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Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
FAST TRACK ARTICL E
[AQ1]
Mindfulness Goes to Work
Impact of an On-Line Workplace Intervention
Kimberly A. Aikens, MD, MBA, John Astin, PhD, Kenneth R. Pelletier, PhD, MD (hc), Kristin Levanovich, MS,
Catherine M. Baase, MD, Yeo Yung Park, PhD, and Catherine M. Bodnar, MD, MPH
Objective: The objective of this study was to determine whether a mindful-
ness program, created for the workplace, was both practical and efficacious
in decreasing employee stress while enhancing resiliency and well-being.
Methods: Participants (89) recruited from The Dow Chemical Company
were selected and randomly assigned to an on-line mindfulness intervention
(n=44) or wait-list control (n=45). Participants completed the Perceived
Stress Scale, the Five Facets of Mindfulness Questionnaire, the Connor-
Davidson Resiliency Scale, and the Shirom Vigor Scale at pre- and postin-
tervention and 6-month follow-up. Results: The results indicated that the
mindfulness intervention group had significant decreases in perceived stress
as well as increased mindfulness, resiliency, and vigor. Conclusions: This
on-line mindfulness intervention seems to be both practical and effective
in decreasing employee stress, while improving resiliency, vigor, and work
engagement, thereby enhancing overall employee well-being.
Occupational pressure is now recognized as the major source of
stress for US adults, representing a serious hazard to employee
health and productivity. Unfortunately, this is an expensive problem,
in part due to the high medical costs associated with chronic long-
term stress, which can contribute to adverse health habits such as
alcoholism, smoking, and obesity.1,2 Furthermore, chronic stress is a
known risk factor in many disease states, including depression,3–5 up-
per respiratory tract infections,6cardiovascular disease,7–9 stroke,10
autoimmune disorders,11, 12 and total mortality.13,14 Unfortunately,
the costs associated with workplace stress go well beyond higher
health care utilization, to include inflated expenses due to increased
absenteeism and presenteeism, reduced productivity, greater com-
pensation claims, and rising health insurance expenses.15 In addition,
other mental health disorders, including anxiety and depression, add
to this burden. According to Health and Safety Executive16 statistics
done in Great Britain, mental ill health, including stress, anxiety,
and depression, gave rise to more working days lost than any other
illness complaint, including musculoskeletal disorders, accounting
for 9.3 million days lost in 2010. This difficult financial problem is
further illustrated by a recent sample of 92,486 employees at seven
organizations over an average of 3 years. In this sample, workers
with depression cost $2184 more (48%) than those not at risk while
workers reporting high stress were $413 more costly. This combined
From the The Aikens Approach, LLC (Dr Aikens), Petoskey, Michigan; Califor-
nia Pacific Medical Center (Dr Astin), San Francisco; University of Arizona
School of Medicine and University of California School of Medicine (Dr
Pelletier), San Francisco; The Dow Chemical Company (Dr Baase), Midland,
[AQ2]
Michigan; Department of Internal Medicine, Cardiology (Dr Park), Univer-
sity of Michigan, Ann Arbor; and The Dow Chemical Company (Dr Bodnar),
Midland, Michigan.
[AQ3]
All funding was provided by the American Health Association.
Dr Kimberly Aikens is the founder of The Aikens Approach LLC and the program
developer. Nevertheless, she received no remuneration of any type for this
research project or the work done at The Dow Chemical Company. Other
authors declare no conflicts of interest.
[AQ4]
Address correspondence to: Kimberly A. Aikens, MD, MBA, The
Aikens Approach, LLC, 7336 Preserve Court, Petoskey, MI 49770
(kim@aikensapproach.com).
[AQ5]
Copyright C2014 by American College of Occupational and Environmental
Medicine
DOI: 10.1097/JOM.0000000000000209
at-risk mental health group represented 4.2% of medical expendi-
tures with a total cost of $15,396,934 annually. This compares, for
example, with an annual cost of $7,472,894 for high blood pressure
and a cost of $9,823,445 for tobacco use.17 Because of the prevalence
and cost of this problem, an intervention with the capacity to help
mitigate employee stress, while simultaneously leading to the devel-
opment of emotional well-being, could be beneficial to employers
from both cost and performance perspectives.
The primary purpose of this study was to determine whether a
shortened, workplace-specific mindfulness program could replicate
the effectiveness of a traditional Mindfulness Based Stress Reduc-
tion (MBSR) program in reducing employee stress while enhancing
measures of mindfulness and employee well-being. Mindfulness,
the concept central to this intervention, has been conceptualized as
a two-component model. The first component consists in focusing
full attention on immediate experience.18, 19 The second component
involves adopting a stance of acceptance, curiosity, and openness
toward one’s experience. In theory, this process of nonevaluative,
nonjudgmental awareness of present moment experience allows for
a detachment from ruminative and elaborate thought patterns regard-
ing those experiences. With practice, this results in a learned skill or
trait, which allows insight into the nature of one’s mind and thoughts.
