Efficacy of mindfulness-based meditation therapy on the sense of coherence and mental health of nurses

doi:10.4236/health.2011.32022

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Vol.3, No.2, 108-122 (2011)

doi:10.4236/health.2011.32022

Health

Efficacy of mindfulness-based medit ation therapy on the

sense of coherence and mental health of nurses

Michiyo Ando1*, Takako Natsume2, Hiroko Kukihara1, Hiroko Shibata3, Sayoko Ito4

1St. Mary’s College, Fukuoka, Japan; *Corresponding Aut hor: [email protected]

2Yame General Hospital, Fukuoka, Japan

3St. Mary’s Hospital, Fukuoka, Japan

4Kyoto Seizan Junior College, Kyoto, Japan

Received 2 December 2010; revised 1 February 2011; accepted 15 February 2011.

ABSTRACT

The primary goal of the study was to assess the

efficacy of mindfulness-based meditation ther-

apy on the psychological well-being and sense

of coherence of nurses with respect to coping

with stress. The participants were 28 nurses

working in a ward for elderly patients, with 15

included in the intervention group and 13 in the

control group. Nurses in the intervention group

received two sessions of mindfulness-based

meditation therapy, including breathing, yoga

movement and meditation. Each nurse was

taught the program in the first session, then

exercised at home w ith a CD, and subsequently

met with an interviewer in a second session

after two weeks. Nurses in the control group did

not receive any interventions. The participants

completed the General Health Questionnaire

(GHQ), including subdomains of physical

symptoms, anxiety and sleep disturbance, in-

terference with social activities, and depression;

and the Sense of Coherence (SOC) question-

naire, which includes three subdomains of

comprehensibility, manageability, and mean-

ingfulness pre- and post-intervention. The GHQ

scores of the intervention group showed a sig-

nificantly greater decrease than those of the

control group. The SOC scores of the interven-

tion group showed a significantly greater in-

crease after the intervention compared to those

in the control group, with the highest score for

the meaningfulness subdomain. These results

indicate that mindfulness-based meditation

therapy is effective for improving the psycho-

logical well-being and sense of coherence of

nurses, which helps them to cope with stress.

Keywords: Meditation Therapy;

Sense of Coherence; Well-Being; Stress; Nurses

1. INTRODUCTION

Nurses tend to feel high levels of stress that may be

caused by multiple factors [1-3]. The conc ept of sen se of

coherence for coping with stress was introduced by An-

tonovsky [4] and includes key factors that affect recov-

ery from illness and maintenance of health. The sense of

coherence consists of three factors: a sense of compre-

hensibility, through which a person can comprehend a

stressful event; a sense of manageability, through which

a person can manage a stressful event; and a sense of

meaningfulness, through which a person feels meaning

in a stressful event [5]. Previous studies have shown an

association of the sense of coherence (SOC) score and

other variables. A high SOC score is related to a low

feeling of fatigue [6 ], low burnout [7], and a low ment al

or physical stress respo ns e [8 ]. For nu rses, a high SOC is

related to low burnout [9,10] and high work satisfaction.

These studies suggest the importance of SOC for coping

with stress.

A mindfulness approach is an effective intervention in

stress management from a psychological perspective.

The Mindfulness-Based Stress Reduction (MBSR) pro-

gram is modeled on the work of Kabat-Zinn and col-

leagues at the Center for Mindfulness at the Massachu-

setts Medical Center [11]. The program is based on the

principle of mindfulness, defined as moment-to-moment,

present-centered, purposive non-judgmental awareness.

The goal of the MBSR program is to guide participants

to achieve greater awareness of themselves, their thoughts,

and their bodies through class discussion, meditation,

and yoga exercises. It is effective for mood disturbance

and stress symptoms [12] and for QOL and the immune

profile [13]. Other studies have shown the effects of

MBSR on symptoms of distress and health-related QOL

M. Ando et al. / Health 3 (2011) 108-1 22

119119

[14] and spirituality [15]. However, few studies have

examined intervention s for stress manag ement in nurses.

Thus, the present study was performed to investigate the

efficacy of mindfulness therapy on the sense of coher-

ence and psychological well-being of nurses. The study

was performed for nurses who work in wards for the

elderly. These nurses may be under particular stress

since many care workers have recently begun to work in

these wards an d the number of nurses has decreased.

2. METHODS

2.1. Participants

The participants were 28 nurses who worked in wards

for elderly patients. Nurses in the intervention group (n =

15) received mindfulness-based therapy, while those in

the control group (n = 13) received no intervention. The

inclusion criterion was age > 20 years old, and the ex-

clusion criterion was the presence of severe mental

problems. The head nurse in the ward selected potential

participants and explained the study to the nurses. All the

subjects voluntarily participated in the study.

