This article was downloaded by: [New York University] On: 18 June 2015, At: 02:45 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Anxiety, Stress, & Coping: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gasc20
A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses a
a
a
Elin Frögéli , Aleksandar Djordjevic , Ann Rudman , Fredrik a
Livheim & Petter Gustavsson
a
a
Click for updates
Department of Clinical Neuroscience, Karolinska Institutet, Nobels väg 9, 171 77 Stockholm, Sweden Accepted author version posted online: 11 Mar 2015.Published online: 07 Apr 2015.
To cite this article: Elin Frögéli, Aleksandar Djordjevic, Ann Rudman, Fredrik Livheim & Petter Gustavsson (2015): A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses, Anxiety, Stress, & Coping: An International Journal, DOI: 10.1080/10615806.2015.1025765 To link to this article: http://dx.doi.org/10.1080/10615806.2015.1025765
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [New York University] at 02:45 18 June 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Anxiety, Stress, & Coping, 2015 http://dx.doi.org/10.1080/10615806.2015.1025765
A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses Elin Frögéli*, Aleksandar Djordjevic, Ann Rudman, Fredrik Livheim and Petter Gustavsson
Downloaded by [New York University] at 02:45 18 June 2015
Department of Clinical Neuroscience, Karolinska Institutet, Nobels väg 9, 171 77 Stockholm, Sweden (Received 23 June 2014; accepted 2 March 2015) Background: Levels of stress and burnout increase during nursing education. This development has consequences for nursing students’ health, learning, competence, and interest in quality issues in health care. Design: In a randomized controlled pilot trial with a sample of 113 nursing students the effect of an intervention using techniques from acceptance and commitment training (ACT) to prevent the development of stress and burnout was evaluated. Method: The 6 × 2-hour program was compared to standard treatment (reflection seminars) post-intervention and at a three-month follow-up using longitudinal analysis of mean response profiles. Mechanisms of change were investigated using a baseline-post intervention two-mediator model. Results: The intervention resulted in increased mindful awareness and decreased experiential avoidance, as well as de‐ creased perceived stress and burnout. Levels of mindful awareness and perceived stress were sustained at follow-up. The proposed mechanisms of change were partly supported by the data. Conclusion: This study shows that techniques from ACT might have the potential to contribute to preventing the development of stress and burnout during nursing education. However, additional studies are needed to validate these results. Keywords: behavior therapy; acceptance and commitment therapy/training; nursing students; prevention; randomized controlled trial; stress
Introduction The years of higher education are often perceived as stressful, and this experience is related to factors at the individual and organizational levels (Byrd & McKinney, 2012; Vollestad, Nielsen, & Nielsen, 2012). Prolonged stress reactions are detrimental to one’s health and can interfere with learning and lead to burnout (McEwen & Gianaros, 2011; Rudman & Gustavsson, 2012). Prospective studies conducted on nursing students indicate that stress and burnout increase during nursing education (Deary, Watson, & Hogston, 2003; Edwards, Burnard, Bennett, & Hebden, 2010; Watson, Deary, Thompson, & Li, 2008), and this development has been contrasted to what is seen in students of other health professions where levels of stress are often stable, or even decrease, during higher education (Nerdrum, Rustøen, & Helge Rønnestad, 2009). Research has shown that on top of the stress inherent in all academic studies the encounter with clinical reality during *Corresponding author. Email: [email protected] © 2015 Taylor & Francis
Downloaded by [New York University] at 02:45 18 June 2015
2
E. Frögéli et al.
training constitutes a source of additional stress for nursing students (Timmins & Kaliszer, 2002). In a prospective study in Sweden, the prevalence of burnout symptoms in a national cohort of nursing students was found to increase from 29% to 41% between the second and sixth semesters, with the steepest increase between the second and fourth semesters (Rudman & Gustavsson, 2012). Students experiencing increased levels of burnout symptoms during their nursing education reported at the last semester of their education that they had higher levels of health problems (e.g. depressive mood), that they were less active in classroom learning situations, and that they felt less prepared and competent to handle their upcoming profession (Rudman & Gustavsson, 2012). In addition, one year after graduation they reported lower levels of mastery of occupational tasks, less interest in quality issues in health care (e.g. utilizing research in their practice), and greater preoccupation with thoughts about leaving the profession compared to their peers (Rudman & Gustavsson, 2012). Therefore, an important research question is what the common symptoms of burnout are and how can they be prevented during nursing higher education. Burnout is related to prolonged stress reactions and is defined by the two core dimensions of exhaustion and disengagement (e.g. Cherniss, 1980; Schaufeli, Leiter, & Maslach, 2009). Exhaustion refers to the physical consequence of efforts expended to manage perceived stressors, and disengagement refers to the behavioral strategies employed to avoid stressors that are perceived as unmanageable. Although these avoidance strategies are often effective in relieving the experience of stress over the short term, they will typically result in increased levels of burnout in the long run. Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2011) is a behavior therapy method with an explicit focus on decreasing avoidance of stressful thoughts, feelings, and sensations. Within ACT, the avoidance of these private events (referred to as experiential avoidance) is assumed to be the basis of much human suffering, including burnout. The theory proposes that when focusing on avoiding internal stressors one is less involved with ongoing experiences and can miss out on information needed for active problem solving. In addition, one is often less inclined to act in ways that can result in increased health and well-being over time. The goal of ACT is to reduce experiential avoidance in order to increase effective values-based actions and to increase the individual’s quality of life. This is done using techniques to increase the acceptance of internal events and to increase present-moment awareness (i.e. mindfulness). In a recent meta-analysis of randomized controlled trials comparing ACT to waitlist, placebo, treatment-as-usual, and different forms of cognitive behavior therapy, a computed overall effect size favoring ACT was small but significant (Öst, 2014). Because the aim of ACT is effective values-based living, not symptom reduction, it has been proposed that the method is also suitable for preventive interventions (Biglan, Hayes, & Pistorello, 2008). Accordingly, over the last 10 years the techniques (referred to as acceptance and commitment training; Hayes et al., 2004) have been adapted and tested for use in nonclinical settings. The abbreviation ACT will hereafter refer to acceptance and commitment training. To our knowledge, no previous study has tested if ACT techniques are effective for preventing or reducing stress among nursing students. Therefore, the aim of the present study was to make a preliminary investigation of the effect of a preventive intervention consisting of six 2-hour group sessions using ACT techniques to target stress during the first semester of nursing training.
Anxiety, Stress, & Coping
3
Hypotheses (1) The intervention will lead to a decrease in experiential avoidance and an increase in mindful awareness (process outcomes). (2) The intervention will lead to decreased levels of stress and burnout (main outcomes). (3) Changes in process outcomes will predict changes in main outcomes.
Downloaded by [New York University] at 02:45 18 June 2015
Method The experimental intervention was compared to an active control condition consisting of reflection seminars for personal and professional development in a randomized controlled trial. The study was approved by the Regional Ethical Review Board in Stockholm (File record 2011/1331-31/4) and complied with the Helsinki Declaration of ethical principles for medical research involving human subjects (World Medical Association, 2014). Study conditions The intervention consisted of six 2-hour group sessions using theory and methods from behavior therapy to target stress in nursing education. The intervention included information about stress and relevant lifestyle factors (e.g. work-life balance, sleep, and exercise), behavior change strategies, communication and assertiveness skills, and training in ACT techniques for managing stressful thoughts and feelings (e.g. defusion and acceptance), values clarification, and mindfulness practice. The protocol can be retrieved from http://ki.se/en/cns/petter-gustavssons-research-group. The intervention called Mind the Gap was contextualized to target stressors in nursing education based on results from the LANE study (Pennbrant, Nilsson, Ohlen, & Rudman, 2013; Rudman & Gustavsson, 2011, 2012; Rudman, Omne-Ponten, Wallin, & Gustavsson, 2010). The group leaders of the intervention were psychology-major students who specialized in cognitive behavior therapy and who were trained in ACT techniques by an internationally peer reviewed and approved ACT trainer. The control condition consisted of two 3-hour reflection seminars for personal and professional development lead by professors of nursing education. There was no pre-set agenda to the reflection seminars. Participating students were invited to discuss and reflect on any matters in relation to their personal or professional development that they found interesting or troubling. Attendance was recorded at each session. Randomization and study design The randomized controlled between-group study design is presented in Figure 1, including the data collection time points and the response and drop-out rates at baseline and at the post-intervention and the follow-up data collections. All data were self-reported through pen-and-paper surveys. With the exception of the baseline survey, all surveys were sent to the participants’ homes by postal mail together with a pre-stamped return envelope. The initial mailings were followed by weekly reminders over the course of a month. Eligible participants were 138 nursing students registered in the first semester of the nursing program at the Karolinska Institutet during the fall of 2011. Recruitment took place at a meeting describing the personal and professional development program offered by the university. Students were informed that they would be invited to participate in the
Downloaded by [New York University] at 02:45 18 June 2015
4
E. Frögéli et al.
Figure 1. Description of the study design and flow of subjects.
usual reflection seminars or a 6-week stress management course that would be followed by the usual reflection seminars. The students would otherwise be treated equally. Prior to this information meeting, students were randomized into 10 groups of 12–15 students (the normal size of the reflection seminar groups) by the university using simple randomization. Due to practical considerations, 6 groups (81 students) were randomized to the stress management course and 4 groups (57 students) were randomized to the reflection seminars using simple randomization. Unaware of their allocated group, 113 students chose to participate in the study, gave their informed consent, and completed the baseline questionnaire. This resulted in a total of 69 participants in the intervention group and 44 in the control group. Absent students were given the information and baseline questionnaire by mail. The six sessions of the intervention were given at three different times each week, and students randomized to the intervention were free to participate in the weekly session that best fit their schedule, thus the intervention groups were not fixed over time. Students were welcome to participate in the reflection seminars as well as the intervention regardless of whether or not they chose to participate in the study. No compensation was given for participation in the study.
Measures The intervention sought to reduce prolonged stress reactions and burnout using techniques to decrease experiential avoidance and increase present-moment awareness. In order to evaluate the intervention, two instruments were used as process outcome measures and two instruments were used as main outcome measures. Full study sample intercorrelations at baseline and follow-up are presented in Table 1.
Anxiety, Stress, & Coping
5
Table 1. Full study sample intercorrelations (Pearson’s r) at baseline (above the diagonal) and at three-month follow-up (below the diagonal). Variable
MAAS
MAAS AFQ-Y PSS BO
−.572 (p < .000) −.614 (p < .000) −.572 (p < .000)
AFQ-Y
PSS
BO
−.528 (p < .000)
−.491 (p < .000) .498 (p < .000)
−.504 (p < .000) .494 (p < .000) .503 (p < .000)
.596 (p < .000) .471 (p < .000)
.698 (p < .000)
p = significance value; MAAS = Mindful Attention Awareness Scale; AFQ-Y = Avoidance and Fusion Questionnaire for Youth; PSS = Perceived Stress Scale; BO = The burnout scale from the Scale of Work Engagement and Burnout.
