Acceptance and commitment therapy can help staff build psychological resilience by improving mindfulness skills and fostering values-based behaviour
Acceptance and commitment therapy (ACT) is a mindfulness-based approach that has recently emerged as a useful tool for improving mental health, and has been shown to be effective in the treatment of a wide range of psychological and behavioural problems. At City, University of London, an occupational health research team created an ACT-based workplace training programme, which was adopted by Northumbria Healthcare Foundation Trust to foster psychological resilience among its staff. This article explains what ACT-based training entails, how it can help nurses and how it is being used – with encouraging results – at the trust.
Citation: Jennings T et al (2017) A resilience training programme to improve nurses’ mental health. Nursing Times [online]; 113: 10, 22-26.
Authors: Teresa Jennings is consultant clinical psychologist at Northumbria Healthcare Foundation Trust; Paul E Flaxman is reader in organisational psychology at City, University of London; Kath Egdell is staff counsellor, Simon Pestell is clinical psychologist; Elaine Whipday is counselling psychologist; and Alison Herbert is CBT therapist, all at Northumbria Healthcare Foundation Trust.
- This article has been double-blind peer reviewed
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The need to maintain good psychological health among employees is a challenge for NHS organisations, which are facing greater demand and tighter finances. The increased pressure on services is being acutely felt by nurses on the front line: between 2013 and 2016, nursing and midwifery was one of the occupational groups with significantly higher rates of work-related stress, anxiety and depression compared with the average for all occupational groups.
In an effort to improve the psychological resilience of its nursing staff, Northumbria Healthcare Foundation Trust has set up a training programme based on acceptance and commitment therapy (ACT), offered to nurses on a voluntary basis, which this article describes.
The need for preventive support
It is estimated that, at any one time, up to one in four NHS workers may be experiencing a common mental health problem, typically anxiety and/or depression (Stride et al, 2007; Wall et al, 1997). Moreover, research has consistently shown that, in healthcare and other sectors, workers’ psychological health is one of the strongest predictors of sickness absence and intention to leave a role (Heinen et al, 2013; Wright and Bonett, 2007; Wright et al, 2004; Hardy et al, 2003).
Traditionally, psychological support services for nurses are mostly ‘reactive’ – that is, they tend to be activated only once nurses have become distressed or been absent from work because of a mental health problem; this type of tertiary therapeutic support for staff is still crucial. Northumbria Healthcare Foundation Trust provides hospital and community health services in North Tyneside and hospital, community health and adult social care services in Northumberland. Nurses are able to access individual therapeutic support by self-referral and via the occupational health team from a small team of occupational health psychologists and counsellors. The service also provides early triage to nurses absent from work due to a mental health problem. This aspect of our staff support is designed to provide easy access to talking therapies and support rapid recovery and return to work.
We recognised a pressing need to develop a larger-scale, more preventive approach to our staff’s psychological wellbeing. This could, for example, help ensure that distress and fatigue are picked up early and do not escalate into burnout, mental health difficulties and reduced job performance. For this aspect of our staff support, we turned to the work of Paul Flaxman and his occupational health research team at City, University of London.
For the past 15 years or so, the team has been adapting ACT as a workplace training programme for improving staff’s psychological health and resilience. We were particularly interested in the fact that relatively short group interventions based on ACT – typically three sessions – can lead to substantial improvements in employees’ mental health (Frögéli et al, 2016; Flaxman et al, 2013; Flaxman and Bond, 2010; Flaxman and Bond, 2006; Bond and Bunce, 2000).
Acceptance and commitment therapy
ACT is one of the more recent mindfulness-based approaches to have emerged in the wider field of cognitive behavioural therapy (Hayes et al, 2012; Hayes et al, 2011; Hayes et al, 1999). ACT interventions aim to improve psychological health and life functioning through the cultivation of psychological flexibility.
Psychological flexibility refers to the ability to experience the present moment and be mindfully aware of thoughts and emotions while engaging in actions that help one express personally valued qualities. Through the development of psychological flexibility, people learn how to express personally chosen values in small daily actions, even while experiencing thoughts, feelings and urges that might have previously functioned as obstacles to values-based behaviour.
Research has shown that ACT is effective in the treatment of a wide range of psychological and behavioural problems, including depression, anxiety, eating disorders, work-related burnout, trauma, chronic pain and psychosis, as well as in supporting diabetes self-management (Hooper and Larsson, 2015; McCracken and Vowles, 2014; Ruiz, 2010).