2.2. Outcome Measures

The Japanese short version of the SOC questionnaire

[16] translated from the original version [5] was used in

the study. The SOC scale has three subdomains that cor-

respond to the sense of comprehensibility, sense of ma-

nageability, and sense of meaningfulness. The short ver-

sion consists of 13 items, each of which is scored on a

7-point Likert scale. The General Health Questionnaire

(GHQ) has 4 subdomains corresponding to physical

symptoms, anxiety and sleep disturbance, interference

with social activities, and depression. We used the Japa-

nese version of GHQ 28[17]. The nurses also provided

written information on stressful issues and commented

on the effects of mindfulness therapy. The FACIT-Sp

[18,19] was used to measure spiritual well-being.

2.3. Interventions and Procedure

A modified version of the MBSR Program, in which

we refer to cyclic meditation as that including both

breathing and meditation, was used in the study. During

meditation, nurses moved their hands or legs to focus

their attention on mind and body. The cyclic meditation

program takes 30 to 60 minutes per session and was

conducted by nurses who received training in this pro-

gram for at least 3 hours. The training included basic

communication skills and Yoga skills learned directly

from a Yoga specialist or using a CD or DVD. The sub-

jects gave informed consent and completed pre- and

post-intervention questionnaires. In the pre-therapy ses-

sion, the subject learned the cyclic meditation program

and it was recommended that the therapy was performed

at home once a day. After 2 weeks, each subject met

with an interviewer in a second session to talk about

their impressions.

2.4. Statistical Analysis

A p value less than 0.05 was taken to indicate a sig-

nificant level in all statistical analyses. All reported p

values are 2-tailed. The statistical procedures were con-

ducted with SPSS ver. 18.0 (Japanese version) for Win-

dows (SPSS Inc.). A two-way repeated measures ANO-

VA [2 (groups: intervention, control) × 2 (period: pre,

post)] was used to evaluate the efficacy of mindfulness

therapy for improving GHQ and SOC scores. A t-test

was performed to compare the scores for the total GHQ

and the GHQ subdomains for the intervention group pre-

and post-intervention. Tw o-way ANOVA was performed

for 2 periods (pre and post) × 3 factors (comprehensibil-

ity, manageability, meaningfulness) to evaluate the effi-

cacy of mindfulness therapy on the SOC subdomains.

The free description of stress and the comments on

mindfulness therapy given by the nurses were evaluated

using content analysis [18].

3. RESULTS

3.1. General Health Questionnaire (GHQ)

Regarding the GHQ (Figure 1), the main effect of pe-

riod was significant (p = 0.00) indicating that GHQ scores

significantly decreased post-intervention. The main ef-

fect of th e group was not significant. The interaction was

also significant at a 10% level (p = 0.059). The total

GHQ scores for the intervention group significantly de-

creased from 11.13 ± 4.72 to 5.93 ± 3.94, indicating an

improvement in general health, whereas those for the

control group did not decrease. The subdomain scores

for the intervention group decreased from 3.93 ± 1.94 to

2.20 ± 1.97 for physical symptoms, from 4.33 ± 2.02 to

2.87 ± 2.00 for anxiety and sleep disturbance, from 1.87 ±

1.77 to 0.53 ± 0.64 for interference with social activ ities,

and from 1.00 ± 1.20 to 0.33 ± 0.62 for depression (Ta-

ble 1).

Figure 1. Changes in GHQ scores from pre- to

pot-intervention. s

M. Ando et al. / Health 3 (2011) 108-1 22

120

Table 1. Pre- and post-intervention scores for the total GHQ and subdomains of the GHQ.

Total GHQ Physical symptomsAnxiety, sleep Social activitiesDepression

Pre 11.1 ± 4.72 3.93 ± 1.94 4.33±2.02 1.87 ± 1.77 1.0 ± 1.20

Post 5.9 ± 3.94 2.20 ± 1.97 2.87±2.00 0.53 ± 0.64 0.33 ± 0.62

t 6.5 5.03 3.08 3.00 2.47

p 0.000 0.000 0.008 0.009 0.027

3.2. Sense of Coherence (SOC)

For SOC (Figure 2), the main effect was not signifi-

cant, but the interaction was significant (p < 0.04). The

SOC score for the intervention group significantly in-

creased after the intervention, whereas that for the con-

trol group did not change. The score for the SOC mean-

ingfulness subdomain significantly increased (F(1,14) =

7.94, p = 0.014), and the score for meaningfulness was

higher than those for comprehensibility and manageab il-

ity (Table 2).

Figure 2. Changes in SOC scores from pre- to

post-intervention.

