ACT-based Stress Management Training Aimed at Improving Workers’ Mental Health in an Intensive Care Unit: A Mixed Methods Study

Abstract

This study aimed to explore whether an acceptance and commitment (ACT) approach to stress management training improved the levels of depression, anxiety, and stress among a group of twenty-two health professionals from an intensive care unit. Questionnaires were administered before and after training, and follow-up was carried out one month after training, including semi-structured interviews with nine participants. The results reflected that the quasi-experimental group reduced their depression and stress levels significantly and showed improvements in stress in the follow-up. A qualitative thematic analysis of interviews showed that nurses were seeking a tool that would help them to cope more effectively with stressful situations and increase their knowledge of stress management. The themes in the professionals’ comments claimed specific improvements in their health, well-being, relationships, and psychological processes. In
conclusion, ACT-based trainings offer a possible framework for mental health promotion in health care organizations.

Full text

Intensive care units (ICUs) are stressful environments in which
pain and human suffering are often experienced alongside great
pressure and temporary urgency to perform work (van Mol et al.,
2015). In these cases, health professionals are subject to extreme
stress and work overload, and are often exposed during their work
to occupational risk factors that have the potential to affect their
mental health and psychological well-being over time (Gómez-
Martínez et al., 2015). In fact, the literature has shown that, within
ICUs, professionals may experience psychological problems such as
burnout, stress, anxiety, and depression (Gómez-Martínez et al., 2015;
van Mol et al., 2015). Nevertheless, many health professionals do not
benefit from interventions introduced by psychology professionals
in their organizations to improve their levels of mental health and
psychological well-being, which could have serious consequences for
workers, patients, and organizations (Bond et al., 2010; Waters et al.,
2018).
Psychosocial interventions to reduce stress and increase
workers’ well-being can take two main forms (Van der Klink et al.,
Clínica y Salud (2021) 32(3) 111-117
Funding: This work was supported by I+D+I National Project of the Ministerio de Ciencia e Innovación (PID2019-106368GB-I00) AEI/10.13039/501100011033.
Correspondence: luismanuel.blanco@uam.es. (L. M. Blanco-Donoso).
Cite this article as: Blanco-Donoso, L. M., Garcia-Rubio, C., Gallardo, J. A., Pereira, G., Rodríguez de la Pinta, M. L., Rubio, J. J., and Garrosa, E. (2021). ACT-based stress management
training aimed at improving workers’mental health in an intensive care unit: A mixed methods study.
Clínica y Salud, 32
(3), 111-117. https://doi.org/10.5093/clysa2021a12
ISSN:1130-5274/© 2021 Colegio Oficial de la Psicología de Madrid. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Clínica y Salud
https://journals.copmadrid.org/clysa
ACT-based Stress Management Training Aimed at Improving Workers’ Mental
Health in an Intensive Care Unit: A Mixed Methods Study1
Primer Premio de la XVII edición del Premio de Psicología Aplicada “Rafael Burgaleta” 2020
Luis M. Blanco-Donosoa, Carlos Garcia-Rubioa, Juan A. Gallardob, Gladis Pereiraa, María L. Rodríguez de la Pintac,
Juan J. Rubioc, and Eva Garrosaa
a
Autonomous University of Madrid, Spain;
b
National Autonomous University of Mexico, Mexico;
c
Puerta de Hierro Hospital, Madrid, Spain
ARTICLE INFO
Article history:
Received 22 November 2020
Accepted 15 March 2021
Available online 28 May 2021
Keywords:
Acceptance and commitment
training
Depression
Stress
Mixed methods design
Health-care workers
ABSTRACT
This study aimed to explore whether an acceptance and commitment (ACT) approach to stress management training
improved the levels of depression, anxiety, and stress among a group of twenty-two health professionals from an intensive
care unit. Questionnaires were administered before and after training, and follow-up was carried out one month after
training, including semi-structured interviews with nine participants. The results reflected that the quasi-experimental
group reduced their depression and stress levels significantly and showed improvements in stress in the follow-up. A
qualitative thematic analysis of interviews showed that nurses were seeking a tool that would help them to cope more
effectively with stressful situations and increase their knowledge of stress management. The themes in the professionals’
comments claimed specific improvements in their health, well-being, relationships, and psychological processes. In
conclusion, ACT-based trainings offer a possible framework for mental health promotion in health care organizations.