Downloaded by [New York University] at 02:45 18 June 2015
Process outcome measures The Avoidance and Fusion Questionnaire for Youth (AFQ-Y; Greco, Lambert, & Baer, 2008) is a self-reported measurement with 17 items with a 5-point response format for assessing experiential avoidance based on questions concerning how one relates to personal thoughts and feelings. Scores are computed as a sum ranging from 0 to 68 points. A higher score represents a higher level of experiential avoidance. The alpha coefficient in this study was .90 at baseline, and the instrument was previously validated in a Swedish population (M [SD] = 19.85 [11.06]; Florin & Wennman, 2010). The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) is a questionnaire with 15 items measuring mindful awareness of moment-to-moment experiences using a 6-point response format. Scores are presented as a sum ranging from 15 to 90 points. A higher score represents a higher level of mindful awareness. The alpha coefficient in this study was .86 at baseline, and the instrument was previously validated in a Swedish population (M [SD] = 65.18 [9.54]; Hansen, Lundh, Homman, & Wangby-Lundh, 2009).
Main outcome measures The Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983) is a selfreported questionnaire with 14 items with a 5-point response format for assessment of perceived stress during the previous week. Scale scores are computed as a sum ranging from 0 to 56 points. A higher score represents a higher level of perceived stress. In this study, the alpha coefficient was .89 at baseline. The instrument was previously validated in a Swedish population (M [SD] = 24.4 [8.0]; Eskin & Parr, 1996). The burnout subscale (BO) from the Scale of Work Engagement and Burnout (Hultell & Gustavsson, 2010) comprises 9 items using a 6-point response format for assessment of burnout. Scores are computed as a mean ranging from 1 to 6 points and a higher score represents a higher level of burnout. In this study, the alpha coefficient was .84 for the BO at baseline. The instrument was previously validated in a Swedish population (estimated M [SD] = 2.43 [0.77]; Hultell & Gustavsson, 2010).
Data analysis The standard principle of analysis in randomized controlled trials is intention-to-treat (ITT) in which all subjects are included in the analysis regardless of whether or not they
6
E. Frögéli et al.
Downloaded by [New York University] at 02:45 18 June 2015
adhered to the intervention (Lachin, 2000). However, in preventive interventions such as the present one, analyses based on the principles of ITT are not necessarily the most appropriate because low levels of adherence are considered an innate problem because subjects are not seeking treatment for an existing illness (Gross & Fogg, 2004; Montori & Guyatt, 2001). A number of alternative principles are available (e.g. Gross & Fogg, 2004), and this study used the following analyses to evaluate the effect of the intervention on process outcomes (Hypothesis 1) and main outcomes (Hypothesis 2): (1) Standard ITT analysis (intervention sample n = 69; control sample n = 44) applying a longitudinal analysis of mean response profiles (Fitzmaurice, Laird, & Ware, 2011) including data from baseline, post-intervention, and three-month follow-up. (2) Efficacy subset analysis applying a longitudinal analysis of mean response profiles including the subjects who participated in at least three out of six sessions (n = 29) compared to the control sample (n = 44) using data from baseline, postintervention, and three-month follow-up. Longitudinal analysis of mean response profiles (Fitzmaurice et al., 2011) was performed using the mixed model procedure in IBM SPSS Statistics 22 (IBM Corp. Released, 2013). A significant group-by-time interaction was interpreted as reflecting differential patterns of change between the groups over time. Post-hoc tests were used to evaluate differences between groups at post-intervention and at follow-up. Between-group effect sizes at postintervention and at follow-up were calculated using Cohen’s d with pooled standard deviations from baseline data. For Cohen’s d, an effect size of 0.2–0.3 is interpreted as a “small” effect, a value around 0.5 as a “medium” effect, and a value of 0.8 and above as a “large” effect (Cohen, 1988). In a previous comparable trial, an effect of .72 was reported for the PSS (Brinkborg, Michanek, Hesser, & Berglund, 2011). Expecting this effect, for a power of 0.80 (and p < 0.05), 60 participants were required in this study. Finally, the relation between changes in process outcomes and changes in the main outcomes (Hypothesis 3) was investigated using path analysis of a baseline-post intervention two-mediator model (MacKinninon, 2008) using MLR estimation in Mplus 7 (Muthén & Muthén, 1998–2014) (Figure 2). MAASPost-intervention
MAASBaseline
c OutcomeBaseline
OutcomePost-intervention
AFQ-YBaseline
AFQ-YPost-intervention
d
e a b Group
Figure 2. Baseline-post intervention two-mediator model.
Anxiety, Stress, & Coping
7
Focus group interviews Focus group interviews were performed by the intervention leaders to gain insight into the participants’ perceptions of the intervention. The names of participants who attended at least four sessions were written on pieces of folded paper, and eight were blindly drawn and invited to participate. The interviews were recorded and transcribed, and the content was analyzed in themes. Results Randomization
Downloaded by [New York University] at 02:45 18 June 2015
Baseline differences between the intervention and control samples were nonsignificant in all variables but one; participants randomized to the control condition had significantly more experience with working in health care (Table 2; Randomization). Attrition At the post-intervention assessment, 49 intervention subjects and 31 control subjects responded (response rate 71%). At the three-month follow-up, the attrition rate was higher resulting in a response rate of 56% (38 and 25 respondents from the intervention and control groups, respectively). Attrition analyses showed no baseline differences between respondents and nonrespondents at the post-intervention or at the three-month follow-up (Table 2; Attrition analyses). Participation in study conditions The mean levels of participation in group sessions were 44% and 64% for the intervention and control conditions, respectively, but participation data were not reported from three out of the eight sessions of the control condition. Table 2. Analyses of randomization and attrition. Randomization INT/control (n = 69/44) Variable Age Gender Country of origin Sweden Pri ex: higher education Pri ex: work in health-care MAAS AFQ-Y PSS BO
Attrition analyses Respondents/non-respondents Post-intervention (n = 80/33)
Three-month follow-up (n = 63/50)
t/χ2
df
p
t/χ2
df
p
t/χ2
df
p
−0.68 0.27 0.52 2.20 4.20 −0.25 0.83 0.79 0.62
111 1 1 1 1 110 110 109 111
.50 .87 .47 .14 .04 .80 .41 .43 .53
−0.82 1.03 1.84 1.16 0.29 0.55 −0.12 −1.34 −0.39
111 1 1 1 1 110 110 109 111
.42 .31 .18 .28 .59 .58 .91 .18 .70
0.68 2.45 3.31 0.82 0.83 −0.18 −1.93 −1.06 −0.73
111 1 1 1 1 110 110 109 111
.50 .12 .07 .36 .38 .85 .06 .29 .47
INT = intervention sample; n = number of subjects; t = t value; χ2 = Pearson chi-square value; df = degrees of freedom; p = significance value; Pri ex = prior experience (yes/no); MAAS = Mindful Attention Awareness Scale; AFQ-Y = Avoidance and Fusion Questionnaire for Youth; PSS = Perceived Stress Scale; BO; The burnout scale from the Scale of Work Engagement and Burnout.
8
E. Frögéli et al.
Downloaded by [New York University] at 02:45 18 June 2015
Hypothesis 1: Impact of the intervention on process outcomes The impact of the intervention on the two process outcomes was examined to determine if the intervention worked as expected, i.e., if it resulted in decreased experiential avoidance and increased mindful awareness. Means and standard errors of measures per group and per measurement occasion from the longitudinal analysis of mean response profiles, as well as the results of post hoc analyses, are presented in Table 3 and graphically displayed in Figures 3a and 3b. In the following section, the results are described by focusing on the efficacy subset (i.e. the participants who attended at least three out of six sessions). The group-by-time interactions indicated that the intervention group and the control group showed different patterns of change from baseline in both mindful awareness (p = .045; Table 3, MAASb) and experiential avoidance (p = .005; Table 3, AFQ-Yb). Post hoc analyses at post-intervention showed that the intervention group reported a significantly higher level of mindful awareness (Cohen’s d = 0.65; Table 3, MAASb; Figure 3a) and a significantly lower level of experiential avoidance (Cohen’s d = 0.51; Table 3, AFQ-Yb; Figure 3b) compared to controls. Post hoc analyses at the three-month follow-up showed that the intervention group reported a significantly higher level of mindful awareness (Cohen’s d = 0.81; Table 3, MAASb; Figure 3a), but there were no significant differences in levels of experiential avoidance (Cohen’s d = 0.10; Table 3, AFQ-Yb; Figure 3b).
Hypothesis 2: Impact of the intervention on main outcomes The impact of the intervention on main outcomes was analyzed using measures of stress and burnout. Means and standard errors of outcome measures per group and per measurement occasion from the longitudinal analysis of mean response profiles, as well as the results of post hoc analyses, are presented in Table 3 and graphically displayed in Figures 4a and 4b. In the following section, the results of the efficacy subset analyses are described. The group-by-time interactions indicated that the intervention group and the control group showed different patterns of change from baseline in terms of perceived stress (p = .001; Table 3, PSSb) and burnout (p = .033; Table 3, BOb). Post hoc analyses at postintervention showed that the intervention group reported significantly lower levels of perceived stress and burnout (Cohen’s d = 1.12 and 0.82, respectively; Table 3, PSSb and BOb; Figures 4a and 4b) compared to the control group. Post hoc analysis at the threemonth follow-up showed that the intervention group reported a significantly lower level of perceived stress (Cohen’s d = 0.66; Table 3, PSSb; Figure 4a) compared to controls. For burnout, the difference in reported levels between the groups was nonsignificant (p = .061). However, the level of the intervention group was lower than that of the control group, and the Cohen’s d effect size was 0.59 (Table 3, BOb; Figure 4b).
