- Burnout has become a global crisis, particularly among healthcare professionals.
- One potential solution may be interventions that focus on promoting psychological flexibility, such as ACT.
- Several recent reviews found that ACT-based interventions reduced emotional distress and job-related stress.
- Such interventions may be especially valuable to early-career healthcare professionals.
The COVID-19 pandemic and its aftermath have intensified the global crisis of stress and burnout in healthcare professionals, escalating this issue into an urgent concern. Numerous studies (e.g., Lluch et al., 2022; Alanazi et al., 2022; Maunder et al., 2021) suggest that healthcare workers are suffering from elevated rates of psychological distress, including depression, anxiety, burnout, and post-traumatic stress disorder (PTSD).
Burnout has reached alarmingly high levels among healthcare professionals in the United States, with over one-half of physicians and one-third of nurses experiencing symptoms (Reith, 2018). This trend has led a significant proportion of healthcare professionals to consider leaving their profession, contributing to the projected shortage of 18 million healthcare workers by 2030 (WHO, 2016).
What’s more, continuing to work despite burnout can potentially lead to medical errors and seriously compromise the quality of patient care. A well-known summary of recent research indicated a 50 percent higher prevalence of medication errors among healthcare workers experiencing burnout symptoms compared to those without (Tawfik et al., 2018).
The Power of Psychological Flexibility
In response to these escalating mental health issues, one potential solution to these concerns may be interventions focused on promoting psychological flexibility. These include acceptance and commitment training, or ACT (Hayes et al., 2006), a mindfulness-based therapy that strives to enhance psychological flexibility, empowering individuals to modify their behaviour in alignment with their values and aspirations, even amidst challenging circumstances (Bond et al., 2000).
Psychological flexibility is a comprehensive tool for understanding and managing stress, helping individuals to engage with their experiences more fully, accept difficult emotions, clarify their values, and take effective action. Through the development of psychological flexibility, individuals can hopefully better navigate life's challenges and reduce their experience of stress.
In a work environment, psychological flexibility implies remaining present in the moment (Kashdan & Rottenberg, 2010), finding ways to step back from thoughts that lead to worry and rumination (Hayes et al., 1999), distancing oneself from unhelpful judgments (Harris, 2006), and making decisions that resonate with personal values (Bond & Bunce, 2000).
Myself, Chris Graham, Daryl O’Connor, and other colleagues conducted a comprehensive systematic review and meta-analysis of 10 articles where we tested the efficacy of ACT-based interventions in mitigating overall distress and job-related stress in healthcare professionals worldwide. We found that ACT interventions positively impacted psychological distress and job-related stress, outperforming control conditions.
Moreover, the study also showed that longer interventions may have a greater impact. The size of the beneficial effect of ACT increased with a larger number of treatment sessions. However, we cautioned that the general quality of studies included in the meta-analysis was not always high.
More recently, myself, Graham, Flaxman, O’Connor, and other colleagues conducted a randomised controlled trial to investigate the effectiveness of a workplace ACT intervention in improving psychological distress among healthcare staff in the UK. This was the first evaluation that aimed also to test whether there was an impact on safe practice in medical and non-medical UK healthcare staff.
The evaluation included assessing psychological flexibility, providing insight into the most effective treatment processes for improving psychological distress and perceived patient safety, and reducing burnout in healthcare staff. The ACT training delivered in four 2-hour sessions was found to be an effective intervention for improving psychological distress and burnout (cognitive weariness) in a range of healthcare staff, including general practitioners, nurses, clinical psychologists, and managers.
Mindfulness, values, and self-compassion were found to be the most influential processes and explained the improvements in psychological distress and in the cognitive weariness component of burnout. Reductions in psychological distress also resulted in an indirect improvement in perceived safe practice, as reported by practitioners who took part in the programme.
We also conducted a final study to explore the predictive influences of psychological flexibility (mindfulness and values) and self-compassion on psychological distress, burnout, and patient practices in healthcare professionals in the UK. This was the first study to explore the association between patient safety and psychological flexibility processes.
This study found that practitioners who reported unsafe practices presented with higher avoidance and a decreased ability to be non-judgmental (two important components of mindfulness). We also found that mindfulness practice could be augmented with value-based exercises (activities or practices aimed at helping individuals identify, understand, and align their behaviours with their personal values such as value identification or clarification or value-action alignment) leading to greater improvements in psychological distress and reduced physical fatigue, suggesting that mindfulness-based programmes delivered in the workplace could be enhanced by including a values-based behavioural activation component. In this study, self-compassion was found related to emotional exhaustion after both mindfulness and values were included in the models, suggesting that ACT programmes for healthcare staff could benefit from the explicit inclusion of strategies designed to cultivate self-compassion.
