques for the management of difficult airway, and look for receiving a formal training. Future strategies for teaching and/or training clinicians in pediatric and neonatal ETI should be evaluated through conducting controlled clinical trials to identify which type is the most effective by considering the less number of attempts and complications.
Positive psychology [1, 2] is an important paradigm in the field of psychology that focuses on the importance of proactivity in human agency. This theoretical positioning places emphasis on a person’s achievement of optimal functioning and his/her state of flourishing. Optimal functioning, in this case, is concerned with the maximization of a person’s internal state of functioning, whether it is mental, cognitive, emotional, and/or social.
An important of research inquiry for consideration may entail examination of optimal functioning. What is the best that I can do as a person, both academically and non-academically? How do I achieve my optimal best in a subject matter? These questions are reflective, in nature, and form the basis for personal growth, where appropriate. The best that a person can do (e.g., achieving exceptional wealth), in this case, indicates his/her internal state of optimal functioning—mediocracy, for example, may indicate an internal state of low optimal functioning. Understanding the nature of a person’s internal state of optimal functioning and how one reaches this state of exceptionality is the central focus of this chapter.
Our cross-cultural research collaboration, merging ideas, knowledge, and philosophical beliefs from both Western and Eastern contexts, has so far resulted in an innovative conceptualization of the theoretical concept of mindfulness [3]. We argue, in this chapter, that personal engagement in mindfulness could actually assist a person to achieve a state of optimal best. This postulation regarding the potential role of mindfulness, we contend, may yield a number of educational significance for educators, school administrators, and industry bodies—for example, the design and creation of an educational program, reflecting the tenets of mindfulness [3], which could then optimize a student’s internal state of functioning (e.g., optimal cognitive functioning).
Positive psychology explores the proactivity of human behavior. This theoretical orientation is non-deficit and suggests that the study of achievable human endeavors is a main priority for consideration [1, 4]. Negative and deficit models of human behavior (e.g., behaviorism) tend to focus on maladaptive functioning (e.g., school disengagement: [5]), pessimism, and preventive measures for rectification purposes. This approach to the study of human behavior is outdated, perhaps, as very little is made to understand about human strengths and the facilitation of self-fulfillment of inner needs.
Positive psychology, credited to Seligman, Csíkszentmihályi, Diener, Maslow, and others is a ‘branch’ of psychology that focuses on inner strengths, resilience, virtues, and personal flourishing. This theoretical orientation places emphasis on the ‘positives’ and the self-gratification and self-fulfillment of a person’s inner needs [1, 2]. Rather than focusing on weaknesses, shortcomings, and preventive measures, positive psychology delves into positive outlooks in life, such as the personal enrichment of positive emotional functioning (e.g., an extreme sense of happiness), positive social climates, and achievement of optimal functioning [6, 7]. In the context of academia, for example, a secondary school student may project and incline towards positive outlooks in life, and not focus on past and/or current shortcomings and failures. This may consist of personal resolve in the learning of different subject areas for mastery, personal growth, and enjoyment purposes. From a non-educational point of view, likewise, a senior citizen may capitalize on his/her positive feel-good experiences to lead a healthier lifestyle.
We contend that optimal functioning is an important facet of personal development. Optimal functioning varies in accordance with the context at hand, for example, an extreme state of happiness that is sustained (e.g., optimal emotional functioning), exceptional mathematic results (e.g., optimal cognitive functioning), and/or proactive social relationships with others in the community, consequently resulting in the establishment of networks, etc. (e.g., optimal social functioning).
Specific to positive psychology is the tenet that individuals, in general, strive to achieve self-fulfillment and live to their fullest potentials [8]. What is of interest for us, as individuals, is how we achieve an internal state of optimal functioning. This is a pervasive issue that a number of scholars, to date, have made concerted attempts to address (e.g., [9, 10]). In the area of student motivation, a number of researchers have proposed different theoretical orientations that could explain students’ motivational beliefs, cognition patterns and learning experiences, for example: personal self-efficacy [11, 12], academic buoyancy [13, 14], optimism [15, 16], and hope [17, 18].
Our own research development has also made theoretical, methodological, and empirical contributions to the study of optimal functioning. In particular, for consideration, clarity, and in-depth understanding, our seminal publication in 2016, titled ‘Introducing the concept of Optimal Best: Theoretical and methodological contributions’, proposed a framework to explain the concept of optimal achievement best [19]. We revised this initial proposition in 2017 and formally introduced our theoretical contribution of optimal functioning, coined as the Framework of Achievement Bests (e.g., [7, 8]). The Framework of Achievement Bests provides theoretical understanding into the process of optimization, which we argue could account and explain a person’s achievement of optimal functioning. Like any other inquiries, our theorization of optimization is ongoing in terms of its development [3]. One notable aspect, arising from the recent Phan et al. [7] publication is a focus on the methodological conceptualization of the process of optimization. In this chapter, we want to delve in detail into a methodological model of optimization for investigation that we have just conceptualized. Some aspects of this innovative conceptualization of optimization have briefly been mentioned in Phan et al [26].