Entrenamiento en el manejo del estrés laboral basado en TAC dirigido a la mejora de
la salud mental de trabajadores de una UCI médica: un estudio con método mixto
RESUMEN
Este estudio tiene como objetivo explorar si un enfoque de aceptación y compromiso (TAC) para el entrenamiento en el manejo
del estrés mejora los niveles de depresión, ansiedad y estrés en un grupo de 22 profesionales de la salud de una unidad de
cuidados intensivos. Los cuestionarios se administraron antes y después del entrenamiento y el seguimiento se llevó a cabo
un mes después del mismo, incluyendo entrevistas semiestructuradas con 9 de los participantes. Los resultados reflejaron
que el grupo cuasiexperimental redujo sus niveles de depresión y estrés significativamente y mejoró el estrés durante el
seguimiento. Un análisis temático cualitativo de las entrevistas mostró que los profesionales de enfermería buscaban una
herramienta que les ayudara a hacer frente más eficazmente a las situaciones de estrés aumentando el conocimiento en su
manejo. Los comentarios de los profesionales reflejaban mejoras específicas en su salud, bienestar, relaciones y procesos
psicológicos. En conclusión, los entrenamientos basados en TAC ofrecen un posible marco para mejorar la salud mental en
las organizaciones de atención médica.
Palabras clave:
Entrenamientos en terapias de
aceptación y compromiso
Depresión
Estrés
Diseño de métodos mixtos
Trabajadores de la salud

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L. M. Blanco-Donoso et al. / Clínica y Salud (2021) 32(3) 111-117
2001): interventions which redesign the job or task to reduce the
workload and pressure faced by workers, or providing them with
greater autonomy and support at work, and interventions which
provide workers with the necessary skills and resources to cope
with stress. These two complementary types of interventions should
not be mutually exclusive. Sources of stress in certain occupations
are, to some extent, inherent and unavoidable (e.g., contact with
pain and death within the health care professions); hence, training
professionals to develop emotional coping strategies can be important
in such a professional context (Bond et al., 2010; García et al., 2018).
Regarding the second type of intervention, stress management
training (SMT) is the most well-known approach (Van der Klink et
al., 2001); it is based mainly on cognitive-behavioral techniques
and its effectiveness has been widely demonstrated by various
meta-analyses (for example Tetrick & Winslow, 2015). SMT provides
workers with tools for identifying dysfunctional thoughts (and
replacing them with more adaptive ones), improving their social and
communication skills, engaging in problem solving and developing
techniques that help them to relax when facing stress.
Within this context, one type of SMT that is attracting increasing
interest among researchers and clinicians is training based on
acceptance and commitment therapy (ACT; Flaxman et al., 2013).
ACT is part of a larger group of cognitive-behavioral therapies, called
third generation or contextual therapies (Hayes et al., 2012), and is
based on a functional contextual perspective derived from behavioral
principles and extended through relational framework theory. ACT
argues that people’s emotional and psychological distress can be
explained not so much by the negative content or frequency of their
internal psychological experiences, but by how they relate to difficult
experiences when they arise (e.g., unpleasant thoughts, emotions,
sensations, or memories; Bond et al., 2010). Mental health problems,
such as depression or anxiety, may be caused by psychological
processes such as attentional rigidity (i.e., not being able to direct
one’s attention to what is happening in the present since attention is
focused on remembering past events or anticipating future events);
avoidance of negative psychological experiences (i.e., devoting
energy to controlling or eliminating negative emotions, feelings, or
thoughts, due to avoidance); or lack of action by the person based
on his or her personal values (i.e., behavior being governed and
regulated by adverse mental content, rather than by contingencies of
the present situation and an individual’s personal values and goals;
Hayes et al., 2012). The ultimate aim of ACT training is therefore to
teach people to pay attention to, and engage with, experiences in the
present moment, relate to their negative internal events with greater
acceptance, and commit to actions that are directed toward their
personal values and goals. ACT aims to generate greater psychological
flexibility in individuals (Hayes et al., 2012; Waters et al., 2018).
Psychological flexibility can be understood as the ability to focus on
the situation one is experiencing in the present and, depending on the
opportunities offered to the person by that situation with reference
to his or her personal values and goals, to take action toward them,
even in the presence of negative internal events (Lloyd et al., 2013).
Interest in this therapy has been growing over the past two
decades and it is already considered to be “possibly efficacious”
for the management of depression, anxiety, and stress at work
(Öst, 2014). In fact, in the field of occupational psychology,
different empirical studies have shown the ability of these ACT
interventions to improve workers’ mental health (Macias et al.,
2019), their resistance to burnout and their psychological well-
being (Frögeli et al., 2016), and/or their personal psychological
flexibility and mindfulness (Frögeli et al., 2016; Waters et al., 2018).
