Enhancing the resilience of nurses and midwives: Pilot of a mindfulnessbased program for increased health, sense of coherence and decreased depression, anxiety and stress

This study tested an adapted mindfulness-based stress reduction (MBSR) program. The intervention involved a one-day introductory workshop followed by a commitment to daily mindfulness meditation practice for 8 weeks.

There was no separate control group in this pilot study. Instead, participants served as their own controls, with their psychological well-being measured before the intervention and again after the 8-week program.

The primary goal was to assess the acceptability and feasibility of this modified MBSR intervention to inform a larger, future randomized controlled trial (RCT). The secondary goal was to explore its effectiveness on several measures of psychological well-being.

The outcome measures used to assess the program's impact were:

**General Health Questionnaire (GHQ-12):** A widely used screening tool for common mental disorders, assessing overall psychological distress. Lower scores typically indicate better general health.

**Sense of Coherence (SOC):** A scale measuring an individual's global orientation to life, specifically their feeling that life is comprehensible, manageable, and meaningful. Higher scores indicate a stronger sense of coherence.

**Depression, Anxiety and Stress Scale (DASS):** A self-report questionnaire designed to measure the three related negative emotional states of depression, anxiety, and stress. The study specifically reported findings for the stress subscale. Lower scores on the DASS stress subscale indicate reduced stress.

The study included a total of 40 participants: 20 midwives and 20 nurses.

All participants were healthcare professionals working in roles known to experience high levels of stress and distress. The study does not specify their age range, gender distribution, specific health status (beyond being employed healthcare workers), or prior experience with mindfulness or meditation. The setting was implied to be within their professional context, likely in Australia given the journal's origin, but specific geographical details are not provided in the abstract.

The study used three standardized, self-report questionnaires to measure changes in psychological well-being before and after the intervention:

**General Health Questionnaire (GHQ-12):** This is a 12-item questionnaire designed to detect psychiatric morbidity in primary care settings. It asks respondents about recent changes in their usual feelings and experiences, such as feeling "constantly under strain" or "losing sleep over worry." Responses are typically scored on a 4-point Likert scale (e.g., "not at all," "no more than usual," "rather more than usual," "much more than usual"), which are then summed to provide a total score. Lower scores on the GHQ-12 indicate better general mental health. The abstract does not specify the exact scoring method used (e.g., 0-0-1-1 or 0-1-2-3), nor the possible range of scores.

**Sense of Coherence (SOC):** This scale measures an individual's capacity to cope with stress and stay healthy. It assesses three components:

* **Comprehensibility:** The extent to which one perceives stimuli from internal and external environments as structured, predictable, and explicable.

* **Manageability:** The extent to which one perceives that they have the resources available to meet the demands posed by these stimuli.

* **Meaningfulness:** The extent to which one feels that life has emotional meaning and that there are reasons to care and to invest energy.

The abstract does not specify which version of the SOC scale was used (e.g., SOC-29, SOC-13) or its scoring range. Higher scores on the SOC indicate a stronger sense of coherence and greater resilience.

**Depression, Anxiety and Stress Scale (DASS):** This is a 42-item self-report instrument designed to measure the severity of symptoms of depression, anxiety, and stress. Each of the three scales contains 14 items. The study specifically reported findings for the **stress subscale**. Items on the stress subscale assess symptoms such as difficulty relaxing, nervous arousal, and being easily upset. Responses are typically rated on a 4-point severity/frequency scale (0 = Did not apply to me at all, 3 = Applied to me very much, or most of the time). Scores for each subscale are summed. Lower scores on the DASS stress subscale indicate reduced stress levels. The abstract does not provide the specific scoring range for the stress subscale.

In addition to these quantitative measures, a subgroup of participants also took part in qualitative interviews or focus group discussions. These qualitative data were used to explore their experiences with the program and their ongoing mindfulness practice, providing insights into the acceptability and feasibility of the intervention.

This study was designed as a **pilot study using a pre- and post-intervention design**. This means that the same group of participants completed the outcome measures (GHQ-12, SOC, DASS) *before* starting the mindfulness program and again *after* completing the 8-week program. The primary purpose of a pilot study is to test the feasibility, acceptability, and preliminary effectiveness of an intervention before committing to a larger, more expensive, and resource-intensive full-scale study, such as a randomized controlled trial (RCT).