How individuals reach their optimal functioning in life is a question that of interest for many scholars. Existing research, interestingly, has explored other theoretical concepts that also connote the importance of optimal functioning: personal best goals [20, 21], flourishing [22, 23], thriving [24, 25], and personal striving [26, 27]. However, despite this development, very little is known about a process that could facilitate achievement of experience of flourishing, thriving, etc.
Optimization is process that could serve to facilitate and optimize a person’s state of functioning. Researchers have often used terminologies and phrases such as ‘optimizing effect’, ‘Variable A can optimize Variable B…’, and ‘human optimization’ without truly explaining what they actually mean. The notion of optimization, we contend, is not analogous to the concepts of ‘enhancement’, ‘predictive effect’, and/or ‘causal flow’. Fraillon’s [9] theoretical overview of subjective well-being briefly mentioned the concept of optimization, which the author theorized as the difference between a person’s actual best functioning and his/her notional best functioning. This definition, despite its limited scope, provided grounding for the development of our Framework of Achievement Bests [7, 8].
Our theorization of the Framework of Achievement Bests, derived from Phan et al.’s [19] article, postulates the dichotomy of levels of best practice by which there are there are different levels of a person’s functioning—for example: realistic achievement best, defined as a person’s actual level of functioning at the present time, and optimal achievement best, defined as a person’s indication at the present time of the maximization of his/her competence in a subject matter. In the context of academia, for example, realistic achievement best focuses on a student’s actual demonstration of knowledge and/or skills (e.g., I can solve 20 easy arithmetic problems and get 90% correct). Optimal achievement best, in contrast, emphasizes a student’s mastery competence of his/her learning, which in this case reflects the best of his/her ability (e.g., I know that I can solve more complex arithmetic problems and get 85% correct). Our theorization [7, 8], this case, contends that reaching optimal achievement best from realistic achievement best would require some ‘form’ of optimization.
Adapting from our recent work [3, 7], Figure 1 illustrates a methodological conceptualization of the process of optimization that we recently developed. We argue that in order to understand the process of optimization, it is important for us to expand on the tenets of optimal functioning. In this analysis, from our conceptualization, an achievement of optimal functioning requires the fulfillment of three main criteria: (i) that there is a point of reference, denoted as L1T1, for personal benchmarking with the level of optimal best, which is denoted as L2T2, (ii) the requirement of time precedence in order for a person to develop and experience an ‘increase’ in optimal functioning, and (iii) the activation and enactment of psychological, educational, and/or psychosocial agencies in order to facilitate, mediate, strengthen, and improve a state of functioning from T1 to T2. Overall then, from this explanation, achievement of optimal functioning is made when we are able to gauge into the difference between L2T2 and L1T1 (i.e., ΔL21), where L1 = realistic achievement best, L2 = optimal achievement best.
Optimization and levels of best practice. Adapted from Phan & Ngu [8] and Phan et al. [7].
Optimization consequently, from our conceptualization, would assist in the achievement of LBT2 from LAT1. Differing from previous theorizations (e.g., [22, 28]), we contend that successful accomplishment of ΔL21 would indicate experience of flourishing. Personal flourishing, in this sense, reflects a person’s successful accomplishment of a state of optimal functioning (i.e., L2T2). Our revision of the Framework of Achievement Bests [3, 7] theorizes that the operational nature of optimization involves the activation and enactment (AE) of psychological (e.g., hope: [29]), educational (e.g., an instructional design: [30]), and psychosocial (e.g., teacher-student relationship: [31]) agencies that serve as sources of personal energization (E), which then stimulates the buoyancy of intrinsic motivation (i.e., defined as a person’s intrinsic motive to persist a course of action—for example, learning Calculus), personal resolve (i.e., defined as a person’s internal state of decisiveness and resolute to strive for optimal functioning), effective functioning (i.e., defined as a person’s purposive state of organization, structured thoughts, and behavioral patterns and his/her deliberate intent to succeed), mental strength (i.e., defined as a person’s mindset that he/she has the capacity to deal with obstacles, stressors, and pressure), and effort expenditure (i.e., a person’s conscious attempt to achieve a particular outcome) in order to arouse, intensify, and sustain (AIS) a person’s state of functioning. We consider the importance of these five comparable attributes for their positive nature—that is, individually and/or in combination, they encourage and facilitate a person to achieve optimal outcomes.