Hypothesis 3: Impact of changes in process variables on changes in outcome variables A baseline-post intervention two-mediator model was examined using path analysis to evaluate if changes in process variables were related to changes in outcome variables. Results are presented in Table 4. The standardized parameter estimates indicated that group (control vs. experiment) predicted changes in the process outcomes, and changes in the process outcomes in turn predicted changes in the main outcomes. In the efficacy subset, change in experiential avoidance was not an independent predictor of changes in the main outcomes. In addition, group predicted change in perceived stress independently
Baseline
Variable MAASa MAASb AFQ-Ya AFQ-Yb PSSa PSSb BOa BOb
Three-month follow-up
Post-intervention
INT
Control
INT
Control
INT
Control
M (SE)
M (SE)
M (SE)
M (SE)
M (SE)
M (SE)
61.5 63.8 22.3 19.7 26.6 24.2 2.5 2.3
(1.4) (2.1) (1.6) (2.4) (1.1) (1.8) (0.1) (0.2)
62.2 62.2 20.3 20.3 25.1 25.1 2.4 2.4
(1.7) (1.7) (1.9) (1.9) (1.4) (1.4) (0.1) (0.1)
66.5 69.2 18.4 13.5 22.3 17.0 2.5 2.1
(1.5) (2.2) (1.6) (2.2) (1.3) (1.8) (0.1) (0.2)
62.6 62.6 20.0 20.0 27.6 27.6 2.8 2.8
(1.9) (1.9) (1.9) (1.9) (1.6) (1.6) (0.2) (0.2)
65.8 67.8 20.3 17.6 22.1 17.9 2.6 2.1
(1.6) (2.3) (1.6) (2.4) (1.3) (1.9) (0.2) (0.2)
60.7 60.7 18.9 18.9 24.1 24.1 2.6 2.6
(2.0) (2.0) (2.0) (2.0) (1.6) (1.6) (0.2) (0.2)
Post hoc tests
Group-bytime interaction
Baseline
Three-month follow-up
Post intervention
F
p
t
p
d
t
p
d
t
p
d
3.84 3.29 2.38 5.83 6.82 9.23 2.41 3.66
.026 .045 .100 .005 .002 .001 .097 .033
0.34 0.56 0.81 0.20 0.82 0.37 0.63 0.33
.736 .578 .418 .846 .412 .707 .530 .746
0.13 0.13 0.15 0.05 0.16 0.09 0.11 0.11
2.28 2.27 2.06 3.11 3.59 4.07 2.19 2.59
.026 .027 .043 .003 .001 .001 .031 .012
0.26 0.65 0.12 0.51 0.58 1.12 0.39 0.82
2.73 2.40 0.34 0.33 1.77 2.27 0.85 1.92
.008 .020 .736 .742 .080 .027 .398 .061
0.52 0.81 0.11 0.10 0.22 0.66 0.00 0.59
Anxiety, Stress, & Coping
Downloaded by [New York University] at 02:45 18 June 2015
Table 3. Results from the randomized controlled study.
Note: Estimated marginal mean scores, test of group-by-time interaction, and post hoc analyses of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT = intervention sample; control = control sample (n = 44); F = F value; M = mean; SE = standard error; t = t value, p = significance value; d = Cohen’s d derived from group differences in estimated marginal means and the pooled standard deviation from baseline full sample data; MAAS = Mindful Attention Awareness Scale; AFQ-Y = Avoidance and Fusion Questionnaire for Youth; PSS = Perceived Stress Scale; BO = The burnout scale from the Scale of Work Engagement and Burnout. a Intention-to-treat sample (n = 69). b Efficacy subset sample (n = 29).
9
10
E. Frögéli et al. 80 75
MAAS
70 INT1
65
INT2 Control
60 55
Baseline
Post-intervention
Follow-up
Figure 3a. Mindful Attention Awareness Scale. Note: Estimated marginal mean scores of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT1, Full intervention (ITT) sample; INT2, Efficacy subset sample.
of the two process variables. The four models showed good fit. Additional analyses excluding the grouping variable showed that both processes could independently predict changes in perceived stress and burnout (data not shown). Focus group interviews According to the focus group interviews, participants acknowledged an increased awareness of thoughts and feelings and a strengthened focus of attention that contributed 35 30 25
AFQ-Y
Downloaded by [New York University] at 02:45 18 June 2015
50
INT1 INT2
20
Control
15 10 5 Baseline
Post-intervention
Follow-up
Figure 3b. Avoidance and Fusion Questionnaire for Youth. Note: Estimated marginal mean scores of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT1, Full intervention (ITT) sample; INT2, Efficacy subset sample.
Anxiety, Stress, & Coping
11
30 25
PSS
20 INT1
15
INT2 Control
10
0 Baseline
Post-intervention
Follow-up
Figure 4a. Perceived Stress Scale. Note: Estimated marginal mean scores of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT1, Full intervention (ITT) sample; INT2, Efficacy subset sample.
to more effective decision-making and problem-solving. An increased balance between different life areas following the intervention was perceived to benefit the participants’ academic studies. For some, participation in the intervention was compromised because of unfortunate scheduling of the sessions (e.g. the intervention followed a lecture-free period or was the only activity during a lecture-free day) or stress due to upcoming exams. Some also expressed having difficulties understanding the purpose of the intervention and of
4.4 3.9 3.4
BO
Downloaded by [New York University] at 02:45 18 June 2015
5
INT1 INT2
2.9
Control
2.4 1.9 1.4 Baseline
Post-intervention
Follow-up
Figure 4b. The burnout scale from the Scale of Work Engagement and Burnout. Note: Estimated marginal mean scores of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT1, Full intervention (ITT) sample; INT2, Efficacy subset sample.
12
E. Frögéli et al.
Table 4. Results from path analysis baseline-post two-mediator model. Group on process MAAS
AFQ-Y
MAAS
AFQ-Y
Group on outcome
Model statistics
Variable
βa
p
βb
p
βc
p
βd
p
βe
p
χ2
p
a
.138 .176 .137 .168
.064 .052 .065 .070
.135 .259 .135 .263
.038 .001 .038 .001
.405 .434 .539 .555
.001 .001 .001 .001
.316 .170 .287 .224
.010 .235 .020 .112
.225 .311 .112 .142
.003 .001 .136 .100
15.4 13.5 14.6 12.5
.939 .968 .944 .903
PSS PSSb BOa BOb
Downloaded by [New York University] at 02:45 18 June 2015
Process on outcome
Note: Standardized β values and chi-square statistics of models using intent-to-treat and efficacy-subset samples. Group = control vs. experiment; a–e = estimated paths in baseline-post intervention two-mediator model (Figure 2); β = standardized beta value; p = significance value; χ2 = chi-square value; MAAS = Mindful Attention Awareness Scale; AFQ-Y = Avoidance and Fusion Questionnaire for Youth; PSS = Perceived Stress Scale; BO = The burnout scale from the Scale of Work Engagement and Burnout. a Intention-to-treat sample (n control = 44; n intervention = 69). b Efficacy subset sample (n control = 44; n intervention = 29).
participating in some of the exercises. Increased ability to handle stressors, whether working as a nurse or not, and being able to handle challenges were expected future benefits of attending the intervention sessions.
Discussion Stress and burnout are significant problems in higher education (Byrd & McKinney, 2012; Vollestad et al., 2012). In nursing education, individuals experiencing higher levels of burnout report higher levels of health problems (e.g. depressive mood) are less active in learning situations and feel less prepared and competent during their last semester to handle their upcoming transition into professional life (Rudman & Gustavsson, 2012). In addition, increasing levels of burnout during education have consequences for mastery of tasks, quality of care, and intention to leave the nursing profession one year after graduation (Rudman & Gustavsson, 2012). The present pilot study shows that the intervention under study resulted in significant effects in the process outcomes of experiential avoidance and mindful awareness as well as the main outcomes of perceived stress and burnout in a sample of nursing students. In addition, changes in the process variables predicted changes in the outcome variables. These results are discussed below.
Impact of the intervention on process outcomes ACT interventions use techniques to decrease experiential avoidance and increase present-moment awareness as a way to increase effective values-based action-taking and to improve quality of life (Hayes et al., 2011). Therefore, the first hypothesis of this study was that the intervention would result in decreased experiential avoidance and increased mindful awareness. In evaluations of preventive interventions, it is recommended to use both ITT and efficacy subset analyses. The former reduce the risk that a subsample of satisfied participants will bias the conclusions (i.e. it reduces the risk of Type I error). The latter reduces the risk that a subsample of participants who perhaps did not attend a single session will bias the conclusions (i.e. it reduces the risk of Type II
Downloaded by [New York University] at 02:45 18 June 2015
Anxiety, Stress, & Coping
13
error; Gross & Fogg, 2004). In the present study, the results of the longitudinal analysis of mindful awareness were not conflicting and showed the intervention to be effective. The effect sizes were larger in the efficacy subset. Three other controlled studies have targeted stress in nonclinical settings using techniques from ACT and have reported betweengroups effects on mindful awareness. One of the studies reported a nonsignificant result (Livheim et al., 2014), and the other two studies, similar to the present study, reported significant medium to large between-groups effects (Jeffcoat & Hayes, 2012; StaffordBrown & Pakenham, 2012). In addition, the mediation analysis in this present study confirmed the effect of the intervention on change in mindful awareness and showed the process to be an independent predictor of change in the main outcomes (see Section Discussion). This is interesting considering that mindfulness meditations in ACT interventions typically consume no more than a couple of minutes per day. These results can be compared to those of interventions such as Mindfulness-based Stress Reduction (MBSR) that include more intensive mindfulness meditations. Cavanagh et al. (2013), de Vibe et al. (2013), Flook, Goldberg, Pinger, Bonus, and Davidson (2013), Jennings, Frank, Snowberg, Coccia, and Greenberg (2013), Robins, Keng, Ekblad, and Brantley (2012), and Roeser et al. (2013) evaluated the effect of MBSR on mindful awareness in controlled studies in nonclinical settings and reported between-groups effects ranging from small to large. This indicates that the effects on mindful awareness in the present study and in other ACT interventions are comparable to those of interventions with more intensive mindfulness practice. Surprisingly, although experiential avoidance decreased during the intervention as indicated by significant between-group differences at post-intervention in both the ITT and the efficacy subset sample, the achieved levels were not sustained at follow-up. The group-by-time interaction was significant in the efficacy subset but not in the ITT sample. This might indicate that more participation is needed to benefit from the intervention. However this might also indicate that a subgroup of participants found the intervention beneficial and, therefore, continued to participate, whereas another subgroup did not find the intervention beneficial and chose to withdraw. A study design where participants are randomized to different levels of participation is needed to answer this question. In addition, although the mediation analysis confirmed the effect of the intervention on change in experiential avoidance, it did not show the process to be an independent predictor of change in the main outcomes in the efficacy subset (see Section Discussion). Impact of the intervention on main outcomes Increased acceptance of internal events and mindful awareness that enables more effective action-taking is assumed to decrease perceived stress, disengagement, and exhaustion. According to the meta-analysis by Öst (2014), in terms of the criteria for evidence based treatments established by the APA Division 12 Task Force, ACT is possibly efficacious for work stress. This means that there is “at least one good study showing the treatment to be efficacious in the absence of conflicting evidence” (p. 170; Öst, 2014). In this present trial, the second hypothesis was that the intervention would result in decreased stress and burnout. This was confirmed by results from the longitudinal analysis with the exception of burnout at the three-month follow-up where the between-groups effect was only significant for the efficacy subset. The mediation analysis showed that changes in perceived stress and burnout were mediated by changes in the process variables (although experiential avoidance was not an independent predictor of change in the efficacy subset), thus
14
E. Frögéli et al.
confirming the proposed processes of change. In addition, the intervention independently predicted change in perceived stress. This indicates that other processes that were not included in the models (e.g. values-based living, work-life balance, or attention from therapists) also contributed to the effect of the intervention on main outcomes. Future studies are needed to better understand these effects.