This form of mental training, with its concomitant growth in aware-
ness and insight, can lead to stress hardiness and an increased ability
to skillfully cope with potentially harmful and maladaptive mental
processes.20
Traditionally delivered MBSR programs, which teach core
mindfulness concepts, have been well researched with beneficial
therapeutic effects found in psoriasis,21 fibromyalgia,22 type 2
diabetes,23 rheumatoid arthritis,24, 25 chronic pain,26–29 chronic
low back pain,30 attention-deficit/hyperactivity disorder,31, 32 and
insomnia.33 Research also indicates that mindfulness-based ther-
apies are beneficial in the treatment of depression,34–36 anxiety
disorders,37, 38 and bipolar disorder.37–41 In addition, studies in the
realm of business have found mindfulness to be beneficial in im-
proving service quality in small to medium employers,42 relationship
quality in service employers,43 marketing strategy,44 quality and reli-
ability in small and large employers,45 quality management,46 prod-
uct failure management,47 task performance,48 employee turnover
intentions,49 and resonant leadership.50
A potential deterrent, however, to the utilization of a tradition-
ally delivered MBSR program in a workplace setting is the expected
participant time commitment. A typical MBSR program requires ap-
proximately 30 hours of teacher-led training, in addition to 30 to 45
minutes of home-based practice daily. To address the more time ur-
gent needs of the workplace environment, we created a mindfulness
intervention delivered via an on-line platform. This program was
significantly modified in content from traditional MBSR to reflect
workplace needs. In addition, this program was shortened, requiring
approximately 25% of the time commitment typical to MBSR cur-
riculum (Table 1). Important aims of this study were to determine [T1]
whether such a modified program would (1) be practical in today’s
workplace, (2) provide the potential for scalability; and (3) remain
efficacious in decreasing perceived stress and enhancing employee
mindfulness.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JOEM rVolume 00, Number 00, 2014 1
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
Aikens et al JOEM rVolume 00, Number 00, 2014
TABLE 1. MBSR vs Dow Mindful Resilience Program Components*
MBSR Dow Mindful Resilience Program
Class 1
Class time 3 hr 1 hr (Theme—Overriding Autopilot)
Home practice Body Scan (45 min) ×6 The Raisin (12 min) ×1
Breath Focus l (12 min) ×2
Body Scan l (22 min) ×2
Class 2
Class time 2.5 hr 1 hr (Theme—Body Awareness)
Home practice Body Scan (45 min) ×6 Coffee Break (11 min) ×1
Walking Focus l (17 min) ×2
Body Scan ll (25 min) ×2
Class 3
Class time 2.5 hr 1 hr (Theme—Breath as an Anchor)
Home practice Body Scan (45 min) ×3
Lying Yoga (45 min) ×3
Breath Focus ll (20 min) ×2
Lying Yoga (35 min) ×2
Three-Minute Breathing Pause
Class 4
Class time 2.5 hr 1 hr (Theme—The Watcher and the Talker)
Home practice Body Scan (45 min) ×3
Standing Yoga (45 min) ×3
Breath Meditation daily (20 min)
Focus on Physical Sensation (23 min) ×2
Walking Focus ll (22 min) ×2
Class 5
Class time 2.5 hr 1 hr (Theme—Acceptance)
Home practice Sitting Meditation (30 min) ×3
Body Scan or Yoga (45 min) ×3
Focus on Sound and Thought (23 min) ×2
Standing Yoga (37 min) ×1
Class 6
Class time 2.5 hr 1 hr (Theme—Thought Is Not Reality)
Home practice Sitting Meditation (30 min) ×3
Body Scan or Yoga (45 min) ×3
Choiceless Awareness Meditation (25 min) ×1
Focus on Bells and Poetry (20 min) ×1
Class 7
Class time 2.5 hr 1 hr (Theme—Difficult Situations)
Home practice Practice as desired (30–45 min) daily Mindful Communication (15 min) ×1
Stress-free Driving (20 min) ×1
Stressful Situations (17 min) ×1
Class 8
Class time 3.5 hr No Class (Theme—Building Your Haven)
Home practice Practice as desired (30–45 min) daily The Window (23 min) ×1
The Oak (27 min) ×1
Progressive Muscle Relaxation (25 min) ×1
Day retreat 7.5 hr None
Time commitment
Classroom 29 hr 7 hr
Home practice 42–48 hr 10.8 hr
Individual interview 1.5 hr None
Total 72.5–75.5 hr 17.8 hr
*All Dow mindfulness exercises were accessed by participants through Web-based audio recordings Home practice time (ie, 45 minutes) denotes time per exercise.
MBSR, Mindfulness Based Stress Reduction.
AIMS AND HYPOTHESIS
The program utilized in this study was tested in a population
of general employees at The Dow Chemical Company (Dow). The
primary hypotheses of the study were that a shortened, Web-based
workplace mindfulness program would (1) increase measures of
mindfulness, (2) decrease stress, (3) enhance resiliency, and (4) im-
prove employee vigor and work engagement, thereby resulting in an
increase in positive organizational behavior and enhanced employee
well-being. We also hypothesized that the on-line applied training
portion of the program, which included personalized progress track-
ing and lifestyle coaching, could affect employee lifestyle choices
such as (1) diet, (2) exercise time, and (3) hours slept per night, over
the course of the program.
METHODS
Design
This study utilized a randomized controlled study design,
which implemented a 2 (intervention vs wait-list control group) ×
3 (baseline, postintervention, 6-month follow-up) format, thereby
allowing between-groups comparisons. Participants were randomly
assigned by computer algorithm to the 7-week workplace-specific
mindfulness program or a wait-list control group. The wait-list con-
trol group received the identical mindfulness treatment immediately
after the intervention group completed the program. Although exact
data are not available, both groups were predominately meditation
naive, with only one participant known to have had prior MBSR
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
2C2014 American College of Occupational and Environmental Medicine
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
JOEM rVolume 00, Number 00, 2014 Mindfulness at Work: Impact of an On-Line Intervention
experience. With regard to outcomes, baseline and postintervention
measures were taken on both the intervention and wait-list control
groups. In addition, wait-list control participants completed a third
set of measures immediately after they received the mindfulness
intervention (postintervention wait-list group [PIWL]). Follow-up
measures for the intervention group were also obtained 6 months
after treatment.