We argue that the differential influences of psychological, educational, and psychosocial agencies are subject to the contextual situation at hand, as well as the timely opportunity that may arise. For example, the optimization of physical functioning (e.g., a football player’s scoring of goals) may benefit more from psychological (e.g., the use of self-efficacy beliefs to convince the football player’s resolve) and/or psychosocial (e.g., the provision of an adequate environment for training) agencies, whereas educational agencies (e.g., the teaching of an effective instructional design) would be more appropriate in the optimization of cognitive functioning (e.g., a student’s academic performance in mathematics). In a similar vein, we argue that on a daily basis, the provision of opportunities for optimization purposes may vary in accordance with the contextual situation and/or other reasons. What this means then, from our conceptualization, is that at any point in time, not all different types of agencies may be available for usage.
The source of energization from psychological, educational, and psychosocial agencies, we contend, may then stimulate the buoyancy of five distinctive and comparable attributes (e.g., intrinsic motivation). The same argument here is that influences from these five attributes to arouse, intensify, and sustain an internal state of functioning also vary. In other words, as an example, the optimizing impact of a psychosocial agency (e.g., teacher-student relationship) on emotional functioning may only stimulate intrinsic motivation and personal resolve. In a similar vein, a psychological agency (e.g., personal self-efficacy for academic learning) to optimize cognitive functioning may stimulate intrinsic motivation, mental strength, personal resolve, and effort expenditure. An effective educational agency (e.g., the use of an appropriate instructional design), likewise, may instead stimulate intrinsic motivation, effective functioning, and effort expenditure.
Our theorization of the concept of optimization, expanding on from our original Framework of Achievement Bests, suggests that unlike associative (i.e., r) and predictive (i.e., β) effects, the impact of optimization would result in a person experiencing some form of ‘energy’, which then could enable the achievement of optimal functioning. One interesting facet for consideration is whether and to what extent we could actually ‘quantify’ the process of optimization. The quantification of optimization, from our point of view, considers the magnitude (or strength) of a person’s experience of energization. In our recent work [3, 8], for example, we introduced the concepts of intensity of optimization (i.e., defined as the amount of resources that would be needed to optimize a person’s level of functioning) and scope of optimization (i.e., defined as the amount of time and effort that would be needed to optimize a person’s level of functioning). The magnitude of optimization, in this case, is postulated to encompass both intensity and scope. A level of optimal functioning that is relatively simple from a current level is likely to require minimal optimization. In contrast, however, a level of optimal functioning that is more complex (e.g., L1T1: knowing how to solve equations with one unknown, x: x + 52 = −10 → L2 T2: knowing how to solve quadratic equations with two unknowns, x and y: (x + y)2 = 4 and −4x + 10y = 20) would require a greater amount of optimization.
With the possible quantification of optimization, we consider a related theoretical concept, which we coin as the index of optimization. We propose that the index of optimization, denoted as γ, is intricately associated with the difference between a person’s current level of functioning and his/her level of optimal functioning (i.e., ΔL21). The quantification of the index of optimization, from our proposition, is as follows:
where γ = index of optimization, AE = activation and enactment of psychological, educational, and psychosocial agencies, E = the experience of energization, which consists of the stimulation and buoyancy of motivation, personal resolve, effective functioning, mental strength, and effort expenditure, and AIS = arousal, intensity, and sustainability.
This postulation regarding the index of optimization and, more importantly, the quantification of optimization is innovative, as it connotes that, likewise, it is possible to measure, assess, and quantify a person’s level of optimal functioning. The index of optimization, in this case, reflects the totality of AE, E, and AIS, and equates to a person’s experience of flourishing—that is, γ ≈ ΔL21. In other words, from our theoretization, a person’s energy is likely to assist and result in a level of optimal functioning. At this stage, however, we recognize one notable issue that is unresolved: the calculation of the index of optimization. Despite this uncertainty, we argue that our expanded theorization of optimization is effectual for its explanatory account of a person’s state of flourishing. The acquisition of a source of energization, in this case, is of interest for us to discuss in detail. The psychological agency, as we explained [7], may serve as a major source of a person’s experience of energization. Our interest for discussion entails the extent to which mindfulness, as a psychological agency, could energize a person to achieve optimal best.
Mindfulness is a psychological process that emphasizes on a person’s meditational state. It is defined as “the unfailing master key for knowing the mind and is thus the starting point; the perfect tool for shaping the mind, and is thus the focal point; and the lofty manifestation of the achieved freedom of the mind, and is thus the culminating point” [32]. In other words, as Kabat-Zinn [32] explains, mindfulness is concerned with a person’s moment-to-moment, non-judgmental self-awareness, which is cultivated by his/her directed attention towards the present moment, non-reactively and non-judgmentally. An envisage of mindfulness as a meditational practice suggests a state of consciousness and self-awareness that may be strengthened over the course of time [33].