Table 2. Pre- and post-intervention scores for sense of co-

herence (SOC) subdomains

3.3. FACIT-Sp

For the FACIT-Sp, the main effects and interaction

were not significant. The FACIT-Sp score for the inter-

vention group increased from 15.5 ± 4.4 to 16.6 ±, and

that for the control group increased from 13.8 ± 3.7 to

13.6 ± 3.1.

ComprehensibilityManageability Meaningfulness

Pre 3.44 ± 0.65 3. 35 ± 0.77 4.08 ± 0.93

Post 3.83 ± 0.79 3.70 ± 0.82 4.52 ± 0.80

t value -2.06 -1.62 -2.30

p value0.058 0.128 0.037

3.4. Comments

Comments on stress and the effects of mindfulness

therapy given by the subjects are shown in Table 3.

Many nurses indicated that a “labor shortage” and

“overtime work” cau sed them to have stress. Th ey found

the mindfulness therapy to be relaxing and refreshing,

and to give them time for reflection.

Table 3. Descriptions of stressful issues and comments on

mindfulness therapy.

Stress

1) Lack of skills and knowledge about nursing

2) Overtime work

3) No payment for overtime work

4) Labor shortage

5) Unable to concentrate on my work

6) Human relationships with my nursing superior

7) Human relationships with doctors

8) Unable to care for patients or families because of too much work

Comments on mindfulness therapy

1) Useful for relaxation

2) Refreshing

3) Useful for reflection on my daily life

4) I found it difficult to focus my attention

5) It was difficult to make time for the mindfulness program

6) Yoga movements were not suitable for me

4. DISCUSSION

The greater decrease in GHQ scores in the interven-

tion group compared to the control group indicates the

efficacy of mindfulness therapy for the psychological

well-being of nurses. Moreover, the scores for each

subdomain significantly decreased after th e intervention,

which indicates the effectiveness of mindfulness therapy

for physical symptoms, anxiety and sleep disturbance,

interference with social activities, and depression. This

result is consistent with those found for the effects of

this therapy on anxiety [19,20] and mood [15]. The ef-

fect of the mindfulness-based meditation therapy is par-

ticularly interesting since the total GHQ score was 11.1

pre-intervention and the cutoff point for stress is 14/28,

indicating that the nurses in the present study did not

have particular mental problems. However, the therapy

Openly accessible at

M. Ando et al. / Health 3 (2011) 108-1 22

121121

was still effective in improving the psychological well-

being of the nu rses.

There was a greater increase in SOC scores in the in-

tervention group than in the control group, which indi-

cates the efficacy of mindfulness therapy on the sense of

coherence in stress management. The standard SOC

score is 54-58, while the scores of the nurses in the pre-

sent study were 53 in the control group and 52 in the

intervention group, indicating that the nurses had a poor

ability to cope with stress. Thus, the resu lts ind icate that

mindfulness therapy is important in facilitating stress

management.

The experience level of nurses might influence the ef-

fects of mindfulness meditation therapy. Furthermore,

the duration of the CD or DVD for this therapy was

about 20 minutes, but some nurses took much more time

to practice this therapy. The depth of meditation and

focus of attention on the therapy might also have dif-

fered among the nurses. A further study including as-

sessment of the experience of the subjects and the depth

of focus during therapy will clarify the effects of these

issues on the therapy.

The score for meaningfulness was the highest among

the three SOC subdomains of comprehensibility, man-

ageability, and meaningfulness. This suggests that the

nurses were able to reflect on the meaning of their life

and work through meditation. They were typically very

busy and burdened by their work, and meditation al-

lowed them to focus their attention on mind and body

and to reflect on their purpos e. In a pr eviou s interv en tion

study, assertive training was show to affect the self- es-

teem of nurses, but had no effect on SOC [21]. This dif-

ference may be due to the type of intervention, since

assertion reflects a positive attitude toward others, but

mindfulness produces an accepting attitude toward oth-

ers. Comprehensibility and manageability did not in-

crease after the mindfulness therapy because nurses re-

ported stress with their workload and the small number

of nurses in the ward.

Cyclic meditation through mindfulness had no effect

on spirituality in the present study. The standard FA-

CIT-Sp score for meaning is 32, whereas the mean

scores were 16 in the intervention group and 13.6 in the

control group. This suggests that the nurses in the study

may have lost a sense of meaning of life or purpose and

peace of mind, and a further intervention to improve

spirituality may be needed.

The study is limited by the small number of partici-

pants. To increase the robustness and reliability of the

findings, a further study in more subjects is required.

Moreover, we did not investigate the long-term effects of

cyclic meditation therapy, and there is a need to test

whether there is still a difference between GHQ and

SOC scores in the interv ention and control groups after a

longer period of time.

5. ACKNOWLEDGEMENTS

This research was supported by a Grant-in-Aid for Scientific Re-

search (C).

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