Impact of virtual group-based acceptance and commitment therapy on social adjustment and work-family conflict among intern nurses: a randomized control trial

An internship is an opportunity for professional development that gives students real-world experience in a field linked to their studies or desired career [1]. It can be challenging to go from being a student to a professional stage in life [2]. It is generally known that most intern nurses experience difficulties in their daily work [3].

One of the most challenging issues for intern nurses is work-family conflict (WFC). Due to the demanding nature of their profession, this entails lengthy shifts, a great deal of emotional and physical stress, and intense patient involvement [4]. According to Greenhaus and Beutell [5], a work-family conflict arises when one role (work or personal life) imposes obligations and demands that are incompatible with the other position. Work-family conflict has a negative impact on the overall healthcare system, increasing absenteeism and turnover while decreasing nurses’ productivity and performance in terms of the quality of patient care provided [6]. Ever since, WFC has been associated with lower levels of life satisfaction and quality of life. Studies have found a direct correlation between psychological conflict, destructive behaviors, and depression [7, 8].

Social adjustment is getting along with other people in a group or community. Numerous studies have found a positive correlation between social adjustment and achievement motivation. Mirmoeini, Bayazi, & Khalatbari [9] found that people with low social adjustment sometimes struggle with verbal communication with others, making plans, caring for themselves, and carrying out everyday tasks. From another perspective, those new nurses need to adjust to people from different cultures, and the new environment is one of the most crucial parts of their experience [10]. Therefore, nurses with high levels of social adjustment will also have high levels of achievement desire [11, 12].

To this end, researchers have adopted virtual mindfulness-based workplace training programs to avoid and minimize intern nurses’ conflict [13]. Such therapy may be simple, cost-efficient, and rapidly disseminated to the nursing population. This novel therapy approach may reduce the need for counseling services and increase the number of individuals treated. Virtual group-based learning may also improve access for remote students [14]. Acceptance and commitment therapy (ACT) is an illustration of these approaches. ACT is being developed with healthcare workers [15]. ACT belongs to a group of third-wave or contextual cognitive-behavioral therapy approaches that focus on altering or changing the relationship of individuals with their unhelpful thoughts and feelings rather than directly trying to change the form or frequency of these internal experiences [15]. Additionally, studies have shown that ACT can enhance other employees’ well-being and performance indicators, such as fostering workplace innovation [16].

The ACT model is conceptually based on the behavioral analytic account of language called Relational Frame Theory (RFT), which aims to reduce the influence of thoughts and language to increase the number of choices concerning following a valued life path [17]. Alternatively, with another meaning, the ultimate goal of ACT is to “bring verbal cognitive processes under better contextual control and encourage the intern nurse to spend more time in touch with the positive effects of his or her actions as part of a valued life path immediately in the present moment [18]. In this respect, Mokhtari, Rezaee, & Baljani [19] confirmed the relationship between work-family conflict and social adjustment among hospital clinical personnel.

Balancing work and family life is challenging and conflicting for any adult needing more psychological flexibility. Sabil et al. [20] verified that when people begin to work, they struggle to balance jobs and family life. Combining work and family is beneficial. The HEXAFLEX model in Fig. 1 demonstrates ACT’s six main theoretical processes that work together to improve psychological flexibility. Although the six processes in the model are described as separate, they are highly interdependent, so beginning to use one strategy is likely to affect the others positively. Subsequently, the absence of one or more of the six psychological flexibility strategies will lead to a risk of psychological inflexibility, which is believed to be the root cause of human suffering and conflicts [18].

Overall, several studies have applied ACT therapy, and the results indicate the effectiveness of this approach in reducing job stress, behavioral and psychosocial problems [21‐23], as well as increasing the well-being, quality of life, resilience, and social and health adjustment of nurses [24, 25].

