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Mindfulness and relaxation : the effects of a program with university hospital workers Mindfulness

Our study compared the effects of mindfulness and relaxation interventions on stress, quality of life, resilience, and mindfulness levels. A total of 29 workers, recruited at a university hospital in the northeastern region of Brazil and distributed in two groups: Mindfulness (89.5% female, age mean 37.5 ± 6.23 years old); and Relaxation (90.0% female, age mean 34.2 ± 8.66). After eight weeks of daily mindfulness or relaxation practices, both groups significantly reduced the perceived stress and stress at work, and increased their mindfulness and resilience levels, as well as the physical and psychological quality of life domains. Our results suggest that both interventions may be effective in the organizational environment, assisting in health promotion and increasing the ability of individuals to recover from an adversity (resilience).

Mindfulness and relaxation-based interventions have been shown to be effective and low-cost, and can easily be adapted to organizational environments. Therefore, the aim of this study was to investigate the effects of mindfulness and relaxation-based interventions lasting a total of eight weeks, and with daily practices from ten to twenty minutes on stress, quality of life, resilience, and mindfulness levels of workers from a university hospital located in the city of Petrolina, in the state of Pernambuco, Brazil. Our hypothesis was that both interventions would reduce stress, improve quality of life and resilience, and only MBI would improve the mindfulness levels of the participants.

Method Participants
A sample of 29 individuals, permanent workers at the Hospital de Ensino Doutor Washington Antônio de Barros -Universidade do Vale do São Francisco (HU-UNIVASF, Doctor Washington Antônio de Barros Teaching Hospital of the Federal University of Vale do São Francisco) of the administrative or health care sectors, participated in this study. The recruitment of participants was performed in the period of one month through posters at the hospital and via email, and applications were received through an online form.
Participants were randomly distributed in two groups (mindfulness, n = 18 and relaxation, n = 11). The total number of participants who completed the intervention phase was 15. The MBI group consisted of 7 workers, from both sectors of the hospital, in which the majority were women (n = 6), with a mean age of 38.6 years (minimum: 26 and maximum: 47, SD = 7.4), and who were either nursing technicians (n = 5) or administrative assistants (n = 2). The RBI group consisted of 8 workers, all female, also from both I. S. LEMOS et al. sectors, whose mean age was 35.9 years (minimum: 24 and maximum: 49, SD = 8.9), and who were nursing technicians (n = 3); an economist (n = 1); an administrator (n = 1); a psychologist (n = 1); and an administrative assistant (n = 2). A CONSORT Flow Diagram showing all the steps of the study is presented on Figure 1. The demographic information for each group is presented in Table 1.

Instruments
The language used in all instruments was Brazilian Portuguese. All scales were previously validated for the Brazilian population and were applied before and after the intervention.
Registration form and Demographic Questionnaire: Available in online format, designed to register participants' demographic information.
Audio Recordings for Mindfulness and Relaxation Practices: Divided between: the practice of body scanning (MBI group); progressive muscle relaxation (RBI group); meditation focusing on breath -10 and 20 minutes (MBI group); loving-kindness meditation (MBI group) and relaxation through visualization (I, II, and III -RBI group). Each group had a total of 4 practices, ranging between 10 and 20 minutes. The audio recordings were based on techniques usually present in mindfulness and relaxation protocols (such as body scanning or progressive muscle relaxation) and were elaborated by the researchers under the supervision of an experienced professional in the field of contemplative practices. All the audios were recorded in a studio and narrated by one of the authors of the present study, who has eight years of experience as a certified instructor of yoga practices (the content of the audios are available upon request).
Perceived Stress Scale (PSS-10): Comprised of 10 items that are used to assess the subject's perceived stress in the last month, with six positive and four negative items, answered in a Likert-type scale of frequency. The version used in this study was translated and adapted to Brazilian Portuguese by Luft, Sanches, Mazo, and Andrade (2007).
Scale of Stress at Work (SSW): Composed of 13 items (Likert-type Scale) that assessed the level of stress related to work. The version used was developed and validated by Paschoal and Tamayo (2004).
Mindful Attention Awareness Scale: Composed of 15 items (Likert-type Scale), which assesses the level of awareness and mindfulness of the subject. The Brazilian version of the Mindful Attention Awareness Scale was validated by Barros, Kozasa, Souza, and Rozani (2015) was used. World Health Organization Quality of Life Instrument (WHOQOL): Developed by the World Health Organization (WHOQOL Group, 1994). We used the brief version WHOQOL-BREF (Qualidep, 1995). The validation study to Brazilian Portuguese was conducted by Fleck et al. (2000).

