A Well-being Promotion Program Increases Self-Compassion, Resilience and Active Coping among Providers Who Work with Children and Families

doi:10.21203/rs.3.rs-3912071/v1

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Research Article

A Well-being Promotion Program Increases Self-Compassion, Resilience and Active Coping among Providers Who Work with Children and Families

https://doi.org/10.21203/rs.3.rs-3912071/v1

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This study examined the effects of the REsilient Attitudes and Living for Professionals (REAL Pro) prevention intervention on the well-being of professionals who work with children and families. The program combines mindfulness and self-compassion practices with cognitive-behavioral tools that aim to promote improved stress management, emotion regulation and well-being, and was evaluated with early childhood (n = 87) and K-12 educators (n = 40), staff serving youth in out-of-school or after-school settings (n = 31), and medical providers (n = 35). Participants completed pre- and post-test assessments, reporting on measures of stress management (perceived stress, self-compassion), emotion regulation (dysregulation, active coping, denial), and well-being (flourishing, resilience, burnout, secondary trauma symptoms). Dependent sample t-tests were conducted, showing significant improvement from pre- to post-test in self-compassion, emotion regulation, active coping, and a trend toward increased resilience. Three-month follow-up in a small subset of the sample (n = 11) suggested potential delayed reduction in burnout and secondary trauma symptoms. The preventive intervention shows promise for providing professionals with tools for stress management and emotion regulation and reducing burnout in providers working with children and families who tend to experience substantial work-related stress.

Child and Family Providers

Mindfulness

Self-compassion

Coping

Emotion Regulation

Intervention

The well-being of professionals engaged in child and family services impacts the quality and efficacy of their work (Salamehe et al., 2021). Among these service providers, including early childhood educators, K-12 educators, community-based organization staff, and medical personnel, there are substantial levels of secondary trauma symptoms and burnout (Faulkner et al.,2016; Grist & Caudle, 2021; Lamson et al., 2014; Ormiston et al., 2022). Research examining the well-being of service providers often focuses exclusively on the well-being of one professional group at a time. Focusing on a single professional population restricts the sample, consequently limiting our understanding of the intersectional impacts of secondary trauma symptoms and burnout across a variety of professions (Ormiston et al., 2022). In turn, this hinders the development of interventions that can be effectively implemented in various contexts. In order to provide high-quality care for a broad spectrum of individuals in caring professions, it is necessary to identify interventions that reduce secondary trauma symptoms and burnout and promote well-being in providers across professions. This study examined the effectiveness of a well-being and resilience promotion program with early childhood and K-12 educators, community-based organization staff, and medical personnel who work with children and families.

Across caregiving professions, levels of stress are high. The 2013 Gallup-Health-Well-Being Index found that 46% of teachers in K-12, 46% of nurses and 45% of physicians report high levels of daily stress, which is the highest among the 14 professional categories included in the study (Gallup, 2014). Additionally, secondary traumatic stress (STS) and burnout are often seen in the context of professions that demand high levels of emotional labor and caregiving, such as healthcare, education, and social services (Lamson et al., 2014; Mulyani et al., 2021; Sinclair et al., 2017). Emotional distress resulting from indirect exposure to a traumatic experience, typically in care professions, can lead to STS (Sinclair et al., 2017; Ormiston et al., 2022). The clinical manifestations of STS are comparable and almost identical to those seen in Post-Traumatic Stress Disorder (PTSD). Affected individuals may experience symptoms such as avoidance, arousal, and feeling that they are re-living the traumatic event (Lamson et al., 2014; Thomas & Wilson, 2004). Professionals who work in caregiving roles are at risk for developing STS due to empathically engaging with individuals who have experienced trauma (Ormiston et al., 2022). In addition, individuals in these professional roles can also experience burnout, which describes a state of chronic physical and emotional exhaustion that may include feelings such as reduced accomplishment and depersonalization, a sense of detachment from oneself, or a loss of personal identity (Andrew, 2015; Cumming & Wong, 2018). STS and burnout can induce heightened irritability, negative self-perceptions, and erosion of emotional reserves. Further, experiencing STS or burnout can decrease one’s capacity for attention to detail and can hinder the formation of meaningful, trusting relationships, thus compromising the overall quality of care, and evidencing the need for prompt and evidence-based intervention (Lamson et al., 2010; Ormiston et al., 2022).

