Evaluating the effect of a psychological skills-training App on the wellbeing and burnout risk among medical students

BRIEF NAME: Acceptance and Commitment Training (ACT) • Arm 1: ACT (individualised) • Arm 2: ACT (non-individualised) • Arm 3: Waiting list (to receive ACT – individualised after waiting period) MATERIALS: Online App (BiSi), available via Google Play Store and Apple App Store Digital device to access App (e.g. iPhone or Android phone, iPad or tablet) – provided by participant. PROCEDURES: 1. Context Acceptance and Commitment Training (ACT) is based on the well-established psychological flexibility model. Psychological flexibility is a set of adaptive behavioural skills that are associated with wellbeing outcomes. The ACT intervention approach facilitates the development of individual psychological flexibility skills for non-clinical populations, promoting and facilitating actions that support individual wellbeing (Biglan, Hayes, & Pistorello, 2008; Frögéli, Djordjevic, Rudman, Livheim, & Gustavsson, 2016). Rather than defining uncomfortable internal experiences (e.g. thoughts, emotions, physical sensations) as “symptoms” that need to be changed or eliminated, ACT focuses on altering the way individuals relate to these internal experiences (Steven C. Hayes, Strosahl, & Wilson, 2012; Reeve, Tickle, & Moghaddam, 2018) and empowering them to respond in ways that are more adaptive in their own lives (Larmar, Wiatrowski, & Lewis-Driver, 2014). This is accomplished through activities that normalise challenging internal experiences, as well as training individuals to strengthen present-moment awareness, recognise the influence of their internal experiences over their actions, learn to alter unworkable responses to these internal experiences, and develop more flexible behavioural repertoires that are consistent with their personally chosen values (Steven C. Hayes et al., 2012; Larmar et al., 2014; Moran, 2010; Reeve et al., 2018). ACT is conceptually well defined and clearly links its interventions to the mechanisms through which it purportedly elicits change: that is, the 6 Psychological Flexibility processes and their corresponding inflexibility processes (Stockton et al., 2019). The components of an ACT intervention include: 1) Present-Moment Awareness (Mindfulness) 2) Cognitive Defusion 3) Self-as-Context 4) Acceptance 5) Values 6) Committed Action 2. Methods Stage 1: All participants will complete a brief introductory module that provides education about burnout and wellbeing, as well as introducing the core concepts for each of the skills trained within the ACT model. Upon completion of Stage 1, participants will be randomised into one of the 3 treatment arms. Participants in Arms 1 and 2 will be given access to Stage 2 of the App. Stage 2: During Stage 2, Arm 1 and 2 participants may access the App at any time during the intervention period. “Part 1: Learn the concepts” - Participants will complete a more in-depth educational module outlining each of the 6 ACT components listed above. “Part 2: Learn the behaviours” - There are six modules, one for each of the ACT intervention components listed above. Each module consists of 20 experiential skill-building activities (duration 3-7 mins each) that train the corresponding ACT skill (n total = 120 activities). The inclusion of this number of activities was guided by previous studies indicating that 28 activities were too few (Levin, Haeger, Pierce, & Cruz, 2017) and 136 were sufficient (Levin, Haeger, & Cruz, 2019). Each time participants access Part 2, they will complete a check-in assessment. This is a single-item question assessing which of the ACT skills they are having the most difficulty with in that moment. • Arm 1 (ACT - Individualised): During Part 2, an Arm 1 participant’s check-in assessment rating at each login session will be used to individualise their intervention experience. Participants indicate which ACT skill they are having the most difficulty with at the time of each check-in, and are subsequently given access to the dashboard for the training module that corresponds with that skill (e.g. if a participant identifies that they are having the most difficulty attending to the present moment, they will be given access to the present-moment awareness module dashboard). The dashboard allows them to either choose one of the 20 skill activities within that module from a list, or request the App to select one of the activities at random. Once they have completed the activity, they have the option of completing another activity or exiting the App. Participants can complete this process as many times as they choose during the intervention period. • Arm 2 (ACT - non-individualised): During Part 2, Arm 2 participants have access to the same intervention materials as those in Arm 1. The only difference between the modules is the method used to select which activity they receive each session. Participants complete the check-in assessment at the beginning of each login session. For this group, the outcomes of this assessment will not be used to select the activity the participant is presented with during that session. Instead, an activity from any of the 6 psychological flexibility modules (n activities = 120) will be presented at random. Upon completion of the random activity, participants will have the option of completing another activity, which will also be selected at random from the full activity pool. If they choose not to complete another activity, they can exit the App. WHO WILL DELIVER THE INTERVENTION The online intervention materials were developed and created by an experienced clinical psychologist, Elizabeth Ditton (19 years’ clinical experience, and 15 years’ experience and training in the intervention model). The intervention is based on established psychological theory, research, and methods. A second clinical psychologist (Brendon Knott) with equivalent experience contributed to the development of the intervention content, and checked the overall intervention for fidelity to the ACT approach and psychological flexibility model. Audio content within the App is delivered by Elizabeth Ditton. MODE OF DELIVERY: All intervention components will be delivered online via the BiSi App, and are presented in a combination of written and audio formats. NUMBER OF TIMES: Stage 1: Participants are required to complete the Stage 1 information session before randomisation to an intervention arm. Stage 2: During Stage 2, participants will be required to complete “Part 1: Learn the concepts” before they are given access to “Part 2: Learn the behaviours”. They may subsequently revisit any element of “Part 1: Learn the concepts” if they choose to, via the App Dashboard. During “Part 2: Learn the behaviours”, participants will be encouraged to practice at least 4 skill activities. Each participant will ultimately choose their own usage frequency. Engagement will be facilitated using daily App notification or email reminders and positive reinforcement pertaining to progress through the App. For both stages, we will collect usage data so we can examine the impact of degree and frequency of intervention engagement on outcomes. DURATION: Stage 1: The introductory module will take approximately 10 mins to complete Stage 2: Participants will have access to Stage 2 for 5 weeks. - Part 1 (Learn the Concepts): This will take approximately 30-40 mins to complete, and can be completed either in one sitting, or multiple sittings within a 2-week period. - Part 2 (Learn the Behaviours): Participants will have access to Part 2 for up to 5 weeks in total, depending on how quickly they complete Part 1 (e.g. participants who complete Part 1 on the first day will have the remaining 5 weeks to use Part 2, while participants who take the full 2 weeks to complete Part 1 will have the remaining 3 weeks to use Part 2). Participants will be asked to complete a minimum of 4 skill activities in Part 2. Participants may use the App at their own chosen frequency. LOCATION: Due to the online and portable nature of the App, participants can engage in the intervention in any location suitable to them. The App is available for free download onto Apple and Android devices. Use of the App will require a study access code, provided to participants after consent is obtained. TAILORING: As previously outlined, the Stage 2 intervention for Arm 1 participants will be individualised, such that they will receive targeted skill activities each time they use the App (compared with the random skill delivery method used for the Arm 2 version of Stage 2). The current study will adopt a “treatment utility” methodology (Steven C. Hayes et al., 2019) that compares the individualised ACT program and the non-individualised ACT program. Using this methodology, we address individual heterogeneity with respect to psychological flexibility at the intervention level, allowing for the group-level comparison of outcomes between individualised and non-individualised intervention groups.