In occupational fields such as health care jobs, these interventions
can help workers to cope with others’ human suffering and prevent
the development of certain psychosocial risks, such as burnout or
secondary traumatic stress and its consequences (Frögeli et al.,
2016; Ortega et al., 2008).
ACT training sessions for managing job stress are commonly short
(workshop format), group-based, and skill-building to fit workers’
organizational and task requirements (Bond et al., 2010; Waters et
al., 2018). In fact, the best-known format involves three face-to-face
sessions of approximately three hours (Flaxman et al., 2013). The brief
nature of this type of intervention is particularly valuable in health
care professions, and even more so in services such as intensive
care, since these require professionals to adapt to dynamic working
conditions (e.g., high staff turnover, sudden shift changes, and long
working days; García et al., 2018; Waters et al., 2018).
This study aims to contribute to the literature exploring the
effect of ACT-based training on mental health in an organizational
environment, and specifically within work contexts characterized
by high work demands, such as a ICUs. Despite the fact that
international studies have shown the value of such a training,
few studies in Spain have explored its effects (Blanco-Donoso et
al., 2017; Ortega et al., 2008); therefore, this study proposed to
explore the impact of ACT training on ICU workers. Specifically,
the study hypothesized that short ACT training sessions would
lead to improved levels of depression, anxiety, and perceived stress
among workers in an ICU in a Spanish tertiary hospital. In addition,
it hypothesized that this improvement would be attributable to
an increase in workers’ levels of psychological flexibility—one of
the core abilities emerging from ACT, which has been shown to
mediate changes in this type of intervention (Waters et al., 2018).
Method
Design
This research had a mixed methods design, using both
quantitative and qualitative methods. The quantitative component
involved a quasi-experimental pre- and post-intervention study
with two groups (quasi-experimental and waiting-list control
group). The participants in the waiting-list control group received
the intervention immediately after the quasi-experimental group
had completed it. Therefore, the quasi-experimental group was
evaluated on three occasions: before (baseline), after, and one
month after the intervention. However, the waiting-list control
group was assessed on four occasions: the first, concurrent with
the first assessment (baseline) of the quasi-experimental group;
the second, at the time of the second assessment of the quasi-
experimental group (to ensure the control condition); the third,
when this group also completed the intervention; and the fourth,
one month later, coinciding with the follow-up measurement of
the quasi-experimental group. Participants were not randomly
assigned to groups due to service restrictions. Specifically, the
groups were formed according to professionals’ work shifts, so that
the quasi-experimental group was made up of workers who had
morning shifts, while the waiting-list control group was made up
of workers on afternoon shifts.
Sample
Twenty-two medical and nursing professionals participated in
the training, most of whom were female nurses from the ICU of a
large public hospital (tertiary level) in Madrid Region, Spain. The
sample was therefore a non-probabilistic, convenience sample. The
only inclusion criterion was that practitioners gave their consent
to voluntarily participate in the study and be evaluated at various
points in time. There were no exclusion criteria. Table 1 shows so-
cio-professional characteristics of the participating sample. As can
be seen in Table 1, there were no significant differences in any so-
cio-professional variables between members of one group and the
other at the beginning of training. Initially, the quasi-experimental

113
ACT-based Stress Management Training in ICUs
group consisted of 14 participants and 13 completed the pre- and
post-measurement. The waiting-list control group was made up of
8 workers, all completing the pre and post measure while on the
waiting list status. However, when the waiting-list control group
conducted and completed the workshop, only 3 completed the post
measure. A total of 16 workers participated in the follow-up. Fina-
lly, 9 nurses agreed to attend the semi-structured interviews at this
phase of the study.
Procedure
First, the approval of the University’s Ethics Committee was
obtained [masked for review]. Thereafter, we contacted the
hospital’s Occupational Risk Prevention Service, which liaised with
the Intensive Care Medicine Service to offer training to its workers.
Unit supervisors informed their teams about the study, which they
advertised as training to help them manage stress in the work
environment. A week before the intervention, enrolled participants
from both groups were invited to a joint briefing about the study
and the intervention. This session was also used for participants to
complete baseline measurements. With regard to post-intervention
measurement (at the end of the workshop) and follow-up (after one
month), evaluation was carried out electronically, with participants
accessing an online questionnaire by means of a personal code.
When the intervention was completed, psychologists who conducted
it invited participants to attend face-to-face interviews (one month
after the intervention), during which they would be asked questions
about their experiences of the implemented program.