Participants
Participants were drawn from a sample of 600 Dow employ-
ees, located in Midland, Michigan, who had completed a health risk
assessment (comprehensive questionnaire and biometrics) in the pre-
ceding 6 months. All employees are invited for health risk assessment
with employees in given departments being scheduled throughout the
year. This recruitment allowed for study access to a good cross sec-
tion of employees because the standard process of invitations would
include all elements of the employee base. Study participant recruit-
ment occurred from March to April 2012 and consisted of one e-mail
notification, which described the free mindfulness-based stress man-
agement program. The e-mail notification explained that the purpose
of the program was to help employees reduce and manage workplace
stress. In response to the e-mail notification, 135 employees signed
up for the program and 90 were randomly selected to participate. In-
clusion criteria included (1) having taken a health risk assessment in
the last 6 months, (2) being a salaried employee of The Dow Chem-
ical Company, and (3) having an age greater than 18 years. There
were no exclusion criteria for this study, although the program was
not offered to hourly workers. In addition, an open invitation was
sent via e-mail to the 90 participants describing a Mindful Leaders
program, which we had developed. This notification explained that
the intent of the Mindful Leaders was to act as champions for the
program within Dow. Of the 90 selected, 89 employees, aged 18 to 65
years, gave informed consent, enrolled in the program, and were sub-
sequently randomly assigned to the mindfulness intervention group
(n=44) or wait-list control (n=45). In addition, six participants in
the intervention group chose to be Mindful Leaders or champions,
as did five participants in the wait-list control group.
Measures
Five Facets of Mindfulness Questionnaire
Because researchers consider mindfulness to be a multidi-
mensional construct with facets that include the ability to observe,
describe, act with awareness, refrain from judgment, and nonreact,51
we utilized the well-validated Five Facets of Mindfulness Question-
naire (FFMQ) to assess potential improvements in all five mindful-
ness domains. The FFMQ is a self-report instrument consisting of
39 items, which measures a trait-like, general tendency to be mindful
on a daily basis.
The Perceived Stress Scale
The Perceived Stress Scale (PSS-14) was used to assess partic-
ipants’ levels of psychological stress. The PSS-14 is a well-validated
stress measurement tool whose items are designed to tap into how
unpredictable, uncontrollable, and overloaded individuals find their
lives.52,53
Connor-Davidson Resilience Scale
We evaluated resiliency with the Connor-Davidson Resilience
Scale (CD-RISC) scale. The CD-RISC consists of 25 items, which
measure an individual’s sense of personal competence, tolerance of
negative emotion, positive acceptance of change, trust in one’s in-
stincts, sense of social support, spiritual faith, and an action-oriented
approach to problem solving.54 Research has shown resiliency to
positively impact job performance, organizational commitment, and
organizational citizenship behavior.55 ,56
Shirom Vigor Scale
We analyzed vigor and work engagement with the 12-item
Shirom Vigor Scale. Shirom57 conceptualized vigor as consisting
of three facets, physical strength, emotional energy, and cognitive
liveliness. The first facet, physical strength, references one’s sense
of high energy when carrying out daily tasks at work. The second
facet, emotional energy, refers to one’s capacity to emotionally in-
vest in relationships with clients and coworkers, as well as the ability
to express sympathy and empathy. The last facet, cognitive liveli-
ness, refers to one’s feelings of mental agility and flow of thought
processes.57–59 In addition, the Shirom Vigor measure is a common
approach to work engagement developed by researchers. The Shi-
rom Scale measures the three components of vigor, which reflects
Kahn’s (1990) original concept of engagement. This concept includes
the use of physical, emotional, and cognitive energetic capacities at
work. Some researchers believe that the Shirom Vigor approach to
engagement may be the better measure in determining the effect of
engagement on organizational outcomes.60
Lifestyle Survey Questions
In addition to the aforementioned outcome measures, we also
analyzed self-reported lifestyle behaviors. Participants were asked
the following questions via weekly on-line surveys over the course
of 7 weeks: (1) average number of servings of fruits and vegetables
daily; (2) average number of fast food meals per week; (3) days per
week with at least 30 minutes of exercise; (4) average hours slept
per night; (5) the number of high stress episodes per week; and (6)
the number of days per week a participant felt too burned out to
work .
Intervention
Mindfulness Program
The mindfulness intervention utilized in this study consisted
of a 7-week program combining live, weekly hour-long virtual class
meetings with accompanying on-line applied training. Once par-
ticipants had been selected for the intervention and had submitted
their completed baseline assessment scales, they were given access
to their unique training dashboard through the program Web site.
Participants also received a workbook, which corresponded to each
weekly lesson and contained a practice guide. The intervention be-
gan with an introductory in-person class meeting, after which par-
ticipants were instructed to read the corresponding section of the
workbook and complete the assigned on-line applied training before
the next class meeting. Subsequent class meetings (with the excep-
tion of the fifth class meeting, which was on site) were conducted
via webinar and followed the same format. Participants could join
these meetings together in a prescheduled conference room at Dow
(which held a webinar broadcast screen) or, if they were traveling,
remotely via the Internet or cell phone. In addition, meetings were
recorded and sent out to participants in the event that they could not
attend.