Psychological flexibility is important for preventing burnout in people who work in emotionally demanding roles (Lloyd et al, 2017; Biron and van Veldhoven, 2012). Interestingly, for healthcare settings, ACT has also been linked to the capacity to engage in compassionate actions, and it has been suggested that training in psychological flexibility is one way of increasing organisational compassion (Atkins and Parker, 2012).
As with other mindfulness-based approaches, ACT is designed to help people relate more skilfully and non-judgementally to difficult thoughts, feelings, urges and sensations. However, it differs from the more meditative approaches, such as mindfulness-based stress reduction and mindfulness-based cognitive therapy, in that it explicitly cultivates mindfulness and acceptance skills to help people become more effective at pursuing behaviours that are consistent with their personal values.
Background and funding
In 2012, Dr Flaxman trained four members of our psychology and counselling team in delivering his ACT-based workplace training programme. This ‘train-the-trainers’ project was funded by a grant awarded by the Economic and Social Research Council (ESRC).
The aim was to provide ACT-based psychological skills training to any members of staff who wanted to improve their personal resilience. An initial evaluation of the training was positive, with significant increases in self-reported psychological wellbeing and improvements in other indicators of effective work functioning.
Due to the success and popularity of the training, we submitted a business case to our trust asking to extend it to qualified nurses. The trust already had a nursing and midwifery strategy in place to improve recruitment and retention, which included actions around health and wellbeing. In the business case, we argued that investing in ACT-based training could improve nurses’ mental health, and potentially tackle staff’s reduced effectiveness at work due to mental health problems as well as improve team functioning.
Another driver was the desire to offer something to our ‘hard-to-reach’ clinicians in front-line jobs, who often find it difficult to attend training due to shift patterns and/or staff shortages.
We obtained approval and funding to recruit a psychological therapist for one year and decided to offer the next round of training to nurses working in front-line leadership roles (bands 6 and 7), such as ward managers, because of their pivotal role in team wellbeing and patient care and then extended it to all qualified nurses.
Our resilience training
We promoted our ACT-based workplace training for nurses as resilience training, to communicate that its emphasis is on improving people’s own psychological resources. It was advertised in a staff briefing and in short presentations to stakeholder groups (such as a workforce committee) and at senior nurse forums. Fliers and information were then cascaded down to nursing staff at acute and community sites.
The reputation of the programme grew via word of mouth from previous participants, some of whom had been receiving support from the occupational health services and others from various occupational groups across the trust – including some nurses. We also ran pilot training courses with ward managers and senior managers in the organisation. This seemed to encourage larger numbers of nurses to sign up for it. Senior nurses, such as matrons, encouraged nursing staff to attend during work time when possible. Attendance was voluntary, as experience has shown that it is unhelpful to compel staff to attend this type of training.
The training we used is delivered over three half-day sessions using a ‘2+1’ method: the first two sessions take place in two consecutive weeks and the third is a booster session held one month later. Each session lasts for two-and-a-half to three hours. The training is delivered to small groups of around 10-12 staff members at a time. Participants are strongly encouraged to attend all three sessions and are provided with resources and with exercises to complete between the sessions.
The training is designed around two core psychological and behavioural skills: mindfulness and values-based action. It is not restricted to wellbeing in the workplace but offers a set of skills that can be applied in all areas of life. Participants practise some ‘classic’ mindfulness exercises such as mindful eating, as well as brief body awareness exercises.
The training also includes exercises helping people clarify their personal values (Box 1). One exercise involves a pack of 50 cards featuring common values such as kindness, generosity, humour, industry and self-care. Participants are prompted to choose those that seem to carry the most personal meaning – the ones they feel most attracted to; they can also come up with their own values and write them on blank cards. After choosing their personal values, participants are invited to identify actions that would help them express these values in daily life. The size of the action is not important, as long as it has the potential to bring a value to life.
Box 1. A quick guide to values-based action
- In our ACT-based training, values are defined as the personal qualities you most want to express in your daily behaviour
- Values are all about actions, what you do and the qualities you express in your actions
- To pin down the values that matter most to you, you might ask yourself: what do I want my life to be about? What personal qualities do I want to show in my actions?