Intervention
The training used a group workshop format, with three sessions of
three hours duration each during a single working week (on alternate
days), but outside working hours. Intervention and interviews were
carried out by the first two authors of this paper, who are health
psychologists trained in ACT and have experience applying such
interventions in work environments. Training sessions followed the
format of standard ACT work manuals (e.g., Flaxman et al., 2013).
The first session identified workers’ stress responses, along with
their main causes, and identified emotional barriers that prevented
workers from achieving full and satisfying lives. Ineffectiveness
and long-term consequences of experiential avoidance were also
analyzed and psychological acceptance was offered as an alternative
strategy. During this session therapists investigated, dialogued with,
and confronted participants on these issues and used metaphors,
paradoxes, and experiential exercises according to standard ACT
practices. In addition, in this session mindfulness was introduced as
a way of achieving an attitude of acceptance toward negative internal
experiences in the present, and attention in breathing and body
scanning were practiced.
During the second session, therapists worked with professionals
on notions of context and cognitive defusion, again supported
by experiential exercises. They also worked on the clarification
workers’ personal objectives, goals, and values through dialogue,
group discussion, and relevant exercises. This session continued the
mindfulness practice to promote contact with the present moment,
and workers conducted meditation on their thoughts to facilitate
cognitive defusion.
Finally, in the third session, therapists again used metaphors and
experiential exercises to reinforce the material. Regarding the practice
of mindfulness, during the session, participants meditated on their
emotions, using self-compassion meditation that aimed to promote
an attitude of acceptance and self-care in the face of emotionally
difficult experiences.
During the three sessions, care was taken that all the examples
and discussions could be applied to both workers’ work and
personal environments. In addition, participants were encouraged
from the first day to carry out exercises at home during the week.
On the same day that participants attended the session, they
received an email containing all the material covered during the
session, together with an audio recording to help them to go deeper
into practice. Finally, throughout the week and during the follow-
up period, participants received messages on their mobile phones
to remind them and motivate them to practice activities at home.
Study Variables
Depression, anxiety, and stress. These factors were evaluated
using the Spanish version of the DASS-21 Scale (Daza et al., 2002),
which consists of 21 items to assess symptoms of depression (7 items;
Table 1. Socio-professional Characteristics of Participants
Quasi-experimental group Waiting-list control group Statistical value
p
Variable
N
%
MSD N
%
MSD
Age 41.36 9.19 48.88 8.90 -1.771.082
Gender
Female
Male
14
0
100
0
7
1
87. 5
12.5
1.8 32.176
Work Shift
Morning
Rotational
2
12
14.3
85.7
2
6
25.0
75.0
0.3932.531
Occupation
Nursing
Medicine
13
1
92.9
7.1
7
1
87. 5
12.5
0.177 2.674
Type of contract
Permanent
Contracted
Temporary
7
7
50
50
6
1
1
75.0
12.5
12.5
4.252.119
Supervisor
Yes
No
2
12
14.3
85.7
2
6
25.0
75.0
0.393 2 .531
Working hours/week 40.57 11.09 40.42 6.12 -0.371.743
Length of time in the hospital 9.78 7.85 12.12 12.73 -1.11 1.297
Seniority in the profession 14.57 8.40 19.87 10.07 -1.29 1 .212
Note
. 1Mann-Whitney
U
; 2chi-square test.
N
= 22.
*
p
< .05.

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L. M. Blanco-Donoso et al. / Clínica y Salud (2021) 32(3) 111-117
e.g., “In the last week, I felt sad and depressed”), anxiety (7 items; e.g.,
“In the last week, I was afraid for no reason”), and stress (7 items;
e.g., “In the last week, I felt very nervous”). The Likert-type response
scale ranged from 0 =
never
to 3 =
most of the time
. Cronbach’s alpha
values for this study were .85, .70, and .91 for depression, anxiety, and
stress, respectively.
Psychological flexibility. Psychological flexibility was evaluated
using the Spanish version of the AAQ-II questionnaire (Ruiz et al.,
2013 ). This questionnaire consists of 7 items (e.g., “My painful
memories prevent me from leading a full life”) and uses a Likert-
type response format ranging from 1 =
never true
to 7 =
always true.
Cronbach’s alpha values for this study was .90.
Semi-structured post-intervention interview. Three questions
were asked of each of the nine professionals who agreed to be inter-
viewed after the intervention: (1) “What was your motivation for
enrolling in the workshop?”, (2) “Has the workshop helped you in
any way?”, and (3) “Have you noticed any changes, since the work-
shop, in the way you relate to stress, to your negative emotions,
feelings, or thoughts, or to others in your work or personal life?”