The program’s weekly on-line applied training material con-
sisted of three parts. The first part consisted of completion of the
assigned experiential audio exercises, which became longer and
more complex as the course progressed. Exercises were framed to
participants as containing mental fitness and focusing techniques
and included training in the following mindfulness practices: (1)
seated focus exercises on the breath, physical sensation, sound, and
thought; (2) a short body scan with progressive focus on physical
sensation throughout the body; (3) walking meditation with focus on
physical sensation and sight; (4) movement exercise with focus on
various stretching postures and awareness of sensation inherent to
body movement; and (5) 3-minute breathing pause with focus on the
breath, physical sensation, and thought, designed to allow intentional
connection with the present moment.61 Additional exercises included
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
C2014 American College of Occupational and Environmental Medicine 3
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
Aikens et al JOEM rVolume 00, Number 00, 2014
FIGURE 1. Participant flowchart. FU, follow-up; PI, postintervention.
[AQ6]
performance-oriented skills such as successful handling of stressful
situations, recognition of autopilot and automatic mind scripts, mind-
ful communication, presentation preparedness, and mindful problem
solving.
The second part of the program’s on-line applied training con-
sisted of a weekly progress tracking survey. The intended purpose of
this survey was twofold: (1) to assess participants’ understanding of
the concepts inherent in each week’s mindfulness material and (2) to
track healthy lifestyle habits and program usage. Each participant re-
ceived pre-programmed e-mail coaching and feedback specific to his
or her individual responses to survey questions. This feedback was
programmed to provide educational material and coaching in areas
where the participant needed improvement as well as encouragement
in areas where the participant excelled.
The last piece of the on-line applied training program was a
customized text messaging system. Participants who decided to “opt
in” received a daily text that corresponded to his or her progress
through the program. These texts provided daily practice reminders
and encouragement specific to the participant’s place in the program.
Wait-List Control
Participants randomized to this group received no active treat-
ment but were offered the intervention at the conclusion of the postin-
tervention period.
Instructor
A board-certified internal medicine physician, with training
in integrative medicine and MBSR, led the intervention. The same
instructor who led the intervention group also led the wait-list con-
trol group sessions. Following the completion of the intervention
group training, participants in the wait-list control group received
the equivalent mindfulness program.
Statistical Analysis
Primary results are based upon intention-to-treat (ITT) analy-
sis. The treatment effect was assessed through (1) comparison of all
scores between intervention and wait-list control in the ITT sample at
postintervention, adjusting for baseline scores, and (2) within-group
comparisons of pre- and postintervention scores using baseline to
postintervention for the intervention group, and from postinterven-
tion to program completion (PIWL) for the wait-list control group.
In addition, a secondary analysis with study completers (participants
who participated in at least 50% of the allocated intervention) is also
reported.
Analysis of covariance was used for the first comparison.
We report effect size (ES) for paired differences for the second
comparison. In addition, the same analysis was performed for the
participants who completed more than 75% of the material. Further-
more, to assess whether there was a linear trend of change in each
lifestyle survey question score as the program progressed, we fit a
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4C2014 American College of Occupational and Environmental Medicine
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
JOEM rVolume 00, Number 00, 2014 Mindfulness at Work: Impact of an On-Line Intervention
TABLE 2. ITT Sample Means and Standard Deviations for All Variables per Group for All 3 Timepoints: Baseline (BL), Postintervention (PI), and
6-Month Follow-Up (FU)*
[AQ7]
Mindfulness Intervention (N=44) Wait List Control (N=45)
BL PI FU PFU ESPI†ESFU‡%PI§ %FUBL PI PIWL PPI PPIWL ESPI ESPIWL¶%PIWL#
FFMQ
Observe 23.25 ±5.54 28.81 ±5.44 29.26 ±5.05 <.001 1.00 1.08 23.9% 25.8% 24.22 ±5.46 23.91 ±5.90 29.91 ±5.60 0.90 <.001 −0.06 1.02 25.1%
Describe 26.43 ±4.73 28.72 ±6.15 31.19 ±5.57 <.001 0.48 1.01 8.7% 18.0% 25.29 ±5.72 25.48 ±4.79 27.16 ±5.23 0.32 0.001 0.03 0.35 6.6%
Act aware 24.11 ±5.01 27.67 ±5.33 28.74 ±5.01 <.001 0.71 0.92 14.8% 19.2% 23.96 ±6.14 24.29 ±6.35 26.50 ±4.93 0.81 0.001 0.16 0.35 9.1%
Nonreact 21.14 ±4.14 24.17 ±4.51 25.26 ±3.88 <.001 0.73 1.00 14.3% 19.5% 21.31 ±4.52 21.43 ±4.10 23.88 ±3.77 0.57 <.001 0.03 0.60 11.4%
Nonjudge 28.50 ±6.14 30.33 ±5.89 31.68 ±5.97 <.001 0.30 0.52 6.4% 11.2% 27.13 ±5.40 27.98 ±5.86 31.06 ±6.26 0.12 <.001 0.16 0.53 11.0%
PSS-14 24.46 ±6.29 18.00 ±7.01 18.81 ±6.72 <.001 1.03 0.90 −26.4% −23.1% 24.76 ±8.16 23.32 ±8.45 19.81 ±7.36 0.04 <.001 0.18 0.42 −15.1%
CD-RISC 68.50 ±12.09 76.11 ±12.14 76.71 ±11.39 <.001 0.63 0.68 11.1% 12.0% 71.02 ±14.29 67.71 ±14.70 76.59 ±13.60 0.90 <.001 −0.23 0.60 13.1%
Vigor
PS 4.08 ±0.96 4.77 ±0.99 4.88 ±0.76 <.001 0.72 0.83 16.8% 19.6% 4.17 ±1.15 4.46 ±1.07 4.81 ±1.12 0.01 <.001 0.25 0.56 7.8%
CL 4.53 ±0.96 5.11 ±0.99 5.08 ±0.86 0.003 0.60 0.57 12.9% 12.1% 4.75 ±0.99 4.69 ±1.03 5.06 ±1.07 0.45 0.002 −0.06 0.31 7.9%
EE 5.07 ±0.89 5.47 ±0.68 5.63 ±0.60 0.001 0.45 0.63 7.7% 11.0% 5.12 ±1.06 5.12 ±.094 5.34 ±1.09 0.89 0.01 0.00 0.21 4.3%
*P Values represent within-group changes from baseline (BL) to postintervention (PI) except for PPIWL, which represents differences between PI and PIWL for wait-list control.