- Start looking for opportunities to express personal values in your actions; the size of the action does not matter; what matters is that it helps you bring your values to life
- Start noticing moments when you engage in actions that take you away from your personal values, and what influences your behaviour in those moments – for example, unhelpful thoughts, feelings or urges
- Notice how it feels when you engage in value-consistent actions, and how it feels when you engage in actions that seem less useful for expressing your personal values
- Start using personal values as a guide to daily action – but remember that one cannot behave in a value-consistent way all the time
The training encourages participants to reflect on internal obstacles to values-based behaviour, particularly thoughts, feelings, sensations and urges that can ‘hijack’ behaviour. A skill cultivated across the programme is the ability to notice, in daily life, when one is behaving in a way that is consistent with one’s values and when not (for example, when one’s actions are being controlled by thoughts, emotions or reactions to others that are not value-consistent).
The training makes good use of ACT metaphors such as the ‘passengers on the bus’ (Hayes et al, 1999). This metaphor portrays the person as the ‘driver’ on the ‘bus of life’ and their thoughts, feelings, memories and other inner experiences as ‘passengers on the bus’. Some passengers are pleasant, some are neutral, others can be unpleasant, difficult or self-critical. The idea is that, if we can learn to relate more skilfully to our inner experiences, they do not have to exert an unhelpful or excessive influence on us, and restrain our ability to use personal values as a guide to action.
The ACT-based resilience training for nurses started in April 2016 and ran for a year until March 2017. So far we have trained approximately 600 nurses on the course, while many more have attended taster sessions, which we have delivered on the wards or on leadership training programmes.
The resilience training has been evaluated by researchers from City, University of London. All nurses who attended the training during the evaluation period (April through to September 2016) were sent a survey link by the researchers.
The evaluation reported in this article is based on a sample of 68 nurses who attended training sessions between April and July 2016, and who completed both pre-intervention and post-intervention surveys. A smaller subgroup of 39 of these 68 nurses also completed a follow-up survey, which was sent two months after the final training session (and three months after the pre-intervention survey). The evaluation occurred over two phases:
- First phase: analysis of changes in the nurses’ self-reported mental health from pre- to post-training (a one-month period); and from pre-training to follow-up (a three-month period);
- Second phase: interviews with a sample of eight nurses who had completed the training. These nurses responded to an invitation to take part in a telephone interview with a member of City’s research team, which was sent in the email with the final follow-up surveys, and also mentioned by the trainers in the final session of training.
To allow us to measure the impact of the training, the nurses who volunteered to participate in the evaluation completed the short form of the General Health Questionnaire (GHQ-12). This is one of the most respected and validated measures for assessing common mental health problems, such as stress, anxiety and depression. In healthcare workers, higher scores on the GHQ-12 are associated with higher levels of sickness absence. The nurses completed the GHQ-12 at three time points:
- Before starting the training (pre-training assessment);
- In the week after the third and final session of training, which took place one month after the first two training sessions (post-training assessment);
- Three months after the pre-training assessment, and two months after training completion (follow-up assessment).
The evaluation also involved measuring the mindfulness skills and values-based action of the nurses at the same three time points. Values-based action was measured with an eight-item version of the valuing questionnaire developed by Smout et al (2014). This assesses whether people feel they are moving towards personally important goals, and whether they are proud of how they have recently been working and living. Higher scores on this measure indicate that they feel more in control of their actions and feel able to express personally valued qualities in their day-to-day behaviour.
Reduced psychological distress
Fig 1 shows that the nurses who responded to the surveys had quite high levels of psychological distress before they started the training. Their mean GHQ-12 score (based on the GHQ’s ‘caseness’ scoring method) before the training was 3.87, which is just short of 4, the cut-off value for the likely presence of clinically relevant mental health difficulties. The reduction in psychological distress that had occurred after two sessions of resilience training was both statistically significant and clinically meaningful.
As Fig 1 shows, at post-training, the nurses’ GHQ-12 score had fallen to a mean of 1.10. This figure indicates a better level of mental health compared with the average GHQ-12 score for comparable groups of NHS workers (Stride et al, 2007). As indicated in Fig 1, this reduction in psychological distress was maintained for the 39 nurses who completed the follow-up assessment two months after the final training session. Taken as a whole, the sample of nurses involved in the evaluation went from being just below the cut-off point for mental health difficulties to a better than average mental health status.
Improved mindfulness and values-based behaviour
Nurses’ scores on other surveys in the evaluation revealed improvements in mindfulness skills and values-based behaviour. Specifically, the nurses experienced a significant improvement on the ‘non-reactivity’ subscale of the Five Facet Mindfulness Questionnaire (FFMQ) (Baer et al, 2006). This suggests that, after the training, they were less likely to react negatively to, or become overly entangled in, stress-related thoughts and feelings, and were likely to be recovering faster from stressful interactions and events (Fig 2).