Procedures
The research was approved by the Universidade Federal do Vale do São Francisco (UNIVASF, Federal University of Vale do São Francisco). Ethics Committee, CAAE: 64237417.1.0000.5196, and followed all the guidelines of Resolution 510/2016, which regulates research in the humanities sciences in Brazil. All subjects gave their written consent regarding the participation in the study that composes this article.
Data collection and interventions were carried out in a room of UNIVASF, located in Petrolina (PE). This location was chosen because it was near the workplace of the participants, contained the appropriate materials for the performed practices, and provided greater comfort and privacy to the individuals. After filling out the online registration form, participants were invited for a meeting, when general information about the research was set out, and the Consent Form was signed by all participants. Following this, the scales (3 -7) were applied, and participants were randomly distributed in two groups: MBI and RBI.

Intervention
The participants received a CD containing four audio tracks according to the type of practices they performed: mindfulness or relaxation. As the total intervention period was of eight weeks' duration, each of the four practices was repeated for two weeks. In the first two weeks of the intervention, the MBI group performed body scanning (with a total duration of 20 min) and the RBI group performed progressive muscle relaxation (with a total duration of 20 min). At weeks three and four, the MBI group performed a meditation practice focused on breathing (total duration of 10 min) and the RBI group performed a relaxation practice through visualization I (total duration of 10 min). At weeks five and six, the MBI group performed a meditation practice focused on breathing (total duration of 20 min) and the RBI group performed a relaxation practice through visualization II (total duration of 20 min). In the last weeks of intervention (seven and eight), the MBI group practiced loving-kindness meditation (duration of 10 min) and the RBI group practiced relaxation through visualization III (total duration of 10 min).
Weekly meetings were held (over the eight weeks of the intervention) with participants and researchers, in which additional information on practices and postures were provided. For control purposes, participants were asked to report if they had missed any of the daily practices of that week. At the end of every weekly meeting, participants were instructed to continue performing their daily practices individually, at the location of their choice (in a comfortable and quiet location, free of interruptions).

Data analysis
Data analyses were performed using the IBM ® SPSS ® Software (version 21). A Mixed-Design Analysis of Variance (ANOVA) was performed for verification and comparison of the effects of the interventions, with the type of intervention as a factor between groups, and time as a factor within groups. A t-test for independent samples was performed to compare the workers from the administrative and health care sectors. The criterion for statistical significance was p < 0.05.

Pre-intervention phase
A total of 29 workers from both sectors (health care and administrative) of HU-UNIVASF, without previous experience with mindfulness or relaxation practices, participated in the pre-intervention phase of the study. Hospital workers had relatively high stress levels, mean mindful attention, resilience, and quality of life levels, as shown in Table 2. No statistically significant differences were found between workers from the administrative and health care sectors. The reference values for each scale are shown in Table 3.   (Luft et al., 2007;Remor, 2006); 2 (Paschoal & Tamayo, 2004); 3 (Atanes et al., 2012;Barros et al., 2015); 4 (Pesce et al., 2005;Slomka, 2011); 5 (Fleck et al., 2000;Talarico, 2013).

Post-intervention phase
A dropout rate of 48.3% was observed over the course of the interventions. The MBI group presented a higher dropout rate (63.1%) in comparison with the RBI group (20.0%). Most participants (13) who dropped out were from the health care sector (nurses, doctors, and nursing technicians).
At the end of the intervention period, it was expected that the participants of both groups (MBI and RBI) had reduced their stress levels. In fact, as evidenced in Figure 2  Note: * Both types of interventions significantly reduced the participants' stress levels (p < 0.05); and significantly increased the participants' mindful attention and resilience (p < 0.05), as well as the quality of life in the physical and psychological domains (p < 0.05). Means of perceived stress levels (A) and stress at work (B); mindfulness (C) and resilience (D); quality of life in the physical domain (E); and psychological domain (F), before and after interventions.

Stress at work
Stress at work (mean) Both interventions (MBI and RBI) resulted in a significant increase in the quality of life physical [F (1.13) = 12.30, p = 0.004, η p 2 = 0.486] and psychological domains [F (1.13) = 5.16, p = 0041, η p 2 = 0.284] of the participants, as shown in Figure 2. The areas of social relations and environment also showed an improvement, but the values were not statistically significant (p > 0.05). According to the correction parameters of the WHOQOL-BREF (Table 2), the means obtained in the physical and psychological domains after interventions in both groups were at a good level, i.e. between 68 and 100. There was no difference between the types of intervention, nor interactions between the type of intervention and time factors (p > 0.05).