Overall, the findings from these studies support the notion that ACT-based interventions can help healthcare workers around the world manage stress more effectively and enhance their overall well-being, leading to improved patient care. Future studies should prioritise high-quality trials, consider patient safety as an important outcome, and incorporate self-compassion principles and practices into their protocols.
What Healthcare Workers Can Do
There are practical steps that healthcare workers like doctors and nurses can take, particularly at the start of their careers. Participating in training programmes that teach mindfulness, understanding of personal values, and self-compassion can be beneficial. For instance, enrolling in an ACT training programme could help equip new healthcare workers with the mental tools needed to handle the pressures and challenges of their jobs.
For those who are more experienced or already stressed and working long shifts, finding time for such programmes can be tough. If they share these struggles with their managers, it may encourage more open conversations about well-being and work fatigue. This could also help in adjusting the training programmes into different formats, making it easier for more people to join in.
On the patient side, the results of these studies show that a mindfulness training programme for staff could also improve patient safety. Feedback from a general practitioner who underwent such a programme suggests that the skills learned can be applied in treating patients.
Teaching healthcare workers psychological techniques to handle patients' mental health challenges could give them extra skills to manage difficult situations. Research shows that these mindfulness skills can be learned equally well whether they're taught by fellow clinicians or non-clinicians. If these mindfulness programmes were made more widely available to all staff in the healthcare system, they could also help combat the overall fatigue resulting from the ongoing pandemic.
Overall, the findings of these studies also suggest that healthcare workers who report that their practice is safe showed higher levels of acceptance, non-judgment, and work-related worry. This is an important finding. It indicates that mindfulness-based programmes aimed specifically at patient safety should perhaps include more techniques focused on promoting acceptance, reducing non-judgment, and managing reactivity, rather than just monitoring attention.
Alanazi, T. N. M., McKenna, L., Buck, M., & Alharbi, R. J. (2022). Reported effects of the COVID-19 pandemic on the psychological status of emergency healthcare workers: A scoping review. Australasian emergency care, 25(3), 197-212.
Bond, F. W., & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5(1), 156-163. https://doi.org/10.1037/1076-8922.214.171.124
Harris, R. (2006). Embracing your demons: An overview of acceptance and commitment therapy. Psychotherapy in Australia, 12(4), 2-8.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2006). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.
Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30(7), 865-878. https://doi.org/10.1016/j.cpr.2010.03.001
Lluch, C., Galiana, L., Doménech, P., & Sansó, N. (2022). The impact of the COVID-19 pandemic on burnout, compassion fatigue, and compassion satisfaction in healthcare personnel: a systematic review of the literature published during the first year of the pandemic. In Healthcare (Vol. 10, No. 2, p. 364). MDPI.
Maunder, R. G., Heeney, N. D., Hunter, J. J., Strudwick, G., Jeffs, L. P., Ginty, L., ... & Wiesenfeld, L. A. (2022). Trends in burnout and psychological distress in hospital staff over 12 months of the COVID-19 pandemic: a prospective longitudinal survey. Journal of Occupational Medicine and Toxicology, 17(1), 1-11.
Prudenzi, A., Graham, C. D., Clancy, F., Hill, D., O'Driscoll, R., Day, F., & O'Connor, D. B. (2021). Group-based acceptance and commitment therapy interventions for improving general distress and work-related distress in healthcare professionals: A systematic review and meta-analysis. Journal of Affective Disorders, 295, 192-202.
Prudenzi, A., D. Graham, C., Flaxman, P. E., & O’Connor, D. B. (2022). Wellbeing, burnout, and safe practice among healthcare professionals: predictive influences of mindfulness, values, and self-compassion. Psychology, Health & Medicine, 27(5), 1130-1143.
Prudenzi, A., Graham, C. D., Flaxman, P. E., Wilding, S., Day, F., & O’Connor, D. B. (2022). A workplace Acceptance and Commitment Therapy (ACT) intervention for improving healthcare staff psychological distress: A randomised controlled trial. PLoS One, 17(4), e0266357.
Reith, T. P. (2018). Burnout in United States healthcare professionals: a narrative review. Cureus, 10(12).
Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., Tutty, M. A., West, C. P., & Shanafelt, T. D. (2018). Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clinic Proceedings, 93(11), 1571-1580. https://doi.org/10.1016/j.mayocp.2018.05.014
World Health Organization. (2016). Global strategy on human resources for health: Workforce 2030. https://www.who.int/hrh/resources/global_strategyHRH.pdf