†ESPI represents within-group effect sizes that reflect differences between (BL) and (PI).
‡ESFU represents within-group effect sizes that reflect differences between (BL) and (FU).
§% PI represents % change at postintervention between BL and PI.
% FU represents % change at 6-month follow-up between BL and FU.
¶ESPIWL represents within-group effect sizes that reflect differences between (PI) and (PIWL).
#% PIWL represents % change for wait-list group between PI and PIWL.
BL, baseline; CD-RISC, Connor-Davidson Resilience Scale; CL, cognitive liveliness; EE, emotional energy; FFMQ, Five Facets of Mindfulness Questionnaire; FU, 6-month follow-up; PI, postintervention; PIWL,
postintervention wait-list group; PS, physical strength; PSS-14, Perceived Stress Scale.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
C2014 American College of Occupational and Environmental Medicine 5
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
Aikens et al JOEM rVolume 00, Number 00, 2014
TABLE 3. Comparison Between Groups Mindfulness
Intervention vs Wait List Control @ PI
ITT vs Wait-List
FFMQ
Observe <0.001
Describe 0.008
Act aware 0.001
Nonreact 0.001
Nonjudge 0.227
PSS-14 <.001
CD-RISC <.001
Shirom Vigor Scale
Physical strength 0.021
Cog liveliness <.001
Emotional energy 0.027
CD-RISC, Connor-Davidson Resiliency Scale; FFMQ -Five Facets of
Mindfulness Questionnaire; ITT, intention-to-treat; PI, postintervention; PSS-14,
Perceived Stress Scale.
linear mixed-effects model between the survey question score and
progressing time (week) using a pooled sample (intervention and
wait-list control). This pooled sample contained 69 participants, who
showed varying levels of completion of the 8-week survey. We report
estimated mean scores at weeks 1 and 8. A significance level of 0.05
was used for this analysis.
RESULTS
Attrition and Adherence to Treatment
The ITT intervention group sample consisted of 44 partici-
pants. The criterion for inclusion in the ITT sample was random-
ization. Of these 44 participants, 6 did not start the program, citing
work obligations and busy schedules as the cause. Of the remaining
38, 2 (5.3%) terminated prematurely because of either scheduling
problems or work commitments within the first 2 weeks of the inter-
vention (Fig. 1). [F1]
The total, completed program sample comprised all partici-
pants who had participated in at least 50% of the allocated inter-
vention and provided data at baseline and postintervention (n=34;
dropout rate =10.5%). Of the 34 program completers in the inter-
vention group, six participants (17.6%) reported completing approx-
TABLE 4. Complete Sample and % Material Means and Standard Deviations for All Variables Per Group for All 3 Timepoints:
Baseline (BL), Postintervention (PI and PIWL), and 6-Month Follow-Up (FU)*
[AQ8]
Mindfulness Intervention (N=34)
FFMQ BL PI FU PFU ESPI†ESFU‡%PI§ %FU
Complete sample: 50%–100% material completed
Observe 23.15 ±4.79 29.15 ±5.41 29.26 ±5.05 <.001 1.252609603 1.28 25.9 26.4
Describe 26.24 ±4.57 29.15 ±5.85 31.19 ±5.57 <.001 0.636761488 1.08 11.1 18.9
Act Aware 24.38 ±5.19 28.27 ±4.73 28.74 ±5.01 <.001 0.749518304 0.84 16.0 17.9
Nonreact 20.71 ±4.30 24.44 ±4.45 25.26 ±3.88 <.001 0.86744186 1.06 18.0 22.0
Nonjudge 27.94 ±6.42 30.24 ±6.03 31.68 ±5.97 <.001 0.358255452 0.58 8.2 13.3
PSS-14 24.79 ±6.71 17.26 ±6.46 18.81 ±6.72 <.001 1.122205663 0.89 −30.4 −24.1
CD-RISC 68.24 ±12.77 76.82 ±12.89 76.71 ±11.39 <.001 0.671887236 0.66 12.6 12.4
Vigor
PS 4.11 ±1.05 4.83 ±0.97 4.88 ±0.61 <.001 0.685714286 0.73 17.5 18.8
CL 4.47 ±1.01 5.16 ±0.99 5.09 ±0.86 0.003 0.683168317 0.61 15.5 13.8
EE 5.13 ±0.79 5.53 ±0.65 5.63 ±0.60 0.001 0.51 0.63 7.7 9.7
Mindfulness Intervention (N=28)
BL PII FU ESPI ESFU % PI % FU
Complete sample: 75%–100% material completed
Observe 23.32 ±4.56 30.00 ±4.51 29.63 ±5.09 1.46 1.38377193 28.6 27.1
Describe 26.89 ±4.19 30.39 ±4.79 32.07 ±5.10 0.84 1.23627685 13.0 19.3
Act Aware 23.93 ±5.15 28.79 ±4.66 29.04 ±5.12 0.94 0.99223301 20.3 21.4
Nonreact 20.79 ±4.00 24.96 ±4.57 25.67 ±3.88 1.04 1.22 20.1 23.5
Nonjudge 28.75 ±6.45 31.39 ±5.60 32.60 ±5.48 0.41 0.60 9.2 13.4
PSS-14 24.50 ±6.16 16.39 ±5.65 18.81 ±6.62 1.32 0.923701299 −33.1 −23.2
CD-RISC 69.21 ±12.39 79.61 ±10.61 78.30 ±10.67 0.84 0.733656174 15.0 13.1
Vigor
PS 4.19 ±1.00 4.86 ±0.66 4.95 ±0.68 0.67 0.76 16.0 18.0
CL 4.52 ±1.05 5.21 ±1.02 5.15 ±0.81 0.66 0.60 15.3 13.8
EE 5.25 ±0.8 5.65 ±0.61 5.74 ±0.53 0.50 0.6125 7.7 9.3
*P values represent within-group changes from baseline (BL) to postintervention (PI) except for PPIWL, which represents differences between PI andPIWL for wait-list control.