The psychological construct of mindfulness is postulated to closely associate with the positive psychology paradigm [1, 4, 34] for its characteristics and emphasis on positive yields. Central to this theoretical contention is the fact that mindfulness is meaningful, and contradicts with the negativities that may exist in life such as pessimism and mindlessness [35]. Mindfulness, in this sense, is a feat of human agency that reflects to a large extent the essence of a person’s temperament, personality, and state of mind. Engaging in the meditational practice of mindfulness produce two important yields [36, 37, 38, 39, 40], namely:
A person’s experience of a present state in any social milieu, which may reveal clear focus and personal contentment. Non-judgmental concentration at the present time, in itself, could serve to instill and facilitate an internal state of calmness, ease, and clarity.
The subsequent outcomes that may arise from the aftermath experience of mindfulness, including positive emotions (e.g., happiness), weakening in negative emotions (e.g., anxiety), and improvement in personal functioning (e.g., performance in a subject matter).
Engagement in mindfulness practices, in this sense, emphasizes personal experience both the present moment and the future state of functioning. The two aforementioned yields signify and support the use of mindfulness theories [41, 42, 43] in educational and non-educational contexts. Educationally, in this case, it has been noted that there are a number of educational programs for usage in the practice of mindfulness (e.g., Master Mind Program: [44], Mindfulness Education: [45]). For example, Schonert-Reichl and Lawlor [45] recently explored the effectiveness of the Mindfulness Education (ME) program, which involves a universal teacher-taught preventive intervention that focuses on “facilitating the development of students’ emotional and social competence via a series of lessons in which ‘mindful attention awareness’ is taught and practiced, and in which students engage in lessons designed to promote optimism and positive affect” (p. 138). The results of the study showed, for example, that adolescents who participated in the ME program improved on their optimistic beliefs.
Meiklejohn et al.’s [33] in-depth review is also interesting, indicating the effectiveness of mindfulness programs for both teachers and students, alike. A number of programs have been developed from different countries to teach and facilitate engagement in mindfulness practices (e.g., Inner Kids Programs from the United States for Pre K-8; Mindfulness in Schools Project (MiSP) from England for children aged 14–18 years; Sfat Hakeshev (The Mindfulness Language) from Israel for children aged 6–13 years). The results arising from implementations of these programs indicate, for example:
For teachers—(i) the cultivation of mindful skills and knowledge in everyday lives, both insider and outside of classroom settings, (ii) improvement in subjective well-being experiences, (iii) improve effectiveness in providing emotional, behavioral, and instructional support to students, (iv) improve engagement and prosocial relationships with students and co-workers, alike, and (v) decrease negative emotions (e.g., anxiety level) and increase motivation towards the profession, in general.
For students—(i) strengthen students’ capacity to self-regulate attention, (ii) facilitate students’ capacities to relate to any experience, whether pleasurable, neutral, stressful, or difficult, (iii) decrease negative emotional functioning (e.g., anxiety level) and behavioral problems, (iv) improvement in social skills and academic performance, (v) increase in optimism, subjective happiness, and mindful awareness, and (vi) improvement in emotional regulation, feelings of calmness, relaxation, and self-acceptance.
The above mentioning provides empirical grounding for further rigorous scientific research development into the efficacy of interventions and programs into mindfulness. According to Meiklejohn et al. [33], there are three major reasons as to this research inquiry is needed, namely: (i) validating the effectiveness of interventions and programs into mindfulness, (ii) how and why the intervention works, and (iii) predictive effects and under what conditions the intervention would be effective. This recommendation from a psychological point of view is valid, and has credence for implementation. Any theoretical orientation in social sciences, for that matter, requires a cogent conceptualization, which is then followed by strong high-quality empirical evidence for efficacy and effectiveness. The authors, for example, recommend the following issues for guidance in the advancement of mindfulness as a distinct theoretical orientation: establish a theory of change for mindfulness-based programs, expanding the evidence-based for mindfulness-based programs, development and validation of appropriate outcome measures, assess socially valid outcome measures, and address school-based implementation barriers.
A persuasive argument could lend itself in terms of providing a conceptualization that focuses on the relationships between mindfulness and levels of personal functioning. This consideration is insightful, aligning to Meiklejohn et al.’s [33] contention for further research development into the operational nature (i.e., predictiveness) of this theoretical construct. The argument here, in this analysis, is that mindfulness could play a central role in the achievement of optimal functioning. Specifically, as discussed in the subsequent sections of this article, it is argued that meditational practice of mindfulness could result in the activation of a series of sub-processes, which may then assist in the optimization of achievement of optimal functioning.
