JMIR Publications

ABSTRACT

Background:

Healthcare workers experience high levels of stress with associated poor mental health and high rates of sickness absence. Accessible, affordable and effective approaches to reducing their stress are lacking. In-person mindfulness-based interventions (MBIs) can effectively reduce healthcare worker stress but are not widely available or accessible for many busy healthcare workers. Unguided digital mindfulness-based self-help (MBSH) interventions show promise and can be engaged with more flexibly. However, their effectiveness at reducing healthcare worker stress has not yet been explored in a definitive multi-site trial.

Objective:

We sought to investigate the effectiveness and mechanisms of action of an unguided digital MBSH application (Headspace) in reducing healthcare worker stress.

Methods:

This was a definitive superiority randomised-controlled trial with 2182 National Health Service (NHS) England staff, allocated 1:1 to Headspace or an active-control (Moodzone) for 4.5 months. Outcomes were measured using: subscales of the short form Depression, Anxiety and Stress (primary outcome) Scale; Short Warwick Edinburgh Mental Wellbeing Scale; Maslach Burnout Inventory; 15-item Five-Facet Mindfulness Questionnaire minus Observe items; short-form Self-Compassion Scale; Compassionate Love Scale; Penn State Worry Questionnaire; brooding subscale of the Ruminative Response Scale and sickness absence.

Results:

Intention-to-treat analysis found that Headspace led to greater reductions in stress over the course of the study compared to Moodzone (b=-0.31, 95% CI: -0.47,-0.14, p<.001) with a small effect size, and 36.76% of Headspace participants who were experiencing at least mild levels of stress at baseline showed reliable improvement in stress over the course of the study, which was significantly more than the 24.09% of Moodzone participants. Small effects of Headspace versus Moodzone over time were also found for depression (b=-0.24, 95% CI: -0.40,-0.08, p=.003), anxiety (b=-0.19, 95% CI: -0.32,-06, p=.004), wellbeing (b=0.14, 95% CI: 0.05,0.23, p=.002), mindfulness (b=0.22, 95% CI: 0.09,0.34, p=.001), self-compassion (b=0.48, 95% CI: 0.33,0.64, p<.001), compassion-for-others (b=0.02, 95% CI: 0.00,0.04, p=.04) and worry (b=-0.30, 95% CI: -0.51,-0.09, p=.005), but not for burnout facets (bs=-0.19, -0.04, 0.13; all 95% CIs cross zero, ps=0.65, 0.67 and 0.35), ruminative brooding (b=-0.06, 95% CI: -0.12,0.00, p=.056) or sickness absence (γ=0.09 95% CI: -0.18, 0.34). Engagement (practice days/week) and improvements in self-compassion during the initial 1.5-month intervention period mediated pre-to-post-intervention improvements in stress. Initial improvements in mindfulness, rumination and worry did not however mediate pre-to-post-intervention improvements in stress. No serious adverse events were reported.

Conclusions:

An unguided digital MBSH intervention (Headspace) can reduce healthcare workers’ stress. Effect sizes are small, but could have population level benefits. However, unguided digital MBSH interventions can only be part of the solution to reducing healthcare worker stress alongside potentially costlier but potentially more effective in-person MBIs, non-mindfulness courses and organisational-level interventions. Clinical Trial: The study was prospectively registered on the International Standard Randomised Controlled Trial Number (ISCTN) Register (https://www.isrctn.com/ISRCTN15424185)