Downloaded by [New York University] at 02:45 18 June 2015
Methodological considerations Because this is a pilot study, additional trials are needed for validation of the results. This study has some important methodological shortcomings that need to be addressed. First, the small sample size and substantial attrition from the study limits the analyses and conclusions. Future studies should include larger samples because dropout is to be expected. Second, longer time and greater contact in the intervention condition (6 × 2 hours) compared to the control condition (2 × 3 hours) might have resulted in over-estimations of the true effects. Future studies should include a control condition comparable to the experimental condition in terms of time and contact. In addition, due to missing data on control subjects the level of participation could not be included in the analyses, and this confounds the interpretation of the results. Third, follow-up analyses at later points in time are needed to further evaluate the preventive effects of the intervention. Adding to that, group effects, therapist effects, and adherence to the protocol could not be accounted for in this study, and future studies should be designed to control for these possibly confounding effects. Conclusion This randomized controlled pilot study adds to the current literature on the effects of interventions targeting stress in nonclinical settings in general and among nursing students in particular. However, the results are preliminary and the shortcomings of this study should be addressed in future studies. In addition, important mediation analyses should be performed to evaluate the proposed processes of the intervention. Randomized controlled trials evaluating isolated behavioral therapy components in real-life settings in relation to stress and burnout would also be of great value in developing the most effective interventions. More knowledge about the specific stressors of nursing students would also benefit this development. Because students with high levels of stress and burnout report a lack of motivation, engagement, and competence (Rudman & Gustavsson, 2012), targeting these constructs could potentially further increase students’ resilience toward stress and burnout. In addition, because this intervention addresses stressors that are also common when entering the profession (Laschinger, Finegan, & Wilk, 2009; Rudman & Gustavsson, 2011), it should also be tested in that context. However, while increasing individual resilience might have great benefits, it is important not to overlook the crucial role of organizational factors as contributors to problems of stress in nursing. Interventions focusing on individual factors should be regarded as complements, not substitutes, to organizational measures. Acknowledgment The authors acknowledge AFA Insurance and the participating nursing students.
Disclosure statement No potential conflict of interest was reported by the authors.
Anxiety, Stress, & Coping
15
Funding This work was supported by AFA Insurance [grant number 070106], [grant number 140007].
Downloaded by [New York University] at 02:45 18 June 2015
References Biglan, A., Hayes, S. C., & Pistorello, J. (2008). Acceptance and commitment: Implications for prevention science. Prevention Science, 9, 139–152. doi:10.1007/s11121-008-0099-4 Brinkborg, H., Michanek, J., Hesser, H., & Berglund, G. (2011). Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial. Behaviour Research and Therapy, 49, 389–398. doi:10.1016/j.brat.2011.03.009 Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848. doi:10.1037/ 0022-3514.84.4.822 Byrd, D. R., & McKinney, K. J. (2012). Individual, interpersonal, and institutional level factors associated with the mental health of college students. Journal of American College Health, 60, 185–193. doi:10.1080/07448481.2011.584334 Cavanagh, K., Strauss, C., Cicconi, F., Griffiths, N., Wyper, A., & Jones, F. (2013). A randomised controlled trial of a brief online mindfulness-based intervention. Behaviour Research and Therapy, 51, 573–578. doi:10.1016/j.brat.2013.06.003 Cherniss, C. (1980). Professional burnout in human service occupations. New York, NY: Praeger Press. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396. doi:10.2307/2136404 de Vibe, M., Solhaug, I., Tyssen, R., Friborg, O., Rosenvinge, J. H., Sorlie, T., & Bjorndal, A. (2013). Mindfulness training for stress management: A randomised controlled study of medical and psychology students. BMC Medical Education, 13, 107. doi:10.1186/1472-6920-13-107 Deary, I. J., Watson, R., & Hogston, R. (2003). A longitudinal cohort study of burnout and attrition in nursing students. Journal of Advanced Nursing, 43(1), 71–81. doi:10.1046/j.1365-2648.2003.02674.x Edwards, D., Burnard, P., Bennett, K., & Hebden, U. (2010). A longitudinal study of stress and selfesteem in student nurses. Nurse Education Today, 30(1), 78–84. doi:10.1016/j.nedt.2009.06.008 Eskin, M., & Parr, D. (1996). Introducing a Swedish version of an instrument measuring mental stress (Report No. 813). Stockholm: Department of Psychology, Stockholm University. Fitzmaurice, G. M., Laird, N. M., & Ware, J. H. (2011). Applied longitudinal analysis. Hoboken, NJ: Wiley. Flook, L., Goldberg, S. B., Pinger, L., Bonus, K., & Davidson, R. J. (2013). Mindfulness for teachers: A pilot study to assess effects on stress, burnout, and teaching efficacy. Mind, Brain, and Education, 7, 182–195. doi:10.1111/mbe.12026 Florin, A., & Wennman, C. (2010). Evaluation of the Avoidance and Fusion Questionnaire for Youth in an Swedish adult population (Unpublished thesis). Department of Psychology, Uppsala Universitet, Uppsala. Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. doi:10.1037/1040-3590.20.2.93 Gross, D., & Fogg, L. (2004). A critical analysis of the intent-to-treat principle in prevention research. Journal of Primary Prevention, 25, 475–489. doi:10.1023/B:JOPP.0000048113.77939.44 Hansen, E., Lundh, L. G., Homman, A., & Wangby-Lundh, M. (2009). Measuring mindfulness: Pilot studies with the Swedish versions of the Mindful Attention Awareness Scale and the Kentucky Inventory of Mindfulness Skills. Cognitive Behaviour Therapy, 38(1), 2–15. doi:10.1080/165060 70802383230 Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., … Niccolls, R. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35, 821–835. doi:10.1016/s0005-7894(04)80022-4 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.
Downloaded by [New York University] at 02:45 18 June 2015
16
E. Frögéli et al.
Hultell, D., & Gustavsson, J. P. (2010). A psychometric evaluation of the Scale of Work Engagement and Burnout (SWEBO). Work, 37, 261–274. doi:10.3233/wor-2010-1078 IBM Corp. Released. (2013). IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: Author. Jeffcoat, T., & Hayes, S. C. (2012). A randomized trial of ACT bibliotherapy on the mental health of K12 teachers and staff. Behaviour Research and Therapy, 50, 571–579. doi:10.1016/j.brat.2012.05.008 Jennings, P. A., Frank, J. L., Snowberg, K. E., Coccia, M. A., & Greenberg, M. T. (2013). Improving classroom learning environments by Cultivating Awareness and Resilience in Education (CARE): Results of a randomized controlled trial. School Psychology Quarterly, 28, 374–390. doi:10.1037/ spq0000035 Lachin, J. M. (2000). Statistical considerations in the intent-to-treat principle. Controlled Clinical Trials, 21, 167–189. doi:10.1016/s0197-2456(00)00046-5 Laschinger, H. K., Finegan, J., & Wilk, P. (2009). New graduate burnout: The impact of professional practice environment, workplace civility, and empowerment. Nursing Economics, 27, 377–383. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20050488 Livheim, F., Hayes, L. J., Ghaderi, A., Magnusdottir, T., Högfeldt, A., Rowse, J., … Tengström, A. (2014). The effectiveness of acceptance and commitment therapy for adolescent mental health: Swedish and Australian pilot outcomes. Journal of Child and Family Studies, 24, 1016–1030. doi:10.1007/s10826-014-9912-9 MacKinninon, D. P. (2008). Introduction to statistical mediation analysis. New York, NY: Taylor & Francis. McEwen, B. S., & Gianaros, P. J. (2011). Stress- and allostasis-induced brain plasticity. Annual Review of Medicine, 62, 431–445. doi:10.1146/annurev-med-052209-100430 Montori, V. M., & Guyatt, G. H. (2001). Intention-to-treat principle. Canadian Medical Association Journal, 165, 1339–1341. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11760981 Muthén, L. K., & Muthén, B. O. (1998–2014). Mplus user’s guide (7th ed.). Los Angeles, CA: Author. Nerdrum, P., Rustøen, T., & Helge Rønnestad, M. (2009). Psychological distress among nursing, physiotherapy and occupational therapy students: A longitudinal and predictive study. Scandinavian Journal of Educational Research, 53, 363–378. doi:10.1080/00313830903043133 Öst, L. G. (2014). The efficacy of acceptance and commitment therapy: An updated systematic review and meta-analysis. Behaviour Research and Therapy, 61, 105–121. doi:10.1016/j. brat.2014.07.018 Pennbrant, S., Nilsson, M. S., Ohlen, J., & Rudman, A. (2013). Mastering the professional role as a newly graduated registered nurse. Nurse Education Today, 33, 739–745. doi:10.1016/j.nedt.2012.11.021 Robins, C. J., Keng, S. L., Ekblad, A. G., & Brantley, J. G. (2012). Effects of mindfulness-based stress reduction on emotional experience and expression: A randomized controlled trial. Journal of Clinical Psychology, 68(1), 117–131. doi:10.1002/jclp.20857 Roeser, R. W., Schonert-Reichl, K. A., Jha, A., Cullen, M., Wallace, L., Wilensky, R., … Harrison, J. (2013). Mindfulness training and reductions in teacher stress and burnout: Results from two randomized, waitlist-control field trials. Journal of Educational Psychology, 105, 787–804. doi:10.1037/a0032093 Rudman, A., & Gustavsson, J. P. (2011). Early-career burnout among new graduate nurses: A prospective observational study of intra-individual change trajectories. International Journal of Nursing Studies, 48, 292–306. doi:10.1016/j.ijnurstu.2010.07.012 Rudman, A., & Gustavsson, J. P. (2012). Burnout during nursing education predicts lower occupational preparedness and future clinical performance: A longitudinal study. International Journal of Nursing Studies, 49, 988–1001. doi:10.1016/j.ijnurstu.2012.03.010 Rudman, A., Omne-Ponten, M., Wallin, L., & Gustavsson, J. P. (2010). Monitoring the newly qualified nurses in Sweden: The Longitudinal Analysis of Nursing Education (LANE) study. Human Resources for Health, 8, 10. doi:10.1186/1478-4491-8-10 Schaufeli, W. B., Leiter, M. P., & Maslach, C. (2009). Burnout: 35 years of research and practice. Career Development International, 14, 204–220. doi:10.1108/13620430910966406 Stafford-Brown, J., & Pakenham, K. I. (2012). The effectiveness of an ACT informed intervention for managing stress and improving therapist qualities in clinical psychology trainees. Journal of Clinical Psychology, 68, 592–513. doi:10.1002/jclp.21844 Timmins, F., & Kaliszer, M. (2002). Aspects of nurse education programmes that frequently cause stress to nursing students – Fact-finding sample survey. Nurse Education Today, 22, 203–211. doi:10.1054/nedt.2001.0698
Anxiety, Stress, & Coping
17
Downloaded by [New York University] at 02:45 18 June 2015
Vollestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness- and acceptance-based interventions for anxiety disorders: A systematic review and meta-analysis. British Journal of Clinical Psychology, 51, 239–260. doi:10.1111/j.2044-8260.2011.02024.x Watson, R., Deary, I., Thompson, D., & Li, G. (2008). A study of stress and burnout in nursing students in Hong Kong: A questionnaire survey. International Journal of Nursing Studies, 45, 1534–1542. doi:10.1016/j.ijnurstu.2007.11.003 World Medical Association (Producer). (2014). WMA declaration of Helsinki – Ethical principles for medical research involving human subjects. Retrieved from http://www.wma.net/en/30pub lications/10policies/b3/
Anxiety, Stress, & Coping: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gasc20
A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses a
a
a
Elin Frögéli , Aleksandar Djordjevic , Ann Rudman , Fredrik a
Livheim & Petter Gustavsson
a
a
Click for updates
Department of Clinical Neuroscience, Karolinska Institutet, Nobels väg 9, 171 77 Stockholm, Sweden Accepted author version posted online: 11 Mar 2015.Published online: 07 Apr 2015.
