| BackgroundPresent studies have shown that nurses are at high risk for anxiety and depression symptoms,especially since the outbreak of COVID-19 pandemic,nurses are faced with a variety of challenges,such as increased workload and shift frequency,high risk of infection,and serious shortage of health care workers,these make their anxiety and depression symptoms more severe.Serious anxiety and depression symptoms not only endanger nurses’ own health and affect their work status,but also have adverse impacts on patient safety.Therefore,it is of great significance to improve the anxiety and depression symptoms of nurses to maintain their own good health and working state and to ensure the safety of patients.As the most representative psychobehavioral therapy in the third generation of cognitive behavioral therapy,Acceptance and Commitment Therapy(ACT)has been widely used in recent years to relieve anxiety and depression symptoms of various populations,and has shown significant improvement.This suggests that ACT may be a viable option to intervene with anxiety and depression symptoms in nurses.In addition,compared with traditional face-to-face interventions,digital interventions,which refer to interventions carried out through social media,mobile applications,websites,phone calls and text messages,have many unique advantages and may be more suitable for the characteristics of nurses’ careers.However,it is still unclear how effective Digital Acceptance and Commitment Therapy(DACT)intervention is in improving anxiety and depression symptoms in nurses,and by which intervention mechanism it works.Study1 To develop a DACT intervention program on anxiety and depression symptoms in nursesObjectivesTo develop a DACT intervention program on anxiety and depression symptoms in nurses.Methods(1)Preliminary development of DACT program:based on the relational framework theory and mindful coping theory,combined with the professional characteristics of nurses,referring to the two ACT intervention reference books to construct a DACT intervention program for anxiety and depression in nurses.(2)Delphi method:select experts in the relevant field to revise the draft intervention program.SPSS 26.0 was used for descriptive analysis,and the evaluation indexes included expert positive coefficient,expert authority coefficient,concentration degree of expert opinions and coordination degree of expert opinions.(3)Pre-experiment:based on its own pre-post control design,descriptive analysis and paired-samples t-test were performed using SPSS 26.0.The primary evaluation indicators included feasibility(recruitment rate,adherence and questionnaire completion rate)and acceptability(open feedback evaluation),and the secondary evaluation indicators were the improvement effects of nurses’anxiety and depression symptoms before and after the intervention.Results(1)DACT intervention program for nurses with anxiety and depression symptoms:the final DACT intervention program consisted of five modules,with a total intervention duration of five weeks,one module per week,and each module includes thematic courses(15-30min video)and homework(worksheet exercises and mindfulness exercises).The five-module intervention themes are:Understanding ACT,observing your mind,mindful living,identifying what matters most and doing what is important.The intervention medium was the Rain Classroom WeChat mini program.(2)Delphi method:a total of 10 experts in related fields were invited for two rounds of correspondence consultation.The positive coefficient of experts was 100%,the judgment coefficient of experts was 0.95,the familiarity of experts was 0.79,and the authority coefficient of experts was 0.87.(3)Pre-experiment:10 nurses who met the inclusion and exclusion criteria participated.Feasibility results:the recruitment rate was 83.3%,the adherence was 70%,and the questionnaire completion rate was 100%.Acceptability results:70%of participants expressed satisfaction with this intervention course.The results of the paired t-test showed that there was no significant difference in the improvement effect of anxiety and depression symptoms before and after the intervention.Conclusions(1)All evaluation indexes of the Delphi were high,suggesting that the DACT intervention program for nurses’ anxiety and depression symptoms was scientific.(2)The pre-experimental results showed that the program has good feasibility and acceptability,however,the improvement effect of DACT on nurses’ anxiety and depression symptoms still needs to be further explored in a larger sample.Study 2 To test the effect of DACT intervention on anxiety and depression symptoms in nursesObjectivesA randomized controlled trial was used to investigate the effect of DACT intervention on primary outcomes(anxiety,depression symptoms)and secondary outcomes(sleep quality,job burnout,work performance)of nurses.MethodsUsing a randomized controlled trial design,nurses with anxiety symptoms or depression symptoms(GAD-7≥5 or PHQ-9≥5)within the last two weeks were recruited nationwide through a combination of online and offline methods from April to August 2022 and randomized to the DACT group and the waiting control group.The intervention course was an online course based on the Rain Classroom WeChat app and of a total duration of 5 weeks(5 units).The primary outcomes of this study were anxiety and depression symptoms,which were assessed using the GAD-7 and PHQ-9 at six time points:baseline,weekly(immediately after the course in weeks 2,3,and 4),post-test(immediately after the course),and follow-up(3 months after intervention).Secondary outcomes were sleep quality,burnout,and job performance,which were assessed using the Pittsburgh Sleep Quality Index Scale,Maslach burnout inventor,and the Work Performance Scale only before,immediately after,and three months after the intervention.SPSS 26.0 was used for statistical analysis,two sides α=0.05 was considered statistically significant.According to the principle of intention-to-treat analysis,the generalized estimating equation(GEE)was used to evaluate the effect of intervention.Results(1)Recruitment process:505 nurses were recruited in this study,and 145 were randomized,including 72 in the intervention group and 73 in the control group.The dropout rate immediately after and three months after intervention were 8.28%(12/145)and 11.03%(16/145),respectively.The dropout rate during total follow-up(dropout at any measurement time point)was 24.83%(36/145).There was no significant difference in baseline general data between missed and unmissed samples(all P>0.05).