The preceding section has described the concept of mindfulness. However, we argue that existing research from Western scholars, placing emphasis on the psychological nature of mindfulness alone is somewhat confined. We make this argument consequently as a result of our own research development into this matter, which takes into account the importance of Taiwanese philosophical beliefs, meditation practices, professional and personal experiences, and Buddhist wisdom and knowledge. Our professional development, especially for authors 3, 4, 5, and 6 includes in-depth knowledge and teaching of Asian philosophies to postgraduate students, extensive research undertakings in the area of mindfulness, teaching meditation to undergraduate students, and daily practice of rituals pertaining Buddhism. Our theoretical positioning of mindfulness is more inclusive and proposes a holistic model for consideration.
A model of mindfulness that we want to consider is shown in Figure 2. This proposed model, which we recently described [3], reflects an integration of both Western and Eastern ideas, knowledge, and philosophical beliefs. Our conceptualization posits mindfulness as a hierarchical and multifaceted structure that encompasses three major components: psychological component, philosophical component, and spiritual component. We contend that this conceptualization of mindfulness is more inclusive, taking into account Eastern ideas, understanding, and philosophical beliefs and the premise of Buddhism. Furthermore, from our proposition, each major component of mindfulness espouses specific attributes—(i) the psychological component espouses the attributes of concentration, relaxation, non-judgment, and self-awareness, (ii) the philosophical component espouses the attributes of non-dualism, ultimate reality, and rationality, and (iii) the spiritual component espouses the attributes of self-discipline, present moment, self-actualization, unity, and harmony. These attributes have been discussed in detail in our recent work [3], and will not be described here.
Conceptualization of mindfulness.
Our proposition of mindfulness is holistic and recognizes the importance of both Western (i.e., the psychological component) and Eastern (i.e., the philosophical component and the spiritual component) ideas and theoretical contributions. From the literature, very little is known about the two non-psychological components that we have proposed. What is unique here, from our conceptualization, is that we consider Buddhism to underpin the nature of the philosophical and the spiritual component of mindfulness. What does this actually mean then, in its totality? Mindfulness, for us as Taiwanese scholars, is more than just a person’s psychological state of ease. It is somewhat limited to infer that mindfulness is simply a reflection of a person’s purposive concentration to ensure that no judgment is made on any aspect of life at the present time. In other words, we argue that personal experience of mindfulness may serve to amplify beyond the actual psychological state of a person’s mindset.
When a person experiences a state of mindfulness, from our conceptualization, he/she seeks ‘nearness’ to Buddha. Hence, in the teaching of meditation practice, we often ask students to ‘visualize’ the image of Buddha as a focal point of concentration. In other words, one major difficulty that many novices face is their inability to concentrate when practicing meditation. Non-judgmental concentration in this sense, according to many Buddhist nuns and monks, is a challenging feat to achieve. Nearness to Buddha or perhaps, Buddhism itself, is to reach nirvana (i.e., enlightenment). According to Buddhist beliefs, a state of enlightenment relates to a person’s experience of contentment, prosperity, happiness, peace, and harmony [46]. Mindfulness through meditation, in this analysis, is more than just a state of concentration and self-awareness; when we practice meditation in order to experience mindfulness, we seek to explore and understand the meaning of life in a non-materialistic sense. An important aspect of Buddhism is for a person to live a life that is full of richness. Life is not simply concerned with having materialistic wealth. An enriched life for any person for that matter is to not have attachment, other than to have Buddhist faith.
Our proposed model of mindfulness is significant for its underpinning of Buddhism, emphasizing the importance of Eastern philosophical beliefs and the nature of spirituality. We argue our conceptualization touches on elements that do not necessarily abide by the natural laws of sciences. This argument posits that understanding of mindfulness in its truest sense requires personal experience that may transcend beyond the realms of reality and the physical world. For example, unlike academic performance, social relationships, and/or achieving economic growth, which are also measurable, mindfulness from our point of view is somewhat different—it is not an easily achievable and/or explanatory feat. True, meaningful understanding of mindfulness requires contemplation, reflection, and true faith in Buddhism. When one successfully reaches a state of mindfulness, there is then ‘evidence’ of inner satisfaction. Mindfulness, in this case, indicates a person’s peaceful ‘Buddha-like’ state of mind, which may detach itself from materialistic things, financial wealth, and worldly success. Moreover, from our point of view, a state of mindfulness would enable a person to live a life that is non-judgmental, non-subjective, and non-biased. In essence, a positive effect of mindfulness would consist of a person’s self-awareness of free will to do things without any negative emotion, and/or to care what others may think.