**Intervention Details:**

**Intervention:** An adapted mindfulness-based stress reduction (MBSR) program. The abstract does not detail how it was adapted from Kabat-Zinn's standard MBSR, which typically involves 8 weekly 2.5-hour sessions and a full-day retreat. This adapted version started with a "one-day workshop" followed by a commitment to "meditate daily for 8 weeks." This suggests a more condensed initial training followed by self-directed practice.

**Duration:** The active intervention period was 8 weeks of daily meditation practice, preceded by a one-day workshop.

**Adherence:** Participants "undertook to meditate daily for 8 weeks," but the abstract does not specify how adherence to this daily practice was monitored or measured.

**Study Design Implications:**

**Randomisation:** There was **no randomisation** in this study. All participants received the intervention. This is a key characteristic of a pre-post design and a major limitation for drawing causal conclusions. In a randomized controlled trial (RCT), participants would be randomly assigned to either an intervention group or a control group, ensuring that any differences between the groups are due to chance and not to pre-existing factors.

**Blinding:** **No blinding** was possible or implemented. Participants were fully aware they were receiving a mindfulness intervention, and they self-reported their outcomes. The researchers were also aware of who received the intervention. In studies with objective measures or a placebo control, blinding participants and/or researchers can help reduce bias (e.g., placebo effect, observer bias). Given the nature of a mindfulness intervention and self-report measures, participant blinding is generally not feasible.

**Control Group:** There was **no separate control group**. This is the most significant methodological limitation of a pre-post design. Without a control group, it's impossible to know if the observed changes were truly due to the mindfulness intervention or to other factors.

**Washout Periods:** Not applicable, as there was no crossover design or multiple interventions requiring a period for effects to dissipate.

**Statistical Approach:** The abstract states "quantitative findings included significant improvements." This implies that statistical tests (ee.g., paired t-tests or repeated measures ANOVA) were used to compare the pre-intervention scores with the post-intervention scores within the single group of participants. However, the specific statistical tests, p-values, or effect sizes are not reported in the abstract.

**What this design can and cannot prove:**

**What it CAN prove:**

* **Feasibility and Acceptability:** The qualitative findings and participant completion rates can demonstrate whether the intervention is practical to implement and well-received by the target population. This was a primary aim of the pilot.

* **Preliminary Evidence of Change:** It can show that *changes occurred* in the measured outcomes within the group over the 8-week period. This provides preliminary data to justify a larger study.

* **Direction of Effect:** It can indicate the *direction* of any observed changes (e.g., scores went up or down).

**What it CANNOT prove:**

* **Causality:** This design **cannot definitively prove that the mindfulness intervention *caused* the observed improvements**. Any changes could be due to a variety of confounding factors, including:

* **Natural progression/regression to the mean:** Participants might have been experiencing particularly high stress levels when they enrolled, and their scores might have naturally improved over time regardless of the intervention.

* **Placebo effect:** The act of participating in a program perceived as beneficial, receiving attention, and having an expectation of improvement can lead to positive changes, even if the specific intervention itself has no inherent effect.

* **Other life events:** Changes in work environment, personal life, or other factors during the 8-week period could have influenced participants' well-being.

* **Maturation:** Participants might have naturally developed coping strategies or improved their well-being over time.

* **Self-selection bias:** Participants who chose to enroll in a mindfulness program might be inherently more motivated to improve their well-being or more receptive to such interventions than the general population.

* **Effectiveness compared to other interventions:** Without a control group receiving a different intervention (or no intervention), it's impossible to say if mindfulness is more effective than other approaches.

**Major Methodological Weaknesses:**

1. **Lack of a Control Group:** As discussed, this is the most significant weakness, preventing causal conclusions.

2. **Small Sample Size (N=40):** While typical for a pilot study, a small sample size limits the statistical power to detect true effects and makes the findings less generalizable.

3. **Self-Reported Measures Only:** All outcome measures were self-reported questionnaires. While valuable, these are susceptible to social desirability bias (participants reporting what they think the researchers want to hear) and recall bias. There were no objective physiological or behavioral measures.

4. **Lack of Adherence Data