To cite this article: Elin Frögéli, Aleksandar Djordjevic, Ann Rudman, Fredrik Livheim & Petter Gustavsson (2015): A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses, Anxiety, Stress, & Coping: An International Journal, DOI: 10.1080/10615806.2015.1025765 To link to this article: http://dx.doi.org/10.1080/10615806.2015.1025765
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [New York University] at 02:45 18 June 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Anxiety, Stress, & Coping, 2015 http://dx.doi.org/10.1080/10615806.2015.1025765
A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses Elin Frögéli*, Aleksandar Djordjevic, Ann Rudman, Fredrik Livheim and Petter Gustavsson
Downloaded by [New York University] at 02:45 18 June 2015
Department of Clinical Neuroscience, Karolinska Institutet, Nobels väg 9, 171 77 Stockholm, Sweden (Received 23 June 2014; accepted 2 March 2015) Background: Levels of stress and burnout increase during nursing education. This development has consequences for nursing students’ health, learning, competence, and interest in quality issues in health care. Design: In a randomized controlled pilot trial with a sample of 113 nursing students the effect of an intervention using techniques from acceptance and commitment training (ACT) to prevent the development of stress and burnout was evaluated. Method: The 6 × 2-hour program was compared to standard treatment (reflection seminars) post-intervention and at a three-month follow-up using longitudinal analysis of mean response profiles. Mechanisms of change were investigated using a baseline-post intervention two-mediator model. Results: The intervention resulted in increased mindful awareness and decreased experiential avoidance, as well as de‐ creased perceived stress and burnout. Levels of mindful awareness and perceived stress were sustained at follow-up. The proposed mechanisms of change were partly supported by the data. Conclusion: This study shows that techniques from ACT might have the potential to contribute to preventing the development of stress and burnout during nursing education. However, additional studies are needed to validate these results. Keywords: behavior therapy; acceptance and commitment therapy/training; nursing students; prevention; randomized controlled trial; stress
Introduction The years of higher education are often perceived as stressful, and this experience is related to factors at the individual and organizational levels (Byrd & McKinney, 2012; Vollestad, Nielsen, & Nielsen, 2012). Prolonged stress reactions are detrimental to one’s health and can interfere with learning and lead to burnout (McEwen & Gianaros, 2011; Rudman & Gustavsson, 2012). Prospective studies conducted on nursing students indicate that stress and burnout increase during nursing education (Deary, Watson, & Hogston, 2003; Edwards, Burnard, Bennett, & Hebden, 2010; Watson, Deary, Thompson, & Li, 2008), and this development has been contrasted to what is seen in students of other health professions where levels of stress are often stable, or even decrease, during higher education (Nerdrum, Rustøen, & Helge Rønnestad, 2009). Research has shown that on top of the stress inherent in all academic studies the encounter with clinical reality during *Corresponding author. Email: [email protected] © 2015 Taylor & Francis
Downloaded by [New York University] at 02:45 18 June 2015
2
E. Frögéli et al.
training constitutes a source of additional stress for nursing students (Timmins & Kaliszer, 2002). In a prospective study in Sweden, the prevalence of burnout symptoms in a national cohort of nursing students was found to increase from 29% to 41% between the second and sixth semesters, with the steepest increase between the second and fourth semesters (Rudman & Gustavsson, 2012). Students experiencing increased levels of burnout symptoms during their nursing education reported at the last semester of their education that they had higher levels of health problems (e.g. depressive mood), that they were less active in classroom learning situations, and that they felt less prepared and competent to handle their upcoming profession (Rudman & Gustavsson, 2012). In addition, one year after graduation they reported lower levels of mastery of occupational tasks, less interest in quality issues in health care (e.g. utilizing research in their practice), and greater preoccupation with thoughts about leaving the profession compared to their peers (Rudman & Gustavsson, 2012). Therefore, an important research question is what the common symptoms of burnout are and how can they be prevented during nursing higher education. Burnout is related to prolonged stress reactions and is defined by the two core dimensions of exhaustion and disengagement (e.g. Cherniss, 1980; Schaufeli, Leiter, & Maslach, 2009). Exhaustion refers to the physical consequence of efforts expended to manage perceived stressors, and disengagement refers to the behavioral strategies employed to avoid stressors that are perceived as unmanageable. Although these avoidance strategies are often effective in relieving the experience of stress over the short term, they will typically result in increased levels of burnout in the long run. Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2011) is a behavior therapy method with an explicit focus on decreasing avoidance of stressful thoughts, feelings, and sensations. Within ACT, the avoidance of these private events (referred to as experiential avoidance) is assumed to be the basis of much human suffering, including burnout. The theory proposes that when focusing on avoiding internal stressors one is less involved with ongoing experiences and can miss out on information needed for active problem solving. In addition, one is often less inclined to act in ways that can result in increased health and well-being over time. The goal of ACT is to reduce experiential avoidance in order to increase effective values-based actions and to increase the individual’s quality of life. This is done using techniques to increase the acceptance of internal events and to increase present-moment awareness (i.e. mindfulness). In a recent meta-analysis of randomized controlled trials comparing ACT to waitlist, placebo, treatment-as-usual, and different forms of cognitive behavior therapy, a computed overall effect size favoring ACT was small but significant (Öst, 2014). Because the aim of ACT is effective values-based living, not symptom reduction, it has been proposed that the method is also suitable for preventive interventions (Biglan, Hayes, & Pistorello, 2008). Accordingly, over the last 10 years the techniques (referred to as acceptance and commitment training; Hayes et al., 2004) have been adapted and tested for use in nonclinical settings. The abbreviation ACT will hereafter refer to acceptance and commitment training. To our knowledge, no previous study has tested if ACT techniques are effective for preventing or reducing stress among nursing students. Therefore, the aim of the present study was to make a preliminary investigation of the effect of a preventive intervention consisting of six 2-hour group sessions using ACT techniques to target stress during the first semester of nursing training.
Anxiety, Stress, & Coping
3
Hypotheses (1) The intervention will lead to a decrease in experiential avoidance and an increase in mindful awareness (process outcomes). (2) The intervention will lead to decreased levels of stress and burnout (main outcomes). (3) Changes in process outcomes will predict changes in main outcomes.
Downloaded by [New York University] at 02:45 18 June 2015
Method The experimental intervention was compared to an active control condition consisting of reflection seminars for personal and professional development in a randomized controlled trial. The study was approved by the Regional Ethical Review Board in Stockholm (File record 2011/1331-31/4) and complied with the Helsinki Declaration of ethical principles for medical research involving human subjects (World Medical Association, 2014). Study conditions The intervention consisted of six 2-hour group sessions using theory and methods from behavior therapy to target stress in nursing education. The intervention included information about stress and relevant lifestyle factors (e.g. work-life balance, sleep, and exercise), behavior change strategies, communication and assertiveness skills, and training in ACT techniques for managing stressful thoughts and feelings (e.g. defusion and acceptance), values clarification, and mindfulness practice. The protocol can be retrieved from http://ki.se/en/cns/petter-gustavssons-research-group. The intervention called Mind the Gap was contextualized to target stressors in nursing education based on results from the LANE study (Pennbrant, Nilsson, Ohlen, & Rudman, 2013; Rudman & Gustavsson, 2011, 2012; Rudman, Omne-Ponten, Wallin, & Gustavsson, 2010). The group leaders of the intervention were psychology-major students who specialized in cognitive behavior therapy and who were trained in ACT techniques by an internationally peer reviewed and approved ACT trainer. The control condition consisted of two 3-hour reflection seminars for personal and professional development lead by professors of nursing education. There was no pre-set agenda to the reflection seminars. Participating students were invited to discuss and reflect on any matters in relation to their personal or professional development that they found interesting or troubling. Attendance was recorded at each session. Randomization and study design The randomized controlled between-group study design is presented in Figure 1, including the data collection time points and the response and drop-out rates at baseline and at the post-intervention and the follow-up data collections. All data were self-reported through pen-and-paper surveys. With the exception of the baseline survey, all surveys were sent to the participants’ homes by postal mail together with a pre-stamped return envelope. The initial mailings were followed by weekly reminders over the course of a month. Eligible participants were 138 nursing students registered in the first semester of the nursing program at the Karolinska Institutet during the fall of 2011. Recruitment took place at a meeting describing the personal and professional development program offered by the university. Students were informed that they would be invited to participate in the
Downloaded by [New York University] at 02:45 18 June 2015
4
E. Frögéli et al.
Figure 1. Description of the study design and flow of subjects.
usual reflection seminars or a 6-week stress management course that would be followed by the usual reflection seminars. The students would otherwise be treated equally. Prior to this information meeting, students were randomized into 10 groups of 12–15 students (the normal size of the reflection seminar groups) by the university using simple randomization. Due to practical considerations, 6 groups (81 students) were randomized to the stress management course and 4 groups (57 students) were randomized to the reflection seminars using simple randomization. Unaware of their allocated group, 113 students chose to participate in the study, gave their informed consent, and completed the baseline questionnaire. This resulted in a total of 69 participants in the intervention group and 44 in the control group. Absent students were given the information and baseline questionnaire by mail. The six sessions of the intervention were given at three different times each week, and students randomized to the intervention were free to participate in the weekly session that best fit their schedule, thus the intervention groups were not fixed over time. Students were welcome to participate in the reflection seminars as well as the intervention regardless of whether or not they chose to participate in the study. No compensation was given for participation in the study.
Measures The intervention sought to reduce prolonged stress reactions and burnout using techniques to decrease experiential avoidance and increase present-moment awareness. In order to evaluate the intervention, two instruments were used as process outcome measures and two instruments were used as main outcome measures. Full study sample intercorrelations at baseline and follow-up are presented in Table 1.
Anxiety, Stress, & Coping
5
Table 1. Full study sample intercorrelations (Pearson’s r) at baseline (above the diagonal) and at three-month follow-up (below the diagonal). Variable
MAAS
MAAS AFQ-Y PSS BO
−.572 (p < .000) −.614 (p < .000) −.572 (p < .000)
AFQ-Y
PSS
BO
−.528 (p < .000)
−.491 (p < .000) .498 (p < .000)
−.504 (p < .000) .494 (p < .000) .503 (p < .000)
.596 (p < .000) .471 (p < .000)
.698 (p < .000)
p = significance value; MAAS = Mindful Attention Awareness Scale; AFQ-Y = Avoidance and Fusion Questionnaire for Youth; PSS = Perceived Stress Scale; BO = The burnout scale from the Scale of Work Engagement and Burnout.
