A cluster randomized controlled trial of online Acceptance and Commitment Therapy (ACT) training to improve mental wellbeing in staff caring for terminally ill people and their caregivers.

Background: Whilst healthcare workers are known to be at risk of poor wellbeing, those that work in palliative care have worse wellbeing and face exposure to unique stressors. Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioural therapy that uses acceptance, mindfulness, and behavioural psychology to help people engage in the things that matter to them, even in challenging situations.

ACT has good evidence for efficacy in occupational stress, though this is less clear for health professionals. Our previous research was a pilot feasibility trial of an online ACT intervention specifically designed for palliative care staff: RESTORE. RESTORE was shown to be feasible, acceptable and improved wellbeing.

Research question: Does RESTORE improve palliative care staff wellbeing compared to usual support, and is this mediated by improvement in psychological flexibility?

Methods, including justification of study design: A parallel arm cluster randomised controlled trial with mechanism evaluation. A target of 352 palliative care staff will be recruited through 16 hospices across the United Kingdom. A cluster design is appropriate because it reduces the risk of contamination of the intervention between experimental and control participants and will control for other influences on wellbeing.

Intervention: RESTORE consists of video, audio and written materials that teach skills in acceptance, mindfulness, perspective taking, values engagement, goal setting, active self-care, and self-compassion. The intervention will also help participants to embed wellbeing behaviours into their workplace, leading to culture change. Four live online facilitated group sessions, a workbook, and message prompts guide participants through the materials.

Control condition participants will receive prompts by email about routine support such as information, webinars, self-help, and online mental health tools. Evaluation will be via online survey using standardised self-report questionnaires of wellbeing, burnout, and intention to leave. Data will be gathered at: Time 0 Recruitment, 1.

Pre intervention, 2. Post intervention, 3. One month follow up and 4.

Three month follow up. Control sites will be offered the intervention on completion of data collection.

Timelines for delivery: From Feb to Sep 2025, we will refine intervention materials, train therapists, and complete research governance. Oct 2025 to Oct 2026 will be an internal pilot phase with four study sites. Oct 2026 represents our GO / NO GO point in deciding whether to continue to the fully powered trial.

From Oct 2026 to Sep 2027, we will deliver RESTORE or the control arm in the remaining 12 sites. Qualitative and quantitative data analysis will take place from May to Nov 2027. Publication and dissemination activity will take place from Aug 2027 to Jul 2028, with the final funder report being produced by end of Feb 2028.

Anticipated impact and dissemination: The study will provide definitive evidence of the efficacy of ACT for the palliative healthcare professional context and will also demonstrate whether it works according to its proposed mechanism of action. In addition to scientific impact, this will give confidence to healthcare organisations in how they can support staff.

Improved staff wellbeing will also be of benefit to patients receiving end of life care. Findings will be disseminated through peer reviewed publications, stakeholder webinars, a summary report and video.