Table 2 presents the distribution of sociodemographic characteristics for two groups of intern nurses, a study group (n = 35) and a control group (n = 35). In the study group, 25.7% of participants were male, while in the control group, 31.4% were male. The difference was not statistically significant (χ2 = 0.280, p = 0.597). Regarding age, the mean age for the study group was 22.27 years (SD = 1.55), while for the control group, the mean age was 22.0 years (SD = 1.12). The difference was not statistically significant (t = 0.696, p = 0.488). Most participants in both groups were single, with 94.28% in the study group and 97.14% in the control group. The difference was not statistically significant (χ2 = 0.022, p = 0.881). Concerning place of residence, most participants in both groups lived in urban areas, with 74.0% in the study group and 73.5% in the control group. The difference was not statistically significant (χ2 = 0.001, p = 0.971). Most participants in both groups had 2–5 family members, with 65.7% in the study group and 62.9% in the control group, while the rest had 5–10 family members. The difference was not statistically significant (χ2 = 0.062, p = 0.803). Also, the previous practical nursing experience showed that 34.3% of participants in the study group and 51.4% in the control group reported having previous practical nursing experience. The difference was not statistically significant (χ2 = 2.100, p = 0.147). Working during an internship revealed that 31.4% of participants in the study group and 34.3% in the control group reported working during internship training. The difference was not statistically significant (χ2 = 0.065, p = 0.799). The mean working hours for both groups were 56 h per week, with a standard deviation of 8 h for the study group and 6 h for the control group. The difference was not statistically significant (t = 0.408, p = 0.703). This table demonstrates no statistically significant difference in the sociodemographic characteristics between the study and control groups, proving that the two groups are equivalent.

Table 3 illustrates the mean scores and standard deviations of the Work-related Acceptance and Action Questionnaire (WAAQ) for the study and control groups pre-intervention, immediate post-intervention, and one-month post-intervention. The higher mean scores indicate greater psychological flexibility. The results show that at the pre-intervention stage, the mean score of the study group (31.00) was significantly lower than the control group (34.62), with a statistically significant difference (p = 0.036). This suggests that the two groups were not initially equivalent regarding psychological flexibility. However, immediately after the intervention, the mean score of the study group (43.11) was significantly higher than that of the control group (34.15) with a statistically significant difference (p < 0.001), indicating a significant improvement in psychological flexibility in the study group compared to the control group. One month after the intervention, the mean score of the study group (41.88) remained significantly higher than that of the control group (33.21), with a statistically significant difference (p < 0.001), indicating that the effect of the intervention was sustained over time. The ANOVA results indicate a statistically significant difference between the study and control groups regarding WAAQ scores across all three stages (F = 128.457, p < 0.001, η2 = 0.791), suggesting a large effect size.

Table 4 presents the mean scores and standard deviations of the Social Adjustment Scale—Self Report (SAS-SR) for the study and control groups pre-intervention, immediate post-intervention, and one-month post-intervention. The lower mean scores indicate higher levels of social adjustment. The results show that at the pre-intervention stage, the study group had significantly lower mean scores than the control group in all four subscales of the SAS-SR (working role, spare time activities, role within the family unit, and total score), with statistically significant differences (p < 0.001) and large effect sizes (η2 = 0.932). This suggests that the two groups were not initially equivalent regarding social adjustment. Immediately after the intervention, the mean scores of the study group improved significantly in all four subscales of the SAS-SR, with statistically significant differences (p < 0.001) and large effect sizes (η2 = 0.906).

The ANOVA results indicate significant differences between the study and control groups regarding SAS-SR scores across all subscales and stages, with large effect sizes. In contrast, the control group showed no significant changes in mean scores. One month after the intervention, the mean scores of the study group remained significantly higher than those of the control group in the Working Role and Total Score subscales, with statistically significant differences (p = 0.025 and p < 0.001, respectively) and moderate effect sizes (η2 = 0.157 and 0.770, respectively). However, the two groups had no significant differences in the Spare Time Activities and Roles within the Family Unit subscales.