Downloaded by [New York University] at 02:45 18 June 2015
Process outcome measures The Avoidance and Fusion Questionnaire for Youth (AFQ-Y; Greco, Lambert, & Baer, 2008) is a self-reported measurement with 17 items with a 5-point response format for assessing experiential avoidance based on questions concerning how one relates to personal thoughts and feelings. Scores are computed as a sum ranging from 0 to 68 points. A higher score represents a higher level of experiential avoidance. The alpha coefficient in this study was .90 at baseline, and the instrument was previously validated in a Swedish population (M [SD] = 19.85 [11.06]; Florin & Wennman, 2010). The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) is a questionnaire with 15 items measuring mindful awareness of moment-to-moment experiences using a 6-point response format. Scores are presented as a sum ranging from 15 to 90 points. A higher score represents a higher level of mindful awareness. The alpha coefficient in this study was .86 at baseline, and the instrument was previously validated in a Swedish population (M [SD] = 65.18 [9.54]; Hansen, Lundh, Homman, & Wangby-Lundh, 2009).
Main outcome measures The Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983) is a selfreported questionnaire with 14 items with a 5-point response format for assessment of perceived stress during the previous week. Scale scores are computed as a sum ranging from 0 to 56 points. A higher score represents a higher level of perceived stress. In this study, the alpha coefficient was .89 at baseline. The instrument was previously validated in a Swedish population (M [SD] = 24.4 [8.0]; Eskin & Parr, 1996). The burnout subscale (BO) from the Scale of Work Engagement and Burnout (Hultell & Gustavsson, 2010) comprises 9 items using a 6-point response format for assessment of burnout. Scores are computed as a mean ranging from 1 to 6 points and a higher score represents a higher level of burnout. In this study, the alpha coefficient was .84 for the BO at baseline. The instrument was previously validated in a Swedish population (estimated M [SD] = 2.43 [0.77]; Hultell & Gustavsson, 2010).
Data analysis The standard principle of analysis in randomized controlled trials is intention-to-treat (ITT) in which all subjects are included in the analysis regardless of whether or not they
6
E. Frögéli et al.
Downloaded by [New York University] at 02:45 18 June 2015
adhered to the intervention (Lachin, 2000). However, in preventive interventions such as the present one, analyses based on the principles of ITT are not necessarily the most appropriate because low levels of adherence are considered an innate problem because subjects are not seeking treatment for an existing illness (Gross & Fogg, 2004; Montori & Guyatt, 2001). A number of alternative principles are available (e.g. Gross & Fogg, 2004), and this study used the following analyses to evaluate the effect of the intervention on process outcomes (Hypothesis 1) and main outcomes (Hypothesis 2): (1) Standard ITT analysis (intervention sample n = 69; control sample n = 44) applying a longitudinal analysis of mean response profiles (Fitzmaurice, Laird, & Ware, 2011) including data from baseline, post-intervention, and three-month follow-up. (2) Efficacy subset analysis applying a longitudinal analysis of mean response profiles including the subjects who participated in at least three out of six sessions (n = 29) compared to the control sample (n = 44) using data from baseline, postintervention, and three-month follow-up. Longitudinal analysis of mean response profiles (Fitzmaurice et al., 2011) was performed using the mixed model procedure in IBM SPSS Statistics 22 (IBM Corp. Released, 2013). A significant group-by-time interaction was interpreted as reflecting differential patterns of change between the groups over time. Post-hoc tests were used to evaluate differences between groups at post-intervention and at follow-up. Between-group effect sizes at postintervention and at follow-up were calculated using Cohen’s d with pooled standard deviations from baseline data. For Cohen’s d, an effect size of 0.2–0.3 is interpreted as a “small” effect, a value around 0.5 as a “medium” effect, and a value of 0.8 and above as a “large” effect (Cohen, 1988). In a previous comparable trial, an effect of .72 was reported for the PSS (Brinkborg, Michanek, Hesser, & Berglund, 2011). Expecting this effect, for a power of 0.80 (and p < 0.05), 60 participants were required in this study. Finally, the relation between changes in process outcomes and changes in the main outcomes (Hypothesis 3) was investigated using path analysis of a baseline-post intervention two-mediator model (MacKinninon, 2008) using MLR estimation in Mplus 7 (Muthén & Muthén, 1998–2014) (Figure 2). MAASPost-intervention
MAASBaseline
c OutcomeBaseline
OutcomePost-intervention
AFQ-YBaseline
AFQ-YPost-intervention
d
e a b Group
Figure 2. Baseline-post intervention two-mediator model.
Anxiety, Stress, & Coping
7
Focus group interviews Focus group interviews were performed by the intervention leaders to gain insight into the participants’ perceptions of the intervention. The names of participants who attended at least four sessions were written on pieces of folded paper, and eight were blindly drawn and invited to participate. The interviews were recorded and transcribed, and the content was analyzed in themes. Results Randomization
Downloaded by [New York University] at 02:45 18 June 2015
Baseline differences between the intervention and control samples were nonsignificant in all variables but one; participants randomized to the control condition had significantly more experience with working in health care (Table 2; Randomization). Attrition At the post-intervention assessment, 49 intervention subjects and 31 control subjects responded (response rate 71%). At the three-month follow-up, the attrition rate was higher resulting in a response rate of 56% (38 and 25 respondents from the intervention and control groups, respectively). Attrition analyses showed no baseline differences between respondents and nonrespondents at the post-intervention or at the three-month follow-up (Table 2; Attrition analyses). Participation in study conditions The mean levels of participation in group sessions were 44% and 64% for the intervention and control conditions, respectively, but participation data were not reported from three out of the eight sessions of the control condition. Table 2. Analyses of randomization and attrition. Randomization INT/control (n = 69/44) Variable Age Gender Country of origin Sweden Pri ex: higher education Pri ex: work in health-care MAAS AFQ-Y PSS BO
Attrition analyses Respondents/non-respondents Post-intervention (n = 80/33)
Three-month follow-up (n = 63/50)
t/χ2
df
p
t/χ2
df
p
t/χ2
df
p
−0.68 0.27 0.52 2.20 4.20 −0.25 0.83 0.79 0.62
111 1 1 1 1 110 110 109 111
.50 .87 .47 .14 .04 .80 .41 .43 .53
−0.82 1.03 1.84 1.16 0.29 0.55 −0.12 −1.34 −0.39
111 1 1 1 1 110 110 109 111
.42 .31 .18 .28 .59 .58 .91 .18 .70
0.68 2.45 3.31 0.82 0.83 −0.18 −1.93 −1.06 −0.73
111 1 1 1 1 110 110 109 111
.50 .12 .07 .36 .38 .85 .06 .29 .47
INT = intervention sample; n = number of subjects; t = t value; χ2 = Pearson chi-square value; df = degrees of freedom; p = significance value; Pri ex = prior experience (yes/no); MAAS = Mindful Attention Awareness Scale; AFQ-Y = Avoidance and Fusion Questionnaire for Youth; PSS = Perceived Stress Scale; BO; The burnout scale from the Scale of Work Engagement and Burnout.
8
E. Frögéli et al.
Downloaded by [New York University] at 02:45 18 June 2015
Hypothesis 1: Impact of the intervention on process outcomes The impact of the intervention on the two process outcomes was examined to determine if the intervention worked as expected, i.e., if it resulted in decreased experiential avoidance and increased mindful awareness. Means and standard errors of measures per group and per measurement occasion from the longitudinal analysis of mean response profiles, as well as the results of post hoc analyses, are presented in Table 3 and graphically displayed in Figures 3a and 3b. In the following section, the results are described by focusing on the efficacy subset (i.e. the participants who attended at least three out of six sessions). The group-by-time interactions indicated that the intervention group and the control group showed different patterns of change from baseline in both mindful awareness (p = .045; Table 3, MAASb) and experiential avoidance (p = .005; Table 3, AFQ-Yb). Post hoc analyses at post-intervention showed that the intervention group reported a significantly higher level of mindful awareness (Cohen’s d = 0.65; Table 3, MAASb; Figure 3a) and a significantly lower level of experiential avoidance (Cohen’s d = 0.51; Table 3, AFQ-Yb; Figure 3b) compared to controls. Post hoc analyses at the three-month follow-up showed that the intervention group reported a significantly higher level of mindful awareness (Cohen’s d = 0.81; Table 3, MAASb; Figure 3a), but there were no significant differences in levels of experiential avoidance (Cohen’s d = 0.10; Table 3, AFQ-Yb; Figure 3b).
Hypothesis 2: Impact of the intervention on main outcomes The impact of the intervention on main outcomes was analyzed using measures of stress and burnout. Means and standard errors of outcome measures per group and per measurement occasion from the longitudinal analysis of mean response profiles, as well as the results of post hoc analyses, are presented in Table 3 and graphically displayed in Figures 4a and 4b. In the following section, the results of the efficacy subset analyses are described. The group-by-time interactions indicated that the intervention group and the control group showed different patterns of change from baseline in terms of perceived stress (p = .001; Table 3, PSSb) and burnout (p = .033; Table 3, BOb). Post hoc analyses at postintervention showed that the intervention group reported significantly lower levels of perceived stress and burnout (Cohen’s d = 1.12 and 0.82, respectively; Table 3, PSSb and BOb; Figures 4a and 4b) compared to the control group. Post hoc analysis at the threemonth follow-up showed that the intervention group reported a significantly lower level of perceived stress (Cohen’s d = 0.66; Table 3, PSSb; Figure 4a) compared to controls. For burnout, the difference in reported levels between the groups was nonsignificant (p = .061). However, the level of the intervention group was lower than that of the control group, and the Cohen’s d effect size was 0.59 (Table 3, BOb; Figure 4b).
Hypothesis 3: Impact of changes in process variables on changes in outcome variables A baseline-post intervention two-mediator model was examined using path analysis to evaluate if changes in process variables were related to changes in outcome variables. Results are presented in Table 4. The standardized parameter estimates indicated that group (control vs. experiment) predicted changes in the process outcomes, and changes in the process outcomes in turn predicted changes in the main outcomes. In the efficacy subset, change in experiential avoidance was not an independent predictor of changes in the main outcomes. In addition, group predicted change in perceived stress independently
Baseline
Variable MAASa MAASb AFQ-Ya AFQ-Yb PSSa PSSb BOa BOb
Three-month follow-up
Post-intervention
INT
Control
INT
Control
INT
Control
M (SE)
M (SE)
M (SE)
M (SE)
M (SE)
M (SE)
61.5 63.8 22.3 19.7 26.6 24.2 2.5 2.3
(1.4) (2.1) (1.6) (2.4) (1.1) (1.8) (0.1) (0.2)
62.2 62.2 20.3 20.3 25.1 25.1 2.4 2.4
(1.7) (1.7) (1.9) (1.9) (1.4) (1.4) (0.1) (0.1)
66.5 69.2 18.4 13.5 22.3 17.0 2.5 2.1
(1.5) (2.2) (1.6) (2.2) (1.3) (1.8) (0.1) (0.2)
62.6 62.6 20.0 20.0 27.6 27.6 2.8 2.8
(1.9) (1.9) (1.9) (1.9) (1.6) (1.6) (0.2) (0.2)
65.8 67.8 20.3 17.6 22.1 17.9 2.6 2.1
(1.6) (2.3) (1.6) (2.4) (1.3) (1.9) (0.2) (0.2)
60.7 60.7 18.9 18.9 24.1 24.1 2.6 2.6
(2.0) (2.0) (2.0) (2.0) (1.6) (1.6) (0.2) (0.2)
Post hoc tests
Group-bytime interaction
Baseline
Three-month follow-up
Post intervention
F
p
t
p
d
t
p
d
t
p
d
3.84 3.29 2.38 5.83 6.82 9.23 2.41 3.66
.026 .045 .100 .005 .002 .001 .097 .033
0.34 0.56 0.81 0.20 0.82 0.37 0.63 0.33
.736 .578 .418 .846 .412 .707 .530 .746
0.13 0.13 0.15 0.05 0.16 0.09 0.11 0.11
2.28 2.27 2.06 3.11 3.59 4.07 2.19 2.59
.026 .027 .043 .003 .001 .001 .031 .012
0.26 0.65 0.12 0.51 0.58 1.12 0.39 0.82
2.73 2.40 0.34 0.33 1.77 2.27 0.85 1.92
.008 .020 .736 .742 .080 .027 .398 .061
0.52 0.81 0.11 0.10 0.22 0.66 0.00 0.59
Anxiety, Stress, & Coping
Downloaded by [New York University] at 02:45 18 June 2015
Table 3. Results from the randomized controlled study.