Discussion
This study investigated the stress, mindfulness, resilience, and quality of life levels of a university hospital workers. The results showed that these professionals have relatively high stress and mean mindfulness, resilience, and quality of life levels. There were no differences between workers from the administrative or health care sectors, suggesting that the hospital environment might be stressful, even for the professionals who do not deal directly with patients. Additionally, two types of interventions were carried out (MBI and RBI) and the pre-and post-intervention comparisons suggested that both may be effective in reducing stress and increasing mindfulness, resilience, and quality of life levels of hospital workers.
This finding is consistent with the literature that has pointed out that there are no major differences between the beneficial effects of an MBI and an RBI when compared with a control group of participants in the waiting list (Jain et al., 2007;Josefsson, Lindwall, & Broberg, 2014). According to Virgili (2015), there is little evidence that mindfulness-based interventions have greater effectiveness for reducing stress, when compared with other types of intervention, such as yoga or relaxation.
Regarding the mindfulness levels, and following our literature findings, our initial hypothesis was that both interventions would be able to reduce stress, improve quality of life and resilience, but only the MBI would improve the mindfulness levels. What we found, however, is that both interventions may have beneficial effects on the level of mindfulness of the participants.
There are still few studies that aim to explain this happening but one factor that might have contributed to this result is the similarity between the practices of both interventions, especially the practice of body scanning and progressive muscle relaxation. Both lead the individuals to focus the attention on different parts of the body, one at a time, which might cause the development of the mindfulness state even when using relaxation practices (Josefsson et al., 2014).
In relation to quality of life, the two areas that showed significant differences were the psychological and the physical domains. According to Talarico (2013), some of the facets of the psychological domain are: positive feelings, thinking, learning, memory, concentration, and self-esteem. In the physical domain, the facets are: pain and discomfort, sleep and rest, and the capability to work. This corroborates what some studies have found about reduction of pain and improvement in sleep quality with both relaxation (Saeedi, Ashktorab, Saatchi, Zayeri, & Amir, 2012;Tsai, Chen, Lai, Lee, & Lin, 2007) and mindfulness practices (Visser, Hirsch, Brown, Ryan, & Moynihan, 2015;Zeidan, Grant, Brown, McHaffie, & Coghill, 2012).
Another important finding, that also corroborates with what has been found in previous studies, is related to the duration of interventions (8 weeks), the practice time (mean of 15 minutes), and the benefits produced by them (Paulik, Simcocks, Weiss, & Albert, 2010;Song & Lindquist, 2015). The results of the present study suggest that daily practices, from 10 to 20 minutes, over eight weeks, might be appropriate and sufficient to promote positive changes. Some MBI, with practices of similar duration have shown to be effective and appropriate to the organizational setting (Virgili, 2015), indicating that even short periods of practice (mindfulness and relaxation) might be beneficial.
The effects of a mindfulness program can persist along the years. Solhaug et al. (2019) demonstrated that the benefits of a seven-week, mindfulness-based stress reduction program were observed four years later in a sample of university students. The participants showed improved scores of mental distress and coping strategies, which suggests that meditation practice is a positive predictor of long-term mindfulness levels. Similar outcomes were found by Braun, Kinser, Carrico, and Dow (2019), who investigated the benefits of a mindfulness-based intervention, in a follow-up study of six to 18 months' duration. Their findings show that three elements of mindfulness increased in the long run: acting with awareness, nonreactivity, and nonjudging. These results show the importance of follow-up studies when investigating the effects of MBI and point out that the inexistence of long-term assessments is an important limitation of the present study.
By the end of this study, 48.3% of the participants had dropped out without completing all proposed practices, which limits the generalization and the inferences of the results for the studied population. The fact that each participant of the study received a CD containing the four audio tracks, according to the type of practices they performed (mindfulness or relaxation), already on the first day of intervention is an important methodological issue that may have contributed to the high dropout rate. This gave participants the possibility of performing the daily practices individually at the location of their choice over the eight weeks without attending the weekly meetings with the researchers.
Most participants who dropped out were part of the health care sector known for the high workload, long working hours, and sleep deprivation. The intense workload of the participants and the unavailability of an appropriate room in the building of the university hospital where the meetings with the researchers could have been held may have also contributed to the low attendance of the participants. In order to prevent excessive dropouts, it is important that future interventions take place at the participants' workplace and on their breaks.
The literature points out that other factors, such as social desirability (Ribas, Moura, & Hutz, 2004) and learning (Oliveira, Trezza, Busse, & Jacob Filho, 2014), might by themselves affect the low response of the participants to the assessment instruments. The inclusion of a third group, which would have not performed any practices (those on the waiting list, for example), would have made it possible to assess the effects of time, social desirability and learning of the scales in the responses of the participants. It is also important to clarify that this study was not submitted to a clinical trial registry before data collection.
Future studies investigating the effects of relaxation-based interventions on mindfulness levels could help us to understand how this type of practice affects this state of consciousness. The use of neuroimaging techniques such as functional magnetic resonance imaging can unveil the neural mechanisms of benefits associated to relaxation techniques and contribute to investigate differences between the underlying mechanisms of relaxation and mindfulness practices.

Conclusion
The results of the present study suggest that professionals of university hospitals may be at psychosocial risk due to stress levels associated with their work contexts. The development of interventions, such as those carried out in this study, is important to prevent the occurrence of health problems. This study adds to the growing literature on the subject, that mindfulness and relaxation practices are cost-effective interventions that can be easily adapted to different work contexts, including the hospital environment.