Data Analysis
First, Mann-Whitney
U
and chi-square tests were performed
to determine whether there were differences between socio-
professional and dependent variables before starting the intervention.
To analyze the effect of the group on the change of dependent
variables, a covariance analysis (ANCOVA) was performed, using
partial eta squared statistic (ηp2) as an indicator of effect size. For
this indicator, values of .01, .06, and .14 indicated small, moderate,
and large effects, respectively (Olejnik & Algina, 2000). A non-
parametric test of Wilcoxon’s sign ranges was carried out to observe
changes before and after the intervention in each of the groups, and
to evaluate changes one month after the end of training in the total
set of participants attending follow-up. In this case,
r
values of. 10,
.30, and .50 were used to reflect small, medium, and large changes,
respectively (Cohen, 1988).
To analyze the indirect effect of the “psychological flexibility”
variable as an element by which change in dependent variables
could be produced, a simple mediation model was tested using a
bootstrapping procedure and the PROCESS macro for IBM® SPSS
Statistics 24 (model 4; Preacher & Hayes, 2008).
Semi-structured interviews were analyzed using a qualitative
methodology based on thematic analysis (Braun & Clarke, 2006).
This was carried out following the six-step procedure proposed
by Braun and Clarke (2006). Specifically, interviews were first
transcribed by one of the authors of this paper. At this point,
interview transcripts were read and re-read, noting main ideas. In
the second phase, carried out by two of the other authors of this
paper independently, interesting characteristics of data were coded
for the whole data set. Codes were then collected for potential
themes, which were identified, defined, compared, discussed,
and refined by researchers. Finally, vivid and clear extracts were
selected and analyzed in relation to research questions.
Results
Quantitative Analysis
Mann-Whitney
U
test (Table 2) revealed that both groups showed
no significant differences in dependent variables before the training
began.
Regarding the results of inter-group comparison, as also shown in
Table 2, results of the ANCOVA test revealed that training produced
significant changes of large magnitude in depression (
F
= 6.98,
p
< .05, ηp2 = .280) and perceived stress (
F
= 5.95,
p
< .05, ηp2 = .248)
variables, with decreased means for the quasi-experimental group
after training; however, there were no changes in either anxiety or
psychological flexibility of professionals. In fact, the latter variable
did not explain changes found in the depression and stress variables
as hypothesized, according to confidence intervals of the mediation
test (estimator = -0.0141,
SE
= 0.08 [0.239, 0.070] and estimator =
-0.0158,
SE
= 0.08 [-0.263, 0.100], respectively).
In terms of changes within both groups, the Wilcoxon test (see
Table 3) revealed that the quasi-experimental group significantly
decreased their levels of perceived stress after training (
z
= -2.24,
p
<
.05,
r
= .43)—a change of medium magnitude. The waiting-list control
group, while remaining in the waiting list condition, increased their
mean for depression (
z
= -2.55,
p
< .01,
r
= -.63), with a large effect size.
Later, when this group moved into training, no significant changes
were observed within the group.
One month after the training, participants in both groups who
completed the follow-up measure showed significant changes in the
Table 2. Means, Standard Deviations, Mann-Whitney
U
, and ANCOVA Results for the Variables
Group Mann-Whitney U (pre mean)
ANCOVA (post mean)
Quasi-experimental group Waiting-list control group
n
= 13
n
= 8
Variable
MDT MDT U F
ratio
gl
ηp2
Depression
Time 1 0.377 0.144 0.717 0.667 -1.860
Time 2 0.252 0.378 1.160 0.865 6.980* 10.280
Anxiety
Time 1 0.663 0.425 0.678 0.462 -0.079
Time 2 0.461 0.463 0.678 0.570 1.330 10.069
Stress
Time 1 1.270 0.700 .17 0 0 0.633 0.323
Time 2 0.923 0.624 1.350 0.685 5.950* 10.248
Psychological flexibility
Time 1 2.940 1.080 3.750 1.320 -1.540
Time 2 2.850 1.620 3.480 1.270 0.004 10.000
Note
. ηp2 = partial eta squared. The Mann-Whitney
U
test assessed whether the means in both groups at T1 (pre-intervention) for the different variables were statistically
different. The ANCOVA assessed whether the means of both groups at T2 (post-intervention) for the different variables were statistically different, controlling for means at T1
(pre-intervention);
*
p
< .05, **
p
< .01.

115
ACT-based Stress Management Training in ICUs
perceived stress variable (
z
= -2.13,
p
< .05,
r
= .43), with a moderate
effect size.