Note: Estimated marginal mean scores, test of group-by-time interaction, and post hoc analyses of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT = intervention sample; control = control sample (n = 44); F = F value; M = mean; SE = standard error; t = t value, p = significance value; d = Cohen’s d derived from group differences in estimated marginal means and the pooled standard deviation from baseline full sample data; MAAS = Mindful Attention Awareness Scale; AFQ-Y = Avoidance and Fusion Questionnaire for Youth; PSS = Perceived Stress Scale; BO = The burnout scale from the Scale of Work Engagement and Burnout. a Intention-to-treat sample (n = 69). b Efficacy subset sample (n = 29).
9
10
E. Frögéli et al. 80 75
MAAS
70 INT1
65
INT2 Control
60 55
Baseline
Post-intervention
Follow-up
Figure 3a. Mindful Attention Awareness Scale. Note: Estimated marginal mean scores of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT1, Full intervention (ITT) sample; INT2, Efficacy subset sample.
of the two process variables. The four models showed good fit. Additional analyses excluding the grouping variable showed that both processes could independently predict changes in perceived stress and burnout (data not shown). Focus group interviews According to the focus group interviews, participants acknowledged an increased awareness of thoughts and feelings and a strengthened focus of attention that contributed 35 30 25
AFQ-Y
Downloaded by [New York University] at 02:45 18 June 2015
50
INT1 INT2
20
Control
15 10 5 Baseline
Post-intervention
Follow-up
Figure 3b. Avoidance and Fusion Questionnaire for Youth. Note: Estimated marginal mean scores of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT1, Full intervention (ITT) sample; INT2, Efficacy subset sample.
Anxiety, Stress, & Coping
11
30 25
PSS
20 INT1
15
INT2 Control
10
0 Baseline
Post-intervention
Follow-up
Figure 4a. Perceived Stress Scale. Note: Estimated marginal mean scores of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT1, Full intervention (ITT) sample; INT2, Efficacy subset sample.
to more effective decision-making and problem-solving. An increased balance between different life areas following the intervention was perceived to benefit the participants’ academic studies. For some, participation in the intervention was compromised because of unfortunate scheduling of the sessions (e.g. the intervention followed a lecture-free period or was the only activity during a lecture-free day) or stress due to upcoming exams. Some also expressed having difficulties understanding the purpose of the intervention and of
4.4 3.9 3.4
BO
Downloaded by [New York University] at 02:45 18 June 2015
5
INT1 INT2
2.9
Control
2.4 1.9 1.4 Baseline
Post-intervention
Follow-up
Figure 4b. The burnout scale from the Scale of Work Engagement and Burnout. Note: Estimated marginal mean scores of intervention participants and controls according to intention-to-treat and efficacy subset analyses. INT1, Full intervention (ITT) sample; INT2, Efficacy subset sample.
12
E. Frögéli et al.
Table 4. Results from path analysis baseline-post two-mediator model. Group on process MAAS
AFQ-Y
MAAS
AFQ-Y
Group on outcome
Model statistics
Variable
βa
p
βb
p
βc
p
βd
p
βe
p
χ2
p
a
.138 .176 .137 .168
.064 .052 .065 .070
.135 .259 .135 .263
.038 .001 .038 .001
.405 .434 .539 .555
.001 .001 .001 .001
.316 .170 .287 .224
.010 .235 .020 .112
.225 .311 .112 .142
.003 .001 .136 .100
15.4 13.5 14.6 12.5
.939 .968 .944 .903
PSS PSSb BOa BOb
Downloaded by [New York University] at 02:45 18 June 2015
Process on outcome
Note: Standardized β values and chi-square statistics of models using intent-to-treat and efficacy-subset samples. Group = control vs. experiment; a–e = estimated paths in baseline-post intervention two-mediator model (Figure 2); β = standardized beta value; p = significance value; χ2 = chi-square value; MAAS = Mindful Attention Awareness Scale; AFQ-Y = Avoidance and Fusion Questionnaire for Youth; PSS = Perceived Stress Scale; BO = The burnout scale from the Scale of Work Engagement and Burnout. a Intention-to-treat sample (n control = 44; n intervention = 69). b Efficacy subset sample (n control = 44; n intervention = 29).
participating in some of the exercises. Increased ability to handle stressors, whether working as a nurse or not, and being able to handle challenges were expected future benefits of attending the intervention sessions.
Discussion Stress and burnout are significant problems in higher education (Byrd & McKinney, 2012; Vollestad et al., 2012). In nursing education, individuals experiencing higher levels of burnout report higher levels of health problems (e.g. depressive mood) are less active in learning situations and feel less prepared and competent during their last semester to handle their upcoming transition into professional life (Rudman & Gustavsson, 2012). In addition, increasing levels of burnout during education have consequences for mastery of tasks, quality of care, and intention to leave the nursing profession one year after graduation (Rudman & Gustavsson, 2012). The present pilot study shows that the intervention under study resulted in significant effects in the process outcomes of experiential avoidance and mindful awareness as well as the main outcomes of perceived stress and burnout in a sample of nursing students. In addition, changes in the process variables predicted changes in the outcome variables. These results are discussed below.
Impact of the intervention on process outcomes ACT interventions use techniques to decrease experiential avoidance and increase present-moment awareness as a way to increase effective values-based action-taking and to improve quality of life (Hayes et al., 2011). Therefore, the first hypothesis of this study was that the intervention would result in decreased experiential avoidance and increased mindful awareness. In evaluations of preventive interventions, it is recommended to use both ITT and efficacy subset analyses. The former reduce the risk that a subsample of satisfied participants will bias the conclusions (i.e. it reduces the risk of Type I error). The latter reduces the risk that a subsample of participants who perhaps did not attend a single session will bias the conclusions (i.e. it reduces the risk of Type II
Downloaded by [New York University] at 02:45 18 June 2015
Anxiety, Stress, & Coping
13
error; Gross & Fogg, 2004). In the present study, the results of the longitudinal analysis of mindful awareness were not conflicting and showed the intervention to be effective. The effect sizes were larger in the efficacy subset. Three other controlled studies have targeted stress in nonclinical settings using techniques from ACT and have reported betweengroups effects on mindful awareness. One of the studies reported a nonsignificant result (Livheim et al., 2014), and the other two studies, similar to the present study, reported significant medium to large between-groups effects (Jeffcoat & Hayes, 2012; StaffordBrown & Pakenham, 2012). In addition, the mediation analysis in this present study confirmed the effect of the intervention on change in mindful awareness and showed the process to be an independent predictor of change in the main outcomes (see Section Discussion). This is interesting considering that mindfulness meditations in ACT interventions typically consume no more than a couple of minutes per day. These results can be compared to those of interventions such as Mindfulness-based Stress Reduction (MBSR) that include more intensive mindfulness meditations. Cavanagh et al. (2013), de Vibe et al. (2013), Flook, Goldberg, Pinger, Bonus, and Davidson (2013), Jennings, Frank, Snowberg, Coccia, and Greenberg (2013), Robins, Keng, Ekblad, and Brantley (2012), and Roeser et al. (2013) evaluated the effect of MBSR on mindful awareness in controlled studies in nonclinical settings and reported between-groups effects ranging from small to large. This indicates that the effects on mindful awareness in the present study and in other ACT interventions are comparable to those of interventions with more intensive mindfulness practice. Surprisingly, although experiential avoidance decreased during the intervention as indicated by significant between-group differences at post-intervention in both the ITT and the efficacy subset sample, the achieved levels were not sustained at follow-up. The group-by-time interaction was significant in the efficacy subset but not in the ITT sample. This might indicate that more participation is needed to benefit from the intervention. However this might also indicate that a subgroup of participants found the intervention beneficial and, therefore, continued to participate, whereas another subgroup did not find the intervention beneficial and chose to withdraw. A study design where participants are randomized to different levels of participation is needed to answer this question. In addition, although the mediation analysis confirmed the effect of the intervention on change in experiential avoidance, it did not show the process to be an independent predictor of change in the main outcomes in the efficacy subset (see Section Discussion). Impact of the intervention on main outcomes Increased acceptance of internal events and mindful awareness that enables more effective action-taking is assumed to decrease perceived stress, disengagement, and exhaustion. According to the meta-analysis by Öst (2014), in terms of the criteria for evidence based treatments established by the APA Division 12 Task Force, ACT is possibly efficacious for work stress. This means that there is “at least one good study showing the treatment to be efficacious in the absence of conflicting evidence” (p. 170; Öst, 2014). In this present trial, the second hypothesis was that the intervention would result in decreased stress and burnout. This was confirmed by results from the longitudinal analysis with the exception of burnout at the three-month follow-up where the between-groups effect was only significant for the efficacy subset. The mediation analysis showed that changes in perceived stress and burnout were mediated by changes in the process variables (although experiential avoidance was not an independent predictor of change in the efficacy subset), thus
14
E. Frögéli et al.
confirming the proposed processes of change. In addition, the intervention independently predicted change in perceived stress. This indicates that other processes that were not included in the models (e.g. values-based living, work-life balance, or attention from therapists) also contributed to the effect of the intervention on main outcomes. Future studies are needed to better understand these effects.