Table 5 presents the mean scores and standard deviations of the Work-Family Conflict Scale (WFCS) for the study and control groups pre-intervention, immediate post-intervention, and one-month post-intervention. The higher mean scores indicate higher degrees of conflict. The results show that at the pre-intervention stage, the study group had significantly higher mean scores than the control group in all three subscales of the WFCS (Work Interference with Family, Family Interference with Work, and Total Score), with statistically significant differences (p < 0.001) and large effect sizes (η2 = 0.851). Immediately after the intervention, the mean scores of the study group improved significantly in all three subscales of the WFCS, with statistically significant differences (p < 0.001) and large effect sizes (η2 = 0.911). This suggests that the two groups were not initially equivalent regarding work-family conflict.

Work and family are the two most influential aspects of a person’s life. The balance between a person’s work and family life has drawn more and more research attention. The conflict between work and family can adversely affect an organization’s and an individual’s health and well-being [8]. Research is necessary to describe, understand, and address work-family conflict because it arises from how people perceive it [19]. According to researchers, studies on social adjustment for healthcare staff and nursing interns are scarce in Egypt. Recently, ACT has been utilized to treat various psychological issues and challenges at work [33]. Therefore, the present study aimed to evaluate the impact of virtual group-based ACT on intern nurses’ social adjustment and work-family conflict.

The researchers in the present study used the work-related acceptance and action questionnaire to measure the effect of ACT on improving work-related psychological flexibility among intern nurses. The current findings reflect a statistically significant difference between the study and control group concerning work-related psychological flexibility after finishing the intervention and after a one-month follow-up with a large effect size of 79%. It can be said that ACT trains students to maintain their attention on the present and take appropriate action toward achieving their goals and upholding their values, even when faced with challenging or unwanted psychological events such as thoughts, feelings, physiological sensations, images, and unwanted memories.

Moran [34] explained that acceptance skills teach employees to behave effectively even during stressful emotions and sensations, increasing psychological flexibility. ACT training teaches people that feelings, urges, memories, and other private psychological experiences occur naturally throughout the workday and should not be eliminated or avoided. This approach implies that contacting psychological experiences willingly is healthier and thus makes the worker more effective.

The current study’s findings revealed a substantial difference in intern nurses’ work-family conflict ratings between the study and control groups. In other words, ACT reduced work-family conflict in the study group compared to the control group before and after, and the effect was sustained with a large effect size (94.3%) throughout a one-month follow-up. However, most intern nurses in the intervention group reported suffering from value conflict between their family and work. In line with our findings, Sabil et al. [20] reported that nurses had varying degrees of conflict while attempting to meet work expectations and family roles. Similarly, Guille et al. [35] surveyed 3121 interns from 44 medical schools in the United States during the 2015–2016 academic year. They found that both males and females experienced an increase in work-family conflict and depression symptoms during the first six months of the internship year, and there was a correlation between the two. Sedoughi et al. [36] explained that nurses spent more time at work than with their families and were more satisfied with their family lives than their profession. Leineweber et al. [37] revealed that the conflict between work and family life affects both men’s and women’s health, even though women experience it significantly more frequently than men. In a study of five Italian public hospitals conducted by Zurlo, Vallone, & Smith [6], 450 nurses (206 males, 244 females) took part. They found differences between the sexes in perceived levels of WFC, anxiety, depression, and somatization with nurses performing. Still, there were no differences in perceived job control, social support, or job satisfaction.

The researchers focused on the two essential areas of life rather than on two conflicting values. They used different ACT skills, like acceptance and present-moment exercises, to overcome thoughts and feelings that interfered with the chosen values. As well as the researchers used the tug-of-war with a monster metaphor as an example to increase the intern nurses’ awareness about accepting their conflicting thoughts rather than resisting them. A group of intern nurses was asked to imagine pulling the robe with a researcher, giving them a chance to provide alternative solutions to that battle when the monster on the other side of the robe was unbeatable. They were convinced to accept and let go of the struggle with their perplexing thoughts and feelings rather than suppress them or avoid them experientially.