Existing research has used quantitative methods to seek clarity into the definition, meaning, and structure of mindfulness. For example, using non-experimental designs, a number of researchers have focused on validating the factorial structure of mindfulness (e.g., [47, 48, 49]). Evidence from Likert-scale and open-ended surveys, in this case, has led to inconsistent perspectives of the factorial structure of mindfulness [3]. We argue that our proposed conceptualization of mindfulness, especially with its emphasis on the philosophical and spiritual component and their respective attributes is relatively difficult to assess, measure, and evaluate. Referring to the preceding sections, the personal achievement of nirvana is not an easily feat to ‘quantify’. Indeed, we recognize the complexity of our proposed model, and contend that other alternative, non-conventional methods may be needed. In a similar vein, we believe that the potential optimizing role of mindfulness in the achievement of optimal functioning is somewhat complex to validate. One notable problem, of course, relates to the issue that we previously outlined, namely, a lack of clarity into the operational nature of optimization. In this section of the chapter, we discuss a methodological conceptualization that could integrate our proposed model of mindfulness within the framework of optimization.
Optimization, we contend, is an underlying process that could assist in the achievement of optimal functioning. Our recent conceptualization of optimization, derived from previous research [7, 8, 9], emphasizes the potential optimizing influences of different psychological, educational, and psychosocial agencies. An important question then is whether and/or to what extent mindfulness, as a multifaceted concept, could operate as a psychological agency and hence, a source of energization in the process of optimization. As a research inquiry into this potentiality, we focus on a methodological conceptualization that we have developed, as shown in Figure 3. This depiction is innovative for its proposition into the optimizing effect of mindfulness.
The relationship between mindfulness and optimal functioning.
According to Figure 3 and taking into consideration our proposed model of mindfulness, the practice of meditation would result in the achievement of nirvana. Nirvana enables a person to experience contentment (i.e., realization that one is fine with life as it is), prosperity (i.e., recognition that one is prosperous in terms of well-being—that is, life is good), a sense of happiness (i.e., one’s experience of internal happiness), peace and harmony (i.e., one’s understanding that life is harmonious with nature and the contextual surroundings), which then operate as energy sources. Our pedagogical practice of meditation involves a number of procedural steps, such as the recitation of specific Buddhist scriptures and chanting (e.g., Amitabha). Visualizing the image of Buddha as we begin would assist with concentration, relaxation, and the experience of ‘nothingness’. Unlike Western perspectives perhaps, mindfulness from an Eastern point of view is concerned with a state of ease and one’s ability to be ‘Buddha-like’ and to reach enlightenment.
From our postulation, a state of nirvana would serve as a source of energization—in this sense, we contend that mindfulness would vitalize a person to recognize that there is no greater cause than for him/her to attain a Buddha-like stature. What does this mean for the process of optimization? A Buddha-like stature would, in our consideration:
Enable a person to feel intrinsically motivated with life itself at the present time, regardless of any obstacles and/or difficulties that may exist. This intrinsic motivation emphasizes the importance of a person’s inclination towards individual growth and non-materialistic matters. For example, in a non-academic sense, a person may feel intrinsically motivated to assist others to be at peace, content, and be happy with themselves. Academically, in contrast, intrinsic motivation may reflect a student’s inner desire to seek new knowledge for interest and intellectual curiosity purposes.
Instill a strong sense of decisiveness and determination to persist in a course of action, academically and/or non-academically. This personal resolve reflects an autonomous and determined mindset, such as a person’s decision to encounter and resolve a problem despite his/her uncertainty. Academically, for example, a sense of decisiveness could compel a student to choose an appropriate course of action (e.g., seeking help from someone capable) for his/her learning purposes. Non-academically, likewise, a person may act on his/her determination to make sound decisions that could impact on others.
Ensure there is consideration of organization, structured thinking, and efficiency in one’s course of action. There is self-awareness of the implication of wasted time and effort, and the weighing of resources that are available. From mindfulness, one is able to accomplish a task or a set of tasks with clear deliberation. Non-academically, for example, a person may seek out pathways to expeditiously complete a task at work, despite numerous disruptions. Academically, likewise, a student may choose an appropriate cognitive strategy to learn Calculus in order to minimize his/her time wasting.
Instill high-energized mental strength to enable a person to face difficulties and obstacles with a sense of resolute and positivity. Consequently as a result of mindfulness, one is able to experience a mindset that is full of clarity, clearness, and unhindered thoughts. Mental strength, we contend, may overcome feelings of pessimism, indecisiveness, and uncertainty. Non-academically, for example, mental strength may assist a person to feel confident and efficacious to combat a health issue. Academically, in contrast, mental strength may help a student to confront his/her learning difficulties with determination, and to persist despite this hardship.