Finally, participants showed a high level of satisfaction with
their participation in this workshop. On a scale of 1 (
very negative
)
to 10 (
very positive
), participants (
n
= 16) indicated a notable de-
gree of learning (
M
= 7.6), and found training extremely useful for
their daily work (
M
= 8.5). In addition, workers indicated that the
content of the workshop aroused their interest (
M
= 8.8), and their
overall satisfaction was high (
M
= 8.5).
Qualitative Analysis
Theme 1: Motivations for participating in the workshop.
Most participants reported that their interest in registering for the
workshop was mainly linked to “finding tools to deal with the stress”
(sub-theme 1.1) that they were experiencing at that time in their lives,
both inside and outside work. One of the nurses expressed this view:
I thought it might help me to improve my anxiety and stress
levels, especially, and my attitude toward my children, my family...
I thought it could help me in that sense (E.9).
Another, smaller, group of professionals claimed that their main
motivation was “the drive to increase their knowledge” (sub-theme
1.2) about SMT. One nurse referred to it as follows:
It’s something I had heard about and didn’t have much
knowledge about ... and I like it, so I’m interested... It’s something I
wanted to know more about really (E.6).
Theme 2: Perceived health, wellness, and interpersonal
relationship benefits. Brief ACT-based SMT produced changes in
nurses’ perceptions of their physical health, energy, and interpersonal
relationships, both on and off the job. Below is one of the professionals’
comment that reflected “improvements in physical symptoms” (sub-
theme 2.1):
Attention on breathing relaxes me and that helps me a lot. Now
I don’t have so much tension. I found that, previously, I had back
pains... also in the shoulders, but now the area is more relaxed
(E.7).
On some occasions, an “improvement in energy and vitality levels”
was also identified (sub-theme 2.2), as stated by this professional:
At work I am more attentive to what I do, which makes me face
things with more equanimity, and with fewer expectations, you
know? Surprisingly I feel more energy. Anyway, I am open to what
comes; bring it on! … It was not so before (E.7).
In addition, interviews revealed a generalized sense that, following
the workshop, professionals experienced an “improvement in their
ways of relating to others, both inside and outside of work” (sub-
theme 2.3):
As for my colleagues, I had a very bad introduction to them; not
with the work itself, but with my colleagues... Taking the course
has served me well, because in the end I have realized that we
are all as we are, and we all do the same work: I no longer get
angry as I did before. Now I focus on me and try to help them [my
colleagues] when I can to generate a good climate (E.3).
Theme 3: Changes in psychological processes. ACT-based
training has always been concerned with knowing what psychological
processes are mobilized during training that can account for changes
in variables such as workers’ health, well-being, or performance. In
this sense, the results of the thematic analysis showed that many
nurses felt that the workshop had contributed, among other aspects,
to “increasing awareness of the present moment” (sub-theme 3.1).
One extract regarding these experiences are given below:
The workshop has helped me to be aware of what I am doing;
to not focus so much on things from past or things that are going
to happen in the future... because you cannot control them, so
focus more on the concrete (E.4).
In addition, the nurses mentioned that they perceived an
“improvement in attention” (subtheme 3.2), which was one of the
aspects on which most of them agreed; for example, one nurse
expressed it as follows:
It’s been good for me. It’s taught me to often stop, think, and
be more attentive. I was never able to breathe properly and try to
relax, and I was very nervous. I felt exhausted because I could not
stop thinking (E.1).
In addition, several professionals expressed the experience of
having learned “to let go of negative thoughts and emotions” (sub-
theme 3.3)—an aspect practiced during the workshop sessions, which
related to other aspects, such as observation of the flow of thought:
I have learned to breathe, to listen to myself, even if I sometimes
don’t succeed... It has helped me with my thoughts. Now I let them
go easily (E.8).
Quite a few participants also alluded in their comments to an
“increase in their personal acceptance levels” (sub-theme 3.4). This
was exemplified by the following excerpt from the comment:
I am very demanding with myself, and it has helped me to be
more tolerant than I used to be (E.4).
The narratives also showed that the attitude of acceptance
went beyond the limits of the self and an “attitude of acceptance
in complicated situations” became widespread (sub-theme 3.5), as
shown by this example:
There are times when I think and ruminate too much... for
example, the other day my son fell and broke his tooth, and I
started thinking about the future and the consequences of having
a broken tooth and my responsibility for not having been there
to watch him... but then I remembered to tell myself that it had
already happened and that I couldn’t control it anymore; to accept
that it had already happened and to think about what to do (E.1).