The present study finding is congruent with a study entitled “Comparison between the effects of group-based ACT and group-based reality therapy on work-family conflict & psychological well-being of married female staff,”. A study using a work conflict questionnaire on 45 employees found that group-based ACT can be utilized to increase psychological well-being and group-based reality therapy can be an effective method for reducing work-family conflicts [38].

ACT improved social adjustment compared to the control group before and after, and the effect persisted over a one-month follow-up. The improvement in social adjustment was remarkably observed in all social adjustment subscales in the study group. It can be regarded as a decrement in the mean scores of the working role subscale, spare time activations, and role within the family unit. These results follow Tanhadoost et al. [39] study of the effectiveness of ACT intervention on loneliness and social adjustment among girls with a social anxiety disorder. They confirmed that ACT improves social adjustment.

Mirmoeini et al. [9] investigate how acceptance- and commitment-based treatment affects social anxiety and adjustment in high school males. Similarly, Ostadian et al. [40], in a quasi-experimental study of 30 males with a physical disability (15 control group and 15 study group). They claimed that a group intervention focused on acceptance and commitment improved social adjustment. The experimental group had six training sessions, with one weekly session lasting 90 min. The findings revealed that ACT impacts high school boys’ social anxiety and adjustment. Such improvements might be rationalized by the activation of normalizing and accepting attitudes toward the intern nurses’ complex thoughts and feelings as an inherent component of the ACT skills. The intern nurses in the study practiced recognizing their challenging ideas as just thoughts, accepting them, and adopting behaviors congruent with their intended values. During these challenging circumstances, the intern nurses also learned to master motivation and conduct planned activities. Some trainees indicated that present-moment exercises and mindfulness allowed them to shift their attention away from their confusing thoughts and feelings, allowing them to focus on essential acts in their life that can enhance their sense of self-worth and self-actualization.

To explain the effect of ACT on social adjustment, we can say that today’s world requires more flexibility and individual and social adjustment than ever. Adaptability and flexibility can improve people’s lives [9]. Individuals with high levels of mindfulness are more aware of their body sensations, thoughts, and emotions with less reactivity, and they maintain a stance of equanimity rather than engaging in suppression or excessive fixation. The non-judgmental perspective and acceptance-based approach facilitate understanding and accepting intrapersonal and interpersonal challenges. The clarity and vividness of the experience and orienting to the present moment with curiosity and openness can help one’s psychosocial adjustment to life changes and new environments [41].

According to the current study findings, sustained improvement in work-family conflict, social adjustment, and work-related psychological flexibility after one month of implementing ACT might be explained by strengthening problem-solving abilities as an essential part of the ACT process. They were encouraged to find different methods to deal with their troubling thoughts and feelings. By this time, these attitudes had been acquired and internalized and could be employed autonomously and successfully. Another possible explanation is the effect of working memory consolidation caused by producing alternate solutions in metaphor demonstration.

ACT delivered in a virtual group setting with intern nurses is a viable method for increasing work-related psychological flexibility and social adjustment while decreasing work-family conflict immediately after intervention and sustained for one month after implementation; the study group experienced a significant difference from the control group. As well as further studies were needed with a large sample size to explore the long-term effects of virtual group-based ACT intervention on intern nurses’ social adjustment and work-family conflict. Future studies could investigate the sustainability of the effects of ACT beyond one month and examine the impact of ACT on other outcomes such as burnout, job satisfaction, and turnover intentions. Moreover, it would be interesting to investigate the effectiveness of ACT interventions on other healthcare professionals, such as physicians and allied health professionals, and explore the potential benefits of integrating ACT into healthcare training programs. Additionally, future research could investigate the effectiveness of different delivery modes, such as individual versus group-based ACT interventions, and examine the feasibility of implementing ACT in different cultural contexts.