Enable a person to focus on the expenditure of time and effort in order to accomplish a given task at the present time. Mindfulness, from our point of view, may serve to negate stagnation, inaction, and procrastination. Consequently, as a result of mindfulness, a person may feel more motivated and compelled to spend time on practicing, revising, and consolidation. Academically, for example, via means of mindfulness a student may come to realize that effort is intricately linked to personal success. It is through effort likewise, as the student comes to realize, that ensures a lay person is able to achieve a Buddha-like stature.
What is important, from the above, is that mindfulness is a source of energy that is positive, in nature. From our theorization, we argue that a state of mindfulness, which results in a perceived sense of enlightenment, is in accord with the paradigm of positive psychology [1, 2]. Mindfulness, for us, consequently, is concerned with the achievement of happiness and the true meaning of life. This experience of energization, as we explained, may stimulate the buoyancy of intrinsic motivation, personal decisiveness and determination, mental strength, effort expenditure, and one’s self-awareness of efficiency. These attributes, in their totality, may then arouse, intensify, and/or sustain a person’s internal state of functioning—whether it is physical, emotional, cognitive, or social.
In terms of functioning, consider the importance of cognitive functioning. In the context of academia, cognitive functioning may consist of academic performance and/or the seeking of mastery competence in a subject matter [7]. Achieving an exceptional result in Calculus, for example, may indicate optimal cognitive functioning in mathematics. It is pertinent then that we consider, conceptually and practically, how we could optimize a student’s academic learning experiences, which may be subject to both performance and mastery-based criteria. The totality of mindfulness, according to our conceptualization, is concerned with a person’s achievement of nirvana. This experience, from our own personal recalls of understanding, knowledge, and experiences over the years, reflects the true meaning of life—to detach oneself and feel unpressured from the competitive and materialistic world. We argue that a mindset void of everything in life, except the fulfillment of contentment, prosperity, happiness, peace and harmony would bring forth a state of serenity and tranquility. Here, at this personal state, a student does not feel pressured and appreciate everything there is to know, regardless of his/her existing level of understanding. What this would mean for a student then, is that academic learning is a personal journey that is full of enrichments and no ends. Acquiring knowledge, in this regard, is autonomous, personal, and free from extraneous influences. Failures and successes, in this case, are irrelevant as the true meaning of learning is to experience life itself. Learning Calculus or any other academic subject matters, in this instance, is part and parcel of being a person where there is no specific ‘timezone’. Importantly, focusing on the philosophical and/or religious beliefs of Buddhism, one realizes that learning is an endless journey that has no destiny to achieve.
Hence, from the preceding section, mindfulness could serve to optimize a person’s cognitive growth. At the same time, of course, we contend that as a psychological agency, mindfulness could also optimize physical (e.g., a healthy lifestyle), emotional (e.g., happiness), and social (e.g., social relationship and friendship) functioning. Considering that ultimately mindfulness is concerned with enlightenment, we argue that the positive psychological, philosophical, and spiritual nature of a person’s mindset would help:
Instill confidence and efficacy for one to live life to the fullest, regardless of existing and/or potential health issues. Life, at the present moment, is concerned with personal enjoyment and appreciation of the fact that one is living, and to recognize there is a karmic cycle (i.e., samsāra).
A person to learn to place emphasis on the notion of ‘nothing’—that is, nothing in the world matters other than the achievement of continuous inner happiness by fulfilling one’s own desire to help others reach a state of nirvana. Negative emotional functioning has no existence, as all positive attributes of Buddhism take precedence.
A person to willingly relate to others within the contextual environment. It is poignant for a person to view the world with a sense of unity. The world, from the view of Buddhism, is a holistic entity with no distinction between us, animals, and nature, in general.
Optimal functioning is an important facet of the totality of human agency. This theoretical concept of optimal functioning reflects the tenets of the paradigm of positive psychology [1, 2]. The study of optimal functioning has, to date, been substantive with research undertakings in the fields of Education, Psychology, and Health Sciences. Our research development, international in scope, has been substantial, especially in terms of our theoretical, methodological, and empirical contributions [3, 26]. One major contribution, which commenced in 2015, consisted of our development of a theoretical model that we argued could explain the achievement of optimal functioning. The Framework of Achievement Bests [7, 8], in this case, emphasizes the importance of optimization, an underlying process that may explain and facilitate the experience of flourishing. We advance this theorization by proposing a revised conceptualization, by which we detail the intricate operational functioning of the process of optimization.