†ESPI represents within-group effect sizes that reflect differences between (BL) and (PI).
‡ESFU represents within-group effect sizes that reflect differences between (BL) and (FU).
§% PI represents % change at postintervention between BL and PI.
% FU represents % change at 6-month follow-up between BL and FU.
BL, baseline; CL, cognitive liveliness; EE, emotional energy; FU, 6-month follow-up; PI, postintervention; PIWL, postintervention wait-list group; PS, physical strength.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
6C2014 American College of Occupational and Environmental Medicine
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
JOEM rVolume 00, Number 00, 2014 Mindfulness at Work: Impact of an On-Line Intervention
imately 50% of course material and attending an average of 6.33 of
eight class meetings. The remaining 28 participants (82.4%) reported
completing 75% to 100% of the program material and attended an
average of 7.4 class meetings. Participants reported practicing mind-
fulness exercises 4.5 days per week in week 1. By week 7, the average
days practiced was 3.8. Overall, practice time averaged 13 minutes
per day or 1.5 hours per week.
Treatment Effect—Intention to Treat
Outcomes obtained through analysis of covariance comparing
postintervention scores for the treatment group versus wait-list con-
trols are shown in Table 2. With regard to the FFMQ, the mindfulness[T2]
intervention group rated themselves significantly higher postinter-
vention on all facets of mindfulness, with the exception of nonjudg-
mental awareness, than control participants (Table 3). In addition, the[T3]
intervention group rated themselves lower on perceived stress (PSS-
14) and higher in resiliency (CD-RISC) than the control group at the
postintervention time point (P<0.001, P<0.001, respectively).
Furthermore, significant postintervention increases were found in
the mindfulness treatment group on all components of vigor (Shi-
rom Vigor Scale) including physical strength (P=0.021), cognitive
liveliness (P<0.001), and emotional energy (P=0.027).
Analysis of within-group pre- to post– ESs showed improve-
ments over the course of the trial in all measures examined. In the
ITT sample, average within-group ES from baseline to postinterven-
tion ranged from d=0.30 to 1.03 (mean =0.67) for the intervention
group and d=−0.23 to 0.25 (mean =0.03) for wait-list controls.
Six-month follow-up showed that the intervention group ES contin-
ued to increase over time, ranging from d=0.52 to 1.08 (mean =
0.81).
Treatment Effect—Completed Program Sample and
% Material
Ten participants in the intervention group did not complete the
treatment protocol at postintervention. After eliminating these par-
ticipants, the effect of the percentage of program material completed
was analyzed (Table 4). Within this sample, those who finished 75%[T4]
to 100% of the course material had a 30% greater ES at postinter-
vention (mean d=0.87) than the ITT group (mean d=0.67) and
a 16% greater ES than the 50% group (mean d=0.75). Neverthe-
less, at 6-month follow-up, this differential had decreased, with the
75% to 100% group showing an ES only 12.3% greater than the
ITT group and 8.8% greater than the 50% group. This change was
predominantly attributed to ongoing improvements in the latter two
groups over the follow-up time period (Table 5).[T5]
Follow-Up
Thirty-one of 44 mindfulness participants completed assess-
ment at 6 months. Because the wait-list group had received the
intervention by the time of follow-up, they could no longer serve
as a control group for this assessment. Therefore, between-group
comparisons were not completed at this time. Nevertheless, base-
line values were compared with 6-month follow-up values for the
intervention group. At the time of follow-up, Pvalues representing
within-group changes from baseline for the intervention group were
all significant. These values ranged from 0.003 to less than 0.001,
indicating that treatment gains were either maintained or further im-
proved over time. The only exception to this was a nonsignificant,
slight increase in perceived stress. By follow-up, measures of mind-
fulness in the ITT sample had improved substantially. Improvements
taken from the FFMQ ranged from an 11.2% increase in the “non-
judgmental awareness” facet from baseline, to a 25.8% increase in
the “observe” facet. In addition, improvements in vigor ranged from
11% for emotional energy to 19.6% for physical strength, while re-
siliency increased 12% and perceived stress declined by 23.1% from
baseline values. Figure 2 shows outcome trends for the intervention[F2]
TABLE 5. Effect Size of ITT vs Complete Groups Based on
% Material Completed @ PI and FU
ITT Group Material 50% Material 75%–100%
FFMQ ES ES ES
Observe
PI 1.00 1.25 1.46
FU 1.08 1.28 1.38
Describe
PI 0.48 0.64 0.84
FU 1.01 1.08 1.24
Act Aware
PI 0.71 0.75 0.94
FU 0.92 0.84 0.99
Nonreact
PI 0.73 0.87 1.04
FU 1.00 1.06 1.22
Nonjudge
PI 0.30 0.36 0.41
FU 0.52 0.58 0.60
PSS-14
PI 1.03 1.12 1.32
FU 0.90 0.89 0.92
CD-RISC
PI 0.63 0.67 0.84
FU 0.68 0.66 0.73
Vigor
Physical strength
PI 0.72 0.69 0.67
FU 0.83 0.73 0.76
Cog liveliness
PI 0.60 0.68 0.66
FU 0.57 0.61 0.60
Emotional energy
PI 0.45 0.50 0.50
FU 0.63 0.63 0.61
Overall mean
PI 0.67 0.75 0.87
FU 0.81 0.84 0.91
CD-RISC, Connor-Davidson Resilience Scale; ES, effect size; FU, follow-up;
ITT, intention-to-treat; PI, postintervention; PSS-14, Perceived Stress Scale.