After the training, quite a few nurses claimed that they had improved
“their ability to manage stressful situations” (subtheme 3.6):
We move in very stressful situations, very in the moment, you
know? I think this course is very good, because now I can control
myself and stop to take a breath in critical situations. I think that it
is very good not to burn ourselves out (E.8).
Finally, participation in the workshop allowed the nurses to
“discover and become aware of new aspects of themselves” (sub-
theme 3.7). The following comment exemplify this:
Table 3. Comparison of pre-post Means (Wilcoxon test) within Each Group and at Follow-up
Quasi-experimental
group
Waiting-list control
group
Quasi-control group
(Intervention)
Entire group
(Follow-up)
Variable
M
pre
M
post
z r M
pre
M
post
z r M
pre
M
post
z r M
pre
M
follow-up
z r
n
= 14
n
=13
n
= 8
n
= 8
n
= 8
n
= 3
n
= 12
n
= 12
Depression 0.377 0.252 -1.61 .31 0.717 1.160 -2.55** -.63 1.090 1.000 -0.447 -.13 0.321 0.297 -0.402 -.08
Anxiety 0.663 0.461 -1.85 -.35 0.678 0.678 -0.710 -.17 0.619 0.428 -1.060 -.32 0.535 0.476 -0.635 -.12
Stress 1.270 0.923 -2.24* -.43 1.170 1.350 -0.849 -.21 1.190 1.330 -0.535 -.16 1.320 0.964 -2.130* .43
Psychological flexibility 2.940 2.850 -1.25 -.24 3.750 3.480 -1.120 -.28 4.610 4.470 0.000 .00 3.100 2.730 -1.330 -.27
Note. z
= non-parametric Wilcoxon test statistics;
r
= indicates the size of the effect of the
z
statistics.
*
p
< .05, **
p
< .01.

116
L. M. Blanco-Donoso et al. / Clínica y Salud (2021) 32(3) 111-117
I value my surroundings a little more, and other people too...
What are you doing in this life? You are getting overwhelmed,
spending time on the wrong things, wasting your years... you
don’t enjoy life and the moment... and I say: “Let’s see! What
am I doing? Slow down a bit... I’m going to relax a bit and enjoy
life (E.5).
Discussion
The aim of this study was to test whether an ACT approach in
SMT was able to improve the levels of depression, anxiety, and stress
among a group of health professionals in an ICU. A mixed quantitative
and qualitative methodology was used for this purpose, employing
questionnaires and semi-structured interviews.
The results of this study reflected that ACT training produced
improvements in workers’ levels of “depression” and “perceived
stress” while maintaining the quasi-experimental condition. In
addition, improvements in stress were observed at intra-group
level in those who received the training, while levels of depression
increased in the waiting-list control group. After one month, the
follow-up showed a significant decrease in stress levels across the
entire group. The study therefore concluded that stress was the
variable on which ACT-based training had the greatest impact, taking
into account its change in the different stages of the study. The results
achieved in this research were congruent with those of other studies
showing the capacity of short ACT-based training to improve aspects
of workers’ mental health (Frögeli et al., 2016; Waters et al., 2018),
especially their stress levels (Öst, 2014).
Regarding the explanatory mechanism for the improvement of
stress levels, the quantitative analysis did not reflect changes in the
“psychological flexibility” variable. Although this variable usually
mediates changes in mental health for this type of training (Lloyd et
al., 2013), this is not always the case (Frögeli et al., 2016). This result
could have been due to the use of the AAQ-II questionnaire to measure
changes in psychological flexibility: according to some authors, the
instrument may be insensitive to changes occurring after this type of
brief training (McConachie et al., 2014).
The thematic analysis of the interviews conducted with a
voluntary subsample of participants revealed that the main reason
why nurses signed up for the workshop was their search for a tool
that would enable them to cope with their stress levels and the
stressful situations they experienced in their daily lives—a finding
that coincided with the results of other similar studies (Kinser et al.,
2016). In fact, the discourses revealed that the levels of stress in this
subsample were high, coinciding with the literature that has explored
this phenomenon among ICU professionals (Gómez-Martínez et al.,
2015; van Mol et al., 2015). The interviews showed that, in line with
the quantitative results of the study, training particularly helped
nurses to manage their perceived stress levels and to have a greater
sense of control when faced with stressful situations, both on and off
the job. This observation was also in line with work that revealed that
this type of training is especially beneficial for alleviating work stress
(Öst, 2014), significantly for those professionals who experience
extreme stress (Waters et al., 2018). In addition, according to the
nurses’ experiences, training promoted other improvements in their
health and well-being that were consistent with previous literature
regarding the effects of this type of intervention; for example, it
helped participants to improve their energy and vitality levels
(Blanco-Donoso et al., 2017), reduce their strain levels (Lloyd et al.,
2013 ), and improve their interpersonal relationships, both on and off
the job (Resnicoff & Julliard, 2018).