Another important contribution, arising from our recent collaboration, consists of the proposition and development of a hierarchical, multifaceted structure of mindfulness, which places emphasis on the positive psychological, philosophical, and spiritual nature of a person’s mindset. Mindfulness is more than just concentration, self-awareness, and/or a relaxed, non-judgmental state. For us, mindfulness is closely associated with Buddhism and more importantly, the achievement of a Buddha-like stature. When experience a state of mindfulness, via means of meditation, we ultimately achieve the experience of enlightenment. Indeed, we argue that our proposed model of mindfulness is innovative for its inclusiveness of both Western and Eastern ideas, knowledge, and philosophical viewpoints. This development of an alternative model has also led us to consider mindfulness, in its totality, as a psychological agency that could operate to optimize a person’s state of functioning.
We recognize that there are some major complexities, which pose difficulties in the assessment and measurement of the conceptualization that is depicted in Figure 3. Social sciences research would require rigorous methodological designs that enable, for example, the quantification of variables and statistical inferences of their relationships [50]. From a Western perspective then, as we previously described, researchers have focused on the factorial structures of mindfulness (e.g., [47, 48]). In this analysis, researchers have varied in their conceptualizations and the subsequent results found from factor analyses—from a one-factor model [51] through to a six-factor model [52]. The issue, however, is that our proposed model of mindfulness is non-conventional, and takes into account Buddhism as an underlying focus of inquiry. How do we measure and assess Buddhism in its entirety? More importantly, referring to our proposition, how do we measure and assess the extent to which one has reached a state of enlightenment? We contend that the notion of spirituality, which is one main component of mindfulness, is extremely difficult to gauge at and/or to measure and assess. Delving into the nature of a person’s contemplation, reflection, and his/her true faith in Buddhism, we contend, is not an easy task to determine. A traditional methodological approach that consists of the use of a Likert-scale measure is somewhat problematic and/or limited, as a subject’s response may not necessarily indicate his/her ‘inner’ feeling and experience of enlightenment.
From our theoretical positioning, enlightenment upon successful meditation would enable a person to experience a Buddha-like stature that, in this sense, reflects contentment, prosperity, happiness, peace and harmony. Some Buddhist nuns and monks, likewise, would argue that in-depth practice of meditation would also enable some to experience transcendence—the perceived ability of a person to exist in another realm that is outside the existing time-space realm. Hence, in a similar vein, we gather that it is non-feasible and non-viable to consider the use of the traditional methodological approaches. In this analysis, it would be more enriching and insightful if we could develop non-traditional methodological means to seek understanding into the nature of our proposed model of mindfulness. As practicing Buddhists, for example, Authors 3, 4, 5, and 6 of this chapter have considered the potentiality of methodological designs that the natural laws of physics may not be able to explain. How this is possible is beyond the scope of our understanding at the present time.
In a similar vein, we recognize the complexity of mindfulness as a psychological agency of the process of optimization. This conceptualization, indeed, is complex and difficult to validate, especially when we consider the limitations of traditional quantitative methods. Notwithstanding the obstacles that we have discussed, over the past couple of years we have explored an interesting line of inquiry, namely, the proposition and development of ‘methodological conceptualization’ that could address a particular area of research. This research-based approach is innovative as emphasis is placed on a researcher’s synthesis of existing studies, in-depth knowledge, and strongly rationalized postulation. The main focus of this discourse is to initiate social dialogs, and to encourage researchers to make theoretical, methodological, and/or empirical contributions to the conceptualized inquiry. A proposition, we contend from our research-based discourse, may be accepted, advanced, and/or revised. Other researchers, for example, may offer their interpretations, viewpoints, and alternatives to a postulation that we propose. Hence, from this personal contention, we argue that our proposed theoretical-conceptual model may have plausible credence, despite its complexity. In particular, aside from mindfulness, we recap and highlight the following inquiries for researchers to explore the following:
Validating the quantification of the process of optimization, especially the proposition regarding the index of optimization (γ). It would be insightful to consider the operational nature and measures of Path A, Path B, and Path C.
Considering the measure of the proposed concept of energization, which may apply and have consistency across different types of functioning—for example: physical functioning versus cognitive functioning.
The derivative and calculation of γ, which we equate it as the sum of AE, E, and AIS. However, despite this proposition of γ, we are uncertain of its standardization—that is, from a quantitative point of view, does a numerical value of ≈8 for γ for optimal physical functioning equate to that of optimal emotional functioning?
This chapter would not have been possible without the assistance of our friends, colleagues, and collaborators from Australia, Malaysia, and Taiwan. We are indebted to a number of colleagues in Taiwan who took time out to generously share with us their knowledge of Buddhism and the importance of mindfulness. This manuscript was conceptualized and prepared in late 2016, when the first author was on sabbatical—hence, a special gratitude to the University of New England for granting this study leave. Thank you, in particular, to Huafan University, Taiwan, and Taipei Medical University, Taiwan, for hosting the first author when he was on sabbatical.
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