group through 6-month follow-up in comparison to waitlist controls
as assessed at the post–wait-list intervention period (PIWL).
Mediation Analysis
To determine mediation, we followed the four-step regression
procedure recommended by Baron and Kenny.62 Using this model,
we examined to what extent changes in mindfulness mediated the
observed improvements in perceived stress and resilience postin-
tervention. Analysis indicates that the observed increases in mind-
fulness partially mediated changes in resilience while mindfulness
fully mediated the changes observed in perceived stress. In terms of
vigor, results indicate that mindfulness partially mediated changes in
cognitive liveliness and fully mediated changes in physical strength.
Lifestyle Survey Questions
Table 6 shows the results of mixed regression analysis for [T6]
each lifestyle survey question and stage. The lifestyle survey ques-
tions that demonstrated significant decreasing trends included (1) the
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C2014 American College of Occupational and Environmental Medicine 7
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
Aikens et al JOEM rVolume 00, Number 00, 2014
FIGURE 2. Outcome measures over time for ITT intervention vs waitlist control groups. Pvalues for IIT intervention vs wait-list
control group at PI. BL, baseline; FU, 6-month follow-up; PI, postmindfulness group intervention; PIWL, postintervention wait-
list control group.
TABLE 6. Mixed Effect Regression Result for Lifestyle
Survey Questions
95% Confidence Interval
Survey Stage
Question Estimate SE Lower Bound Upper Bound
Fruits/vegetables 0.09** 0.02 0.05 0.12
Fast food meals −0.05* 0.02 −0.08 −0.02
Burn out days −0.15** 0.02 −0.19 −0.10
Stress episodes −0.18** 0.03 −0.24 −0.13
Exercise days 0.03 0.02 −0.02 0.08
Sleep hours −0.003 0.01 −0.02 0.02
*P=0.01; **P<0.001.
number of fast food meals eaten weekly (P=0.01), (2) the number
of high stress episodes weekly (P<0.001), and (3) the number of
days too burned out to work weekly (P<0.001). Similarly, the sur-
vey question for daily fruit and vegetable intake showed a significant
increasing trend (P<0.001). No significant trends were found for
either exercise or sleep.
DISCUSSION
We conducted a randomized, wait-list control study with ade-
quate statistical power, to investigate the effects of a 7-week mindful-
ness intervention tailored for the workplace and delivered through an
on-line platform. We investigated this program’s impact on measures
of mindfulness, perceived stress, and other parameters indicative of
positive organizational behavior and employee well-being, such as
resiliency, vigor, and work engagement. Comparisons were made
among the mindfulness intervention group and the control group.
Multivariate analysis, adjusting for baseline differences, of the ITT
sample showed significant postintervention reductions in perceived
stress as well as improvements in resiliency, vigor, and mindfulness
as compared with controls. These results were either maintained or
further improved at the 6-month follow-up mark. As we did not
assess the degree of home practice at 6 months, we could not deter-
mine whether this continued response was due to an ongoing active
meditation practice as opposed to a honeymoon effect or ongoing
personal integration of critical cognitive behavioral course concepts.
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8C2014 American College of Occupational and Environmental Medicine
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
JOEM rVolume 00, Number 00, 2014 Mindfulness at Work: Impact of an On-Line Intervention
Nevertheless, membership in the higher category for percentage of
material completed did tend to predict ES, although this differential
decreased over time.
In addition to the aforementioned findings, we analyzed pro-
gram ratings and dropout rates. Intervention and wait-list control
participants gave the program an average satisfaction rating of
87% of 100%. Furthermore, the intervention group dropout rate
of 5.3% compares favorably with typically reported MBSR inter-
vention dropout rates of less than 20%.26, 27
With regard to lifestyle surveys, analysis of survey responses
revealed significant trends in four of the six variables studied
(Fig. 3). The combined intervention and wait-list groups showed[F3]
a 31% reduction in the number of fast food meals eaten at 8 weeks,
which was a significant decrease (P=0.005). In addition, this com-
bined group showed a 17% increase in fruit and vegetable intake,
which was a significant increase (P<0.001). These trends indi-
cate that the on-line applied training segment of the program, with
programmed educational responses based on weekly survey an-
swers, could have a significant impact on healthy dietary choices.