Nurses’ comments also identified improvements in psychological
processes relating to elements that are properly addressed by
ACT training; for example, improvements in present moment
awareness, mindfulness, acceptance, and observation of flow of
thought (associated with the acquisition of a perspective of the self
as context and cognitive defusion). These four elements more closely
related to “processes of acceptance and mindfulness” proposed
by the ACT Hexaflex model, than to “commitment and behavior
change processes” (Flaxman et al., 2013), and they seemed to be
the ones most impacted by training (Rise et al., 2015). In fact, other
qualitative studies have reported that developing mindfulness skills
is an interesting means of gaining perspective, learning to focus
attention, and increasing levels of non-reactive awareness (Kinser et
al., 2016; Resnicoff & Julliard, 2018). In addition, nurses reported a
change in attitude emphasizing acceptance and self-care, which may
have related to the introduction of self-compassion practices in this
training, as previously reported by other studies (García et al., 2018).
The results of this research should be interpreted taking into
account its limitations. First, in relation to the sample, the number
of participants was small, their participation was voluntary, and
they could not be randomized to different experimental and control
groups; therefore, the internal validity of the study was jeopardized.
The impossibility of randomizing participants was due to working
conditions and needs that are inevitable within an ICU. The study
nevertheless had the value of being developed in a real environment,
with professionals who are difficult to access and highly specialized,
which may have contributed to increasing the external validity of the
study. In addition, participants in both groups showed no differences
in pre-training measures, nor in their socio-professional variables
or variables relating to their health and well-being. Future research
should include a larger number of participants, randomized to
different experimental conditions.
Second, also in relation to the sample, the flow of participants
revealed a significant attrition, especially in the follow-up. Although
the problem of participant drop-out is frequent in organizational
interventions (Flaxman & Bond, 2010), and may even be more
pronounced in work environments such as ICUs, because of their
work overload and dynamic nature (Blanco-Donoso et al., 2017), it
is important to bear this in mind when generalizing the results. It
is possible that e-mail follow-up could have boosted this attraction.
Third, the quasi-experimental design included only one waiting-
list control group and, in order to increase its internal validity, future
research should include other groups with different psychological
treatments to form active control groups and facilitate comparison
with the experimental one.
Fourth, the majority of participants in this study were women;
hence, future research should check whether this type of training has
gender-differentiated effects. Predominance of women in this type of
intervention is, however, common, as is their more frequent presence
in the health care professions.
Finally, this study reported only statistically significant changes,
but not at clinical level. Participating sample was not a clinical
sample and values for initial mental health variables were relatively
low. It would be desirable for future studies to test the effects of
such training with clinical samples of workers and analyze clinically
significant changes.
Despite these limitations, this study gained value by providing
empirical evidence of the effectiveness of short ACT-based training
for improving Spanish workers’ mental health and psychological
well-being using a mixed quantitative and qualitative methodology.
Studies designed with a mixed methodology are especially important
when the questionnaires used in a research do not fully reflect the
direct experience of people (Grossman & Van Dam, 2011), as was the
case in this research.
We hope that studies such as this one will encourage other
researchers in Spain to continue developing and evaluating this
type of program with different methodologies within different
organizations. We believe that an ACT approach can be highly
relevant to addressing emotional issues generated by the COVID-19
crisis among health professionals working in ICUs. Its approach

117
ACT-based Stress Management Training in ICUs
to working with emotional suffering and negative internal events
(e.g., traumatic memories or feelings of guilt), its emphasis on
behavioral activation, its orientation toward personal values, and
its recent incorporation of aspects such as self-compassion, make it
an ideal intervention for use in the present crisis. Nevertheless, we
insist on the need to implement, together with this type of worker-
centered intervention, actions aimed at redesigning the workplace
and improving organizational conditions, in order to carry out
more holistic interventions that can generate greater impact.
Conflict of Interest
The authors of this article declare no conflict of interest.
Acknowledgements
The authors would like to thank the Occupational Risk
Prevention Service and the Intensive Care Medicine Service of the
Puerta de Hierro Hospital for making this research possible.
Note
1This research has received the Rafael Burgaleta Award, XXVII
edition, granted by the Colegio Oficial de la Psicología de Madrid.
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