Vol.3, No.2, 108-122 (2011)
doi:10.4236/health.2011.32022
C opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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:
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
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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
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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
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M. Ando et al. / Health 3 (2011) 108-1 22
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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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