In addition, participants also reported a significant decrease in
days too burned-out to work by one full day per week or 66%
(P<0.001). Participants also reported a decline in weekly high
FIGURE 3. Mixed regression analysis of lifestyle survey trends over time.
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C2014 American College of Occupational and Environmental Medicine 9
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
Aikens et al JOEM rVolume 00, Number 00, 2014
stress episodes by 33%, which is a significant downward trend
(P<0.001).
An interesting point to these results is the timing of Dow’s lay-
off announcements in 2012. These layoffs marked one of the largest
in the company’s history and occurred at the same location as the
study. The first layoffs were announced in early April 2012, approx-
imately 2 weeks before the baseline assessment scales were admin-
istered. A subsequent, more substantial, announcement occurred in
late October 2012, which included the closing of a local plant. This
second announcement coincided closely with the administration of
follow-up outcome measures. It is possible that such events could
have significantly impacted the perceived stress and resiliency mea-
sures of employees participating in the study. Our follow-up analy-
sis showed only a very slight, nonsignificant increase in perceived
stress from postintervention assessment. Furthermore, the follow-up
analysis showed continued improvements in mindfulness, resiliency,
and vigor. These results, which occurred despite widespread lay-
offs, may indicate that this intervention can have significant protec-
tive effects on employees, regardless of difficult corporate economic
circumstances.
Another interesting element to this study is reflected in a cost–
benefit analysis based on the program’s survey question regarding
self-reported burnout. This analysis showed a significant decline in
self-reported burnout in both the intervention and wait-list groups,
which decreased by one full day per week at postintervention (P<
0.001). This decrease in self-reported burnout represents a signif-
icant (20%) potential increase in worker productivity. Because the
current average yearly wage for Dow reported in December 2012
was $112,900, a 20% increase in worker productivity could repre-
sent an employer savings of up to $22,580 per employee year, if the
improvements in burnout are sustained over time. This savings is
due to potential declines in absenteeism and presenteeism, perhaps
associated with a decreased employee burnout rate.
LIMITATIONS AND CAVEATS
Some limitations and caveats to this study should be men-
tioned. First, this study had results from a relatively small number
of participants (n=79), creating the need for a larger randomized
control trial to confirm the results. In addition, 12-month follow-up
was not completed to avoid overburdening busy employees. This
study limitation precludes us from making a more definitive as-
sessment regarding the long-term effectiveness of the mindfulness
intervention.
A further limitation is suggested by our mediation analy-
sis, which showed that improvements in resiliency, as well as the
emotional liveliness element of the Shirom Vigor Scale, were only
partially mediated by mindfulness. On the basis of this finding, it
is possible that nonspecific factors, such as receiving increased at-
tention, being part of a credible treatment program, or social and
group-related factors may have partially contributed to some of the
study outcomes.
Reliance on self-report measures is yet another limitation that
needs to be acknowledged. We used only self-report measures during
the study, which makes it possible that there was some degree of
response bias or social desirability affecting participant reporting on
the study outcome measures.
A final study caveat is whether the study findings can be gen-
eralized to other employers. Employees vary in terms of education,
compensation, motivation, and employer support. This holds even
within the same sector, such as the petrochemical sector for Dow.
Because we focused on Dow, we are not certain that these results can
be generalized to other petrochemical employers or for employers in
other sectors. Nevertheless, nothing in our results indicates that this
impact would not hold true for comparable employers.
CONCLUSION
The present findings have significant potential implications
for corporate health and human performance. The program studied
was a mindfulness intervention, which was modified in length, con-
tent, and messaging to fit workplace needs and delivered through an
on-line platform that included personal coaching. Overall, the ESs
obtained in this study were in the moderate to large range and were
either maintained, or further improved, overtime. This indicates that a
shortened, Web-based mindfulness program can replicate the results
of traditionally delivered MBSR. In addition, program compliance
was significant, suggesting that a workplace specific mindfulness in-
tervention is practical within an employer setting. Furthermore, we
looked at, not only levels of stress, but at outcome measures, which
have been shown to impact human performance and are indicative of
employee well-being. Our results suggest that mindfulness training
is more than just an effective stress management solution but an effi-
cacious intervention for the development of positive organizational
behavior, which can be used throughout the employee base. Although
ROI is difficult to measure because of the many ways mindfulness [AQ9]
can impact the organization, widespread application has the poten-
tial to result in significant employer competitive advantage through
a combination of improved employee well-being, enhanced human
performance, and decreased health care costs.
ACKNOWLEDGMENT
The University of Arizona Corporate Health Improvement
Program (no monetary support).
[AQ10]
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C2014 American College of Occupational and Environmental Medicine 11
Article: JOEM-13-4531 Date: May 15, 2014 Time: 14:27
Title: Mindfulness Goes to Work: Impact of an On-Line Workplace Intervention
Author: Kimberly A. Aikens, John Astin, Kenneth R. Pelletier, Kristin Levanovich, Catherine M. Baase, Yeo Yung Park, Catherine M. Bodnar
Author Queries
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[AQ8]: Please check whether column heads in Table 4 are OK.
[AQ9]: Please provide the expansion of ROI.
[AQ10]: Please verify the Acknowledgment section.
[AQ11]: For ref. 16, please provide the access date.
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