(2)Baseline data:Nurses who underwent randomization had a mean age of 35.36±7.22 years at baseline and 97.24%were female.There was no significant difference in baseline general data between the DACT group and the waiting control group(all P>0.05).(3)Intervention completion:in the DACT group,62 individuals completed at least half(3 sessions)of the courses,and 53 individuals completed all the courses,with an intervention completion rate of 73.61%(53/72).(4)The intervention effect of DACT on the primary outcome of nurses(anxiety and depression symptoms).1)GEE analysis of anxiety symptoms:the main effect of group,the main effect of time,and the interaction effect of time × group were statistically significant(Waldχ2=5.66,P=0.017;Waldχ2=61.36,P<0.001;Waldχ2=20.50,P=0.001).The results of the comparison between groups at each time point showed that anxiety symptom scores of the control group were higher than those of the DACT intervention group immediately after intervention(mean difference=2.57,P<0.001)and 3 months after intervention(mean difference=2.34,P=0.002),and the difference was statistically significant.2)GEE analysis of depression symptoms:the main effect of the group,the main effect of time,and the interaction effect of time × group were statistically significant(Waldχ2=6.95,P=0.008;Waldχ2=401.03,P<0.001;Waldχ2=21.29,P=0.001).The results of comparison at each time point showed that depression symptom scores in the control group were higher than those in the DACT group at the fourth week of intervention(mean difference=1.51,P=0.007),immediately after intervention(mean difference=2.74,P=0.001)and at 3 months after intervention(mean difference=3.26,P<0.001),and the difference was statistically significant.(5)The intervention effect of DACT on secondary outcomes(sleep quality,job burnout and work performance).1)GEE analysis of sleep quality:the main effect of group,the main effect of time and the interaction effect of time × group were statistically significant(Waldχ2=14.24,P<0.001;Waldχ2=37.91,P<0.001;Waldχ2=30.76,P<0.001).The results showed that the sleep quality scores of the control group were higher than those of the DACT group immediately after intervention(mean difference=2.11,P=0.001)and 3 months after intervention(mean difference=2.50,P<0.001),and the difference was statistically significant.2)GEE analysis of burnout:the main effect of group,the main effect of time and the interaction effect of time × group were statistically significant(Waldχ2=5.25,P=0.022;Waldχ2=17.92,P<0.001;Waldχ2=10.53,P=0.005).The results of comparison between groups at each time point showed that the burnout score of control group was higher than those of the DACT group immediately after intervention(mean difference=8.23,P=0.023)and 3 months after intervention(mean difference=11.80,P=0.001),and the difference was statistically significant.3)GEE analysis of work performance:the main effect of group and the interaction effect of time × group were statistically significant(Waldχ2=4.08,P=0.043;Waldχ2=8.46,P=0.015).The results of the comparison between groups at each time point showed that the control group had lower work performance scores than the DACT intervention group only at 3 months postintervention(mean difference=-3.44,P=0.015),and the difference was statistically significant.Conclusions(1)The dropout rates in this study ranged from 8.28%to 24.83%,and the DACT intervention completion rate was 73.61%.(2)The DACT intervention not only significantly improved nurses’ anxiety and depression symptoms immediately after the intervention,but also maintained this improvement effect three months after the intervention.(3)The DACT intervention significantly improved nurses’ sleep quality and burnout,and work performance.Study3 To explore the mechanism of DACT on anxiety and depression symptoms in nursesObjectivesMediation analysis was used to explore the potential psychological mechanism of DACT intervention on the improvement of anxiety and depression symptoms in nurses.MethodsBased on a randomized controlled trial in Study 2,this study only focused on changes in participants’ mediating and outcome variables before and after intervention.According to the hexagonal treatment model of ACT,psychological flexibility,cognitive defusion,mindfulness,and value were selected as mediating variables,and were measured at baseline,immediately after intervention.Model 4 in the PROCESS plug-in was used to test the mediation effect of the mechanism variables.The residual change scores of each mechanism and outcome variable were calculated based on the linear regression model to represent the changes of individual mechanism and outcome variables before and after intervention,and the residual change score was used as the mediating variable and outcome variable respectively for mediation analysis.The bias-corrected nonparametric percentile Bootstrap method(n=5000)was used to test for mediating effects,and a significant mediating effect was implied if the 95%CI of the mediating effect did not contain 0.Results(1)Anxiety symptom residuals were used as outcome variables:Bootstrap test results of the mediation analysis showed that the mediation effects of psychological flexibility residual,cognitive defusion residual,value progression dimension residual and value obstacle dimension residual were significant,and their respective mediation effects were-0.267(95%CI:-0.447～0.984),-0.343(95%CI:-0.554～-0.161),-0.142(95%CI:-0.326～-0.028),-0.141(95%CI:0.299～-0.036).However,the mediation effect of mindfulness residuals was not significant,which was-0.137(95%CI:-0.273～0.001).(2)Depression symptom residuals were used as outcome variables:Bootstrap test results of mediation analysis showed that the mediation effects of psychological flexibility residuals,cognitive defusion residuals,value progression residuals and value obstacle residuals were all significant,and their respective mediating effects were-0.231(95%CI:-0.431～-0.074),-0.245(95%CI:-0.400～-0.115),0.163(95%CI:-0.357～-0.035),0.127(95%CI:-0.287～-0.022).However,the mediation effect of mindfulness residual was not significant,which was-0.113(95%CI:-0.258～0.000).Conclusions(1)Changes in psychological flexibility,cognitive defusion and values were mediating variables in the effect of DACT on nurses’ anxiety symptoms.(2)Changes in psychological flexibility,cognitive defusion and values were mediating variables in the effect of DACT on nurses’ depression symptoms. |
PDF Full Text Request