The spectrum of child and family service providers includes early childhood and K-12 educators, community-based organization staff, and medical personnel. STS and burnout have been shown to reduce these professionals’ capacity to provide quality care. One study found that the incidence of depressive symptoms in early childhood educators predicted poorer education quality, which, in turn, was related to worse cognitive outcomes for the learning children (Miller & Flint-Stipp, 2019). This suggests that educator depression negatively impacted children’s cognitive outcomes, with the quality of education acting as a mediator in this relationship. Additionally, systematic review found evidence that teacher burnout is associated with worse academic achievement and lower quality student motivation (Madigan & Kim, 2021). Another systematic review found that nurse burnout is associated with worsening safety and quality of care, as well as decreased patient satisfaction (Jun et al., 2021).

Currently, there are several existing programs that seek to ameliorate the high levels of stress and burnout for caring professionals. While these programs have yielded some positive results, the studies all have important limitations to consider. The Facilitating Attuned Interactions (FAN) approach represents one example of a program that, despite employing an intricate 15-month mentorship process, did not conclusively reduce burnout among child welfare professionals (Hazen et al., 2020). Similarly, Orsi et al.’s (2023) Resilience Alliance (RA) intervention failed to significantly influence job satisfaction and turnover rates, despite showing some impact on turnover ideation. While Luthar & Mendes (2020) were able to illuminate some of the unique challenges faced by educators working through traumatic environments, their study’s limited sample size raised concerns about its generalizability.

The REAL Pro (REsilient Attitudes and Living for Professionals) intervention, a multi-profession program designed to enhance well-being and mitigate stress and burnout among service providers, offers an innovative solution by integrating universal principles that are applicable across various professional groups. Rather than an emphasis on the unique stressors faced by each profession, evidence-based cognitive-behavioral and mindfulness practices form the foundation of the intervention; the versatility of these techniques provides a broad but effective means for fostering emotional regulation and resilience (Neff, 2009; Castillo-Gualda, 2019). REAL Pro is a relatively brief, 9-to-12-hour intervention, typically delivered across 6 sessions that each focus on developing practical emotion regulation and coping skills that professionals can integrate into their day-to-day life and work.

In this study, we expected that, across diverse professions, those who participated in the intervention would cultivate improved capacities for self-compassion, emotional regulation and effective coping strategies. In this way, stress and burnout should be reduced in these individuals, thus supporting the intervention’s wide-reaching applicability. By implementing and evaluating the REAL Pro intervention, this study aimed to establish a novel mechanism for reducing STS and burnout and improving well-being in providers across various care settings. We conducted a preliminary evaluation of the REAL Pro intervention to explore its potential effectiveness in promoting provider well-being. By performing pre- and post-test analyses of participants’ perceived stress, emotional regulation, and overall well-being, this study aimed to provide preliminary evidence of the REAL Pro intervention's impact on these professional groups and evaluate the best practices for its successful implementation.

Participants

Over a 2-year period, 193 professionals who work with children, youth and families participated in REAL Pro training as part of professional development in their respective work settings. Work settings included organizations offering early childhood and after-school programs to families in low-income contexts; K-12 public school educators of an urban public school with 32% of families qualifying for free and reduced lunch, 54% BIPOC, and 21% non-English speaking background; and medical professionals working at a university hospital that provides 60% of hospital charity care and 50% of hospital care for Medicaid recipients in the county in which it is located. All participants were invited to enroll in the evaluation study and complete pretest and posttest assessments, and of those, 136 (70%) enrolled. Professionals enrolled in the evaluation included early childhood educators (n = 87), K-12 educators (n = 40), medical providers (n = 35), and staff who work with K-12 age youth in out-of-school or after-school services (n = 31). Three of the agencies had a strong dual language program for English language learners. Of those enrolled in the study, 98 (72%) completed posttest assessments. As a result of additional funding available at one early childhood site, a small number of participants (n = 11) were asked to complete a 3- month follow-up assessment. In addition, nine participants from that site volunteered to participate in a focus group for the qualitative component of this research.