There were also improvements in the ability of some nurses to engage in values-based action (Fig 3). Interestingly, this effect was found only in a subgroup of 28 nurses who had higher pre-training levels of psychological distress than their peers. In this subgroup of more psychologically distressed nurses, engagement in values-based action increased significantly from pre-training to post-training; 17 of these nurses also responded to the survey at follow-up. This finding suggests that the nurses in this subgroup had become more aware of personally meaningful values and were using these as a more prominent guide in their daily lives.
Taken together, the results of the quantitative evaluation allow us to conclude that:
- The resilience training led to a significant improvement in nurses’ general mental health;
- The benefits of the training were at least partly due to:
- Nurses learning to be less reactive to, and so able to recover more quickly from, stressful events;
- A growing tendency to use personal values as a guide to daily action.
In the qualitative data from the interviews a number of nurses reported a heightened ability to ‘pause’ before reacting in difficult situations – a further demonstration of improved ‘non-reactivity’ skills. One said:
“[I learned to] just literally take a breath and step back; give myself a moment and clear my head; and think about how I want to approach the person.”
It was striking how many nurses said that they felt the training had given them ‘permission’ to focus on self-care. This is an important outcome for professionals who often give a lot to their role, but are at high risk of burnout if they do not take time for recovery. One participant said:
“[The training] made me more aware of the conflicting pressures and my need to self-care as well as caring for others.”
Box 2 features the personal story of a nurse who undertook the training and the benefits she obtained from it.
Box 2. How resilience training can help nurses: a personal story
Wendy Smith*, a staff nurse on an elderly care ward, attended the resilience training while on sick leave. In her personal life, she was finding it difficult to cope with her teenage son’s long-term condition, which also put a strain on her marriage. There was no time for Mrs Smith to look after herself or to consider what she and her husband needed as a couple. She loved her job but felt too anxious about her son to come to work.
Mrs Smith was encouraged to attend the training by her manager, whom she found very supportive. Practising mindfulness to step back from her anxious thoughts helped.The exercises about personal values made her realise that she had been neglecting her own needs for too long and needed to ‘refuel’. The training gave Mrs Smith an opportunity to share her experience with colleagues and she discovered that a lot of them struggled to look after themselves, just like her.
Soon after completing the training, Mrs Smith returned to work. She felt able to step back from her fear of leaving her son alone and began to establish self-care as a regular routine, including putting time aside for her and her husband. She had found the training so useful that she wanted her colleagues to benefit, so she made copies of some of the mindfulness scripts and put them up in the staff room along with the course CD.
* The nurse’s name has been changed to protect her confidentiality
ACT-based resilience training has transformed our trust’s provision of staff support. There is a huge amount of interest in this type of training among our healthcare staff and we have found it easy to fill training places. It is encouraging that the training has attracted nurses who were unlikely to self-refer for one-to-one psychological therapy despite experiencing high levels of distress.
Another encouraging aspect is the positive way in which nurses talk about the training with colleagues after the sessions. This has resulted in numerous requests for the training to be offered to other occupational groups.
The service evaluation has provided a useful external validation and confirmed our own anecdotal experiences of the training. Despite the fact that the training is relatively brief, many participants reported significant changes in their lives as result of it. It is also interesting to note that nurses who have gone through the training are adopting a more compassionate stance toward themselves. Improved compassion for oneself is linked to an increased capacity to show compassion to others – an attitude that is considered vital for good patient experience.
Members of the psychology and counselling team have felt personally and professionally invigorated by learning and using ACT – both as part of this training project and in their individual therapeutic practice. ACT is a highly experiential approach, and during the sessions our trainers were able to share their experiences of engaging in values-based action in their own lives.
Due to the positive findings from this evaluation we are delighted that the trust has agreed to invest in further funding to continue the programme of training to even more nurses as well as other occupational groups.
- Up to one in four NHS workers may be experiencing a common mental health problem such as anxiety or depression at any one time
- Acceptance and commitment therapy aims to improve psychological health by fostering mindfulness and values-based behaviour
- Training based on the therapy cultivates psychological flexibility and increases compassion towards oneself and others
- Staff reflect on the values that are important to them and how to express them in daily actions
- At Northumberland Healthcare Foundation Trust, the training improved nurses’ psychological resilience
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