Downloaded by [New York University] at 02:45 18 June 2015
Methodological considerations Because this is a pilot study, additional trials are needed for validation of the results. This study has some important methodological shortcomings that need to be addressed. First, the small sample size and substantial attrition from the study limits the analyses and conclusions. Future studies should include larger samples because dropout is to be expected. Second, longer time and greater contact in the intervention condition (6 × 2 hours) compared to the control condition (2 × 3 hours) might have resulted in over-estimations of the true effects. Future studies should include a control condition comparable to the experimental condition in terms of time and contact. In addition, due to missing data on control subjects the level of participation could not be included in the analyses, and this confounds the interpretation of the results. Third, follow-up analyses at later points in time are needed to further evaluate the preventive effects of the intervention. Adding to that, group effects, therapist effects, and adherence to the protocol could not be accounted for in this study, and future studies should be designed to control for these possibly confounding effects. Conclusion This randomized controlled pilot study adds to the current literature on the effects of interventions targeting stress in nonclinical settings in general and among nursing students in particular. However, the results are preliminary and the shortcomings of this study should be addressed in future studies. In addition, important mediation analyses should be performed to evaluate the proposed processes of the intervention. Randomized controlled trials evaluating isolated behavioral therapy components in real-life settings in relation to stress and burnout would also be of great value in developing the most effective interventions. More knowledge about the specific stressors of nursing students would also benefit this development. Because students with high levels of stress and burnout report a lack of motivation, engagement, and competence (Rudman & Gustavsson, 2012), targeting these constructs could potentially further increase students’ resilience toward stress and burnout. In addition, because this intervention addresses stressors that are also common when entering the profession (Laschinger, Finegan, & Wilk, 2009; Rudman & Gustavsson, 2011), it should also be tested in that context. However, while increasing individual resilience might have great benefits, it is important not to overlook the crucial role of organizational factors as contributors to problems of stress in nursing. Interventions focusing on individual factors should be regarded as complements, not substitutes, to organizational measures. Acknowledgment The authors acknowledge AFA Insurance and the participating nursing students.
Disclosure statement No potential conflict of interest was reported by the authors.
Anxiety, Stress, & Coping
15
Funding This work was supported by AFA Insurance [grant number 070106], [grant number 140007].
Downloaded by [New York University] at 02:45 18 June 2015
References Biglan, A., Hayes, S. C., & Pistorello, J. (2008). Acceptance and commitment: Implications for prevention science. Prevention Science, 9, 139–152. doi:10.1007/s11121-008-0099-4 Brinkborg, H., Michanek, J., Hesser, H., & Berglund, G. (2011). Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial. Behaviour Research and Therapy, 49, 389–398. doi:10.1016/j.brat.2011.03.009 Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848. doi:10.1037/ 0022-3514.84.4.822 Byrd, D. R., & McKinney, K. J. (2012). Individual, interpersonal, and institutional level factors associated with the mental health of college students. Journal of American College Health, 60, 185–193. doi:10.1080/07448481.2011.584334 Cavanagh, K., Strauss, C., Cicconi, F., Griffiths, N., Wyper, A., & Jones, F. (2013). A randomised controlled trial of a brief online mindfulness-based intervention. Behaviour Research and Therapy, 51, 573–578. doi:10.1016/j.brat.2013.06.003 Cherniss, C. (1980). Professional burnout in human service occupations. New York, NY: Praeger Press. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396. doi:10.2307/2136404 de Vibe, M., Solhaug, I., Tyssen, R., Friborg, O., Rosenvinge, J. H., Sorlie, T., & Bjorndal, A. (2013). Mindfulness training for stress management: A randomised controlled study of medical and psychology students. BMC Medical Education, 13, 107. doi:10.1186/1472-6920-13-107 Deary, I. J., Watson, R., & Hogston, R. (2003). A longitudinal cohort study of burnout and attrition in nursing students. Journal of Advanced Nursing, 43(1), 71–81. doi:10.1046/j.1365-2648.2003.02674.x Edwards, D., Burnard, P., Bennett, K., & Hebden, U. (2010). A longitudinal study of stress and selfesteem in student nurses. Nurse Education Today, 30(1), 78–84. doi:10.1016/j.nedt.2009.06.008 Eskin, M., & Parr, D. (1996). Introducing a Swedish version of an instrument measuring mental stress (Report No. 813). Stockholm: Department of Psychology, Stockholm University. Fitzmaurice, G. M., Laird, N. M., & Ware, J. H. (2011). Applied longitudinal analysis. Hoboken, NJ: Wiley. Flook, L., Goldberg, S. B., Pinger, L., Bonus, K., & Davidson, R. J. (2013). Mindfulness for teachers: A pilot study to assess effects on stress, burnout, and teaching efficacy. Mind, Brain, and Education, 7, 182–195. doi:10.1111/mbe.12026 Florin, A., & Wennman, C. (2010). Evaluation of the Avoidance and Fusion Questionnaire for Youth in an Swedish adult population (Unpublished thesis). Department of Psychology, Uppsala Universitet, Uppsala. Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. doi:10.1037/1040-3590.20.2.93 Gross, D., & Fogg, L. (2004). A critical analysis of the intent-to-treat principle in prevention research. Journal of Primary Prevention, 25, 475–489. doi:10.1023/B:JOPP.0000048113.77939.44 Hansen, E., Lundh, L. G., Homman, A., & Wangby-Lundh, M. (2009). Measuring mindfulness: Pilot studies with the Swedish versions of the Mindful Attention Awareness Scale and the Kentucky Inventory of Mindfulness Skills. Cognitive Behaviour Therapy, 38(1), 2–15. doi:10.1080/165060 70802383230 Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., … Niccolls, R. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35, 821–835. doi:10.1016/s0005-7894(04)80022-4 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.
Downloaded by [New York University] at 02:45 18 June 2015
16
E. Frögéli et al.
Hultell, D., & Gustavsson, J. P. (2010). A psychometric evaluation of the Scale of Work Engagement and Burnout (SWEBO). Work, 37, 261–274. doi:10.3233/wor-2010-1078 IBM Corp. Released. (2013). IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: Author. Jeffcoat, T., & Hayes, S. C. (2012). A randomized trial of ACT bibliotherapy on the mental health of K12 teachers and staff. Behaviour Research and Therapy, 50, 571–579. doi:10.1016/j.brat.2012.05.008 Jennings, P. A., Frank, J. L., Snowberg, K. E., Coccia, M. A., & Greenberg, M. T. (2013). Improving classroom learning environments by Cultivating Awareness and Resilience in Education (CARE): Results of a randomized controlled trial. School Psychology Quarterly, 28, 374–390. doi:10.1037/ spq0000035 Lachin, J. M. (2000). Statistical considerations in the intent-to-treat principle. Controlled Clinical Trials, 21, 167–189. doi:10.1016/s0197-2456(00)00046-5 Laschinger, H. K., Finegan, J., & Wilk, P. (2009). New graduate burnout: The impact of professional practice environment, workplace civility, and empowerment. Nursing Economics, 27, 377–383. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20050488 Livheim, F., Hayes, L. J., Ghaderi, A., Magnusdottir, T., Högfeldt, A., Rowse, J., … Tengström, A. (2014). The effectiveness of acceptance and commitment therapy for adolescent mental health: Swedish and Australian pilot outcomes. Journal of Child and Family Studies, 24, 1016–1030. doi:10.1007/s10826-014-9912-9 MacKinninon, D. P. (2008). Introduction to statistical mediation analysis. New York, NY: Taylor & Francis. McEwen, B. S., & Gianaros, P. J. (2011). Stress- and allostasis-induced brain plasticity. Annual Review of Medicine, 62, 431–445. doi:10.1146/annurev-med-052209-100430 Montori, V. M., & Guyatt, G. H. (2001). Intention-to-treat principle. Canadian Medical Association Journal, 165, 1339–1341. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11760981 Muthén, L. K., & Muthén, B. O. (1998–2014). Mplus user’s guide (7th ed.). Los Angeles, CA: Author. Nerdrum, P., Rustøen, T., & Helge Rønnestad, M. (2009). Psychological distress among nursing, physiotherapy and occupational therapy students: A longitudinal and predictive study. Scandinavian Journal of Educational Research, 53, 363–378. doi:10.1080/00313830903043133 Öst, L. G. (2014). The efficacy of acceptance and commitment therapy: An updated systematic review and meta-analysis. Behaviour Research and Therapy, 61, 105–121. doi:10.1016/j. brat.2014.07.018 Pennbrant, S., Nilsson, M. S., Ohlen, J., & Rudman, A. (2013). Mastering the professional role as a newly graduated registered nurse. Nurse Education Today, 33, 739–745. doi:10.1016/j.nedt.2012.11.021 Robins, C. J., Keng, S. L., Ekblad, A. G., & Brantley, J. G. (2012). Effects of mindfulness-based stress reduction on emotional experience and expression: A randomized controlled trial. Journal of Clinical Psychology, 68(1), 117–131. doi:10.1002/jclp.20857 Roeser, R. W., Schonert-Reichl, K. A., Jha, A., Cullen, M., Wallace, L., Wilensky, R., … Harrison, J. (2013). Mindfulness training and reductions in teacher stress and burnout: Results from two randomized, waitlist-control field trials. Journal of Educational Psychology, 105, 787–804. doi:10.1037/a0032093 Rudman, A., & Gustavsson, J. P. (2011). Early-career burnout among new graduate nurses: A prospective observational study of intra-individual change trajectories. International Journal of Nursing Studies, 48, 292–306. doi:10.1016/j.ijnurstu.2010.07.012 Rudman, A., & Gustavsson, J. P. (2012). Burnout during nursing education predicts lower occupational preparedness and future clinical performance: A longitudinal study. International Journal of Nursing Studies, 49, 988–1001. doi:10.1016/j.ijnurstu.2012.03.010 Rudman, A., Omne-Ponten, M., Wallin, L., & Gustavsson, J. P. (2010). Monitoring the newly qualified nurses in Sweden: The Longitudinal Analysis of Nursing Education (LANE) study. Human Resources for Health, 8, 10. doi:10.1186/1478-4491-8-10 Schaufeli, W. B., Leiter, M. P., & Maslach, C. (2009). Burnout: 35 years of research and practice. Career Development International, 14, 204–220. doi:10.1108/13620430910966406 Stafford-Brown, J., & Pakenham, K. I. (2012). The effectiveness of an ACT informed intervention for managing stress and improving therapist qualities in clinical psychology trainees. Journal of Clinical Psychology, 68, 592–513. doi:10.1002/jclp.21844 Timmins, F., & Kaliszer, M. (2002). Aspects of nurse education programmes that frequently cause stress to nursing students – Fact-finding sample survey. Nurse Education Today, 22, 203–211. doi:10.1054/nedt.2001.0698
Anxiety, Stress, & Coping
17
Downloaded by [New York University] at 02:45 18 June 2015
Vollestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness- and acceptance-based interventions for anxiety disorders: A systematic review and meta-analysis. British Journal of Clinical Psychology, 51, 239–260. doi:10.1111/j.2044-8260.2011.02024.x Watson, R., Deary, I., Thompson, D., & Li, G. (2008). A study of stress and burnout in nursing students in Hong Kong: A questionnaire survey. International Journal of Nursing Studies, 45, 1534–1542. doi:10.1016/j.ijnurstu.2007.11.003 World Medical Association (Producer). (2014). WMA declaration of Helsinki – Ethical principles for medical research involving human subjects. Retrieved from http://www.wma.net/en/30pub lications/10policies/b3/