Procedures

There were 3 staff facilitators, all of whom had multiple years of related training and experience. Two programs were delivered in-person at the workplace setting, and the remaining eight were delivered online due to the COVID19 pandemic related closures. For this study, the program was implemented 10 times and was adapted in length and format to meet the needs of the organizations participating. As such, 7 cohorts met weekly for 90 minutes for 6 weeks, 1 cohort met weekly for 60 minutes for 8 weeks, 1 cohort met for three 2-hour workshops and 1 cohort met for two 6-hour workshops. All study procedures were approved by the University of Washington’s Human Subjects Division, and participant informed consent was obtained from all participants prior to their participation in the research. Two weeks prior to the start of each program, group participants were sent an email asking them to participate in the research study and complete an online survey. Immediately following the program, participants were again prompted to complete the research survey. Participants at one site were also invited to complete a 3-month follow up assessment. Study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the University of Washington (Harris et al. 2009). REDCap is a secure, web-based software platform designed to support data capture for research studies. Participants were compensated $20 and $25 for completing the pre- and post-test surveys, respectively. All program attendees were additionally asked to complete a feedback survey at the end of the program.

In order to gain a deeper understanding of participants' experiences with REAL Pro, we conducted a focus group at one of the research sites. The focus group was held online via Zoom with nine participants, who were all staff members from the same site. All staff members who had attended REAL Pro training were sent an invitation via email to participate in a focus group. They signed up to participate via an online form, were allowed work time to attend, and were provided a $20 gift card as compensation. To limit bias, the focus group was led by two of the co-authors who were not part of the intervention or quantitative data collection and analyses. The group lasted one hour and was led using a semi-structured format with questions prepared in advance with spontaneous follow-up questions and prompts.

Intervention

REAL Pro (Resilient Attitudes & Living for Professionals) is a mindfulness and self-compassion based coping enhancement program grounded in psychology, neuroscience, and contemplative practice research. Each session includes a mix of mindfulness practices (e.g., breath awareness, Hatha yoga, guided meditation practices) and cognitive behavioral emotion regulation skills (e.g., cognitive reframing, balanced decision making, radical acceptance, stress tolerance). The content focuses on promoting personal well-being while also supporting the socio-emotional development of children, improving relationships with colleagues and families, and building a culture of compassion and resilience at work. (see Table 1).

Table 1

REAL Pro Intervention Content
Content	Related Practices
Stress & Resilience overview Physiological stress response and how stress affects us mentally, emotionally and physically. How mindfulness and self-compassion support resilience and well-being.	● Body Scan ● Yoga ● Tuning into the Breath
Noticing Our Thoughts Learning to notice the mind’s patterns and to identify and label thoughts.	● Labeling Thoughts ● Sounds & Thoughts Meditation ● Mindfulness of the Senses
Wise Mind Awareness of the benefits of balancing emotion and reason to make decisions and be effective.	● Wise Mind Breathing ● Be in the Pause
Emotion Regulation Purpose of emotions and goals of emotion regulation. Normalizing emotional experiences. Understanding how culture and family affect emotional acceptance and expression.	● + 2 Breathing ● Yoga ● 3 − 2–1 ● Willing Hands
Window of Tolerance What expands or shrinks our ability to cope. Discussion of in the moment coping tools.	● The 3 Ps: pause, be present, proceed ● Progressive Muscle Relaxation
Radical Acceptance Navigating situations we cannot change. Identifying our locus of control when faced with challenging situations. Identifying ways to support oneself in these situations.	● Radical Acceptance worksheet
Common Humanity Recognizing interconnectedness. Developing the ability to intentionally feel connected to others.	● Just Like Me ● Peace & Kindness (metta practice)
Self-Compassion How self-compassion supports resilience. Noticing the inner voice/critic. Modeling self-compassion with families.	● How would I treat a friend? ● Self-Compassion Break ● Breathing with Anchor Phrases

Measures

For the quantitative assessment, participants completed self-report measures assessing self-compassion, perceived stress, emotion regulation, coping, indicators of well-being including resilience and flourishing, and indicators of professional burnout and secondary traumatic stress. Measures were selected to assess the targets of the program including reducing stress, improving emotion regulation, enhancing active coping, and promoting well-being.

Perceived Stress was assessed using the 10-item Perceived Stress Scale (PSS; Cohen et al., 1983) which assesses current levels of perceived stress (6 items) and appraisal of ability to cope with stress (4 items). Internal consistency was 𝛼 = .68 in this study.

Self-Compassion was measured using the 12-item Self-Compassion Scale-Short Form (Raes et al., 2011) which assesses dimensions of self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identification on 5-point scale (1 = almost never – 5 = almost always). Response options include “I’m intolerant and impatient towards those aspects of my personality I don’t like,” and “I try to see my failings as a part of the human condition”. Internal consistency of .80 − .92 has been reported and was 𝛼 = .89 in this study.

Emotion Dysregulation was measured using the brief 18-item Difficulties in Emotion Regulation Scale (Victor & Klonsky, 2016), scored so that it represented deficits in awareness, understanding, and acceptance of emotions, impulse control, and access to emotion regulation strategies. Participants rate statements such as “I pay attention to how I feel,” and “When I am upset, I become out of control,” on a 5-point scale (1 = almost never – 5 = almost always). Internal consistency reliability of .97 has been reported and was .91 in this study.

Coping was assessed using the 24-item short form of the Brief COPE inventory (Carver et al., 1989), which asks participants what they do or feel during a stressful event. In this study, we assessed engagement strategies, which combined active (i.e. “I concentrate my efforts on doing something about it”), planning (i.e. “I make a plan of action”), positive reappraisal (i.e. “I try to see it in a different light, to make it seem more positive”), and acceptance (i.e. “I get used to the idea that it happened”) coping strategies, with 𝛼 = .83. We also assessed denial (i.e. “I refuse to believe that it has happened”) as a disengagement strategy, with 𝛼 = .82.

Well-being was indicated with measures of resilience and flourishing. On the 6-item Brief Resilience Scale (Smith et al., 2008) respondents indicated on a 5-point scale their ability to cope with and recover from stressful situations (1 = strongly disagree – 5 = strongly agree). Examples include “I tend to bounce back quickly after hard times,” and “I have a hard time making it through stressful events”. Internal consistency ranging from .80 − .91 has been reported, and was .87 in this study. Well-being was also assessed using the 8-item Flourishing Scale (Diener et al., 2010). Respondents indicate on a 7-point scale (1 = strongly disagree – 7 = strongly agree) their agreement with items such as “I am engaged and interested in my daily activities,” and “I lead a purposeful and meaningful life”. Alpha was .87.

Burnout and secondary traumatic stress were assessed using 2 subscales (10 items each) from the Professional Quality of Life Measure (ProQOL; Stamm, 2010). Participants rated items assessing feeling overwhelmed, worn out, ineffective and unsupported in their work. Internal consistency reliabilities were 𝛼 = .64 for burnout and 𝛼 = .87 for secondary traumatic stress in this study.

Analytic Plan

The aim of the study was to evaluate the benefit of REAL Pro to providers and staff who work with children and families. Dependent measures t-tests were conducted to examine changes in outcomes from pretest to posttest. Intent to treat analyses were used such that everyone enrolled in the study was included in analyses regardless of their degree of participation. Missing posttest values were substituted with the sample posttest mean value. Consequently, analyses were conducted on the 136 providers who enrolled in the study and completed pretest surveys. Mean-value substitution addresses bias potentially introduced by attrition while preserving power for analyses and preserving the estimate of the magnitude of the effect. Additional dependent measures t-test were conducted to assess the degree of change from pretest to follow-up assessments in the small number (n = 11) of participants who were asked to complete a 3-month follow-up assessment (all participants at one early childhood site). These analyses provide preliminary evidence about whether program benefits continued or were maintained over time.

Qualitative analyses were conducted for a focus group held with a sub-sample at one early childhood education site serving families living in low-income contexts. Participants were informed that the purpose of the group was to provide insight into what worked well, what was useful to them and what didn’t work as well in the REAL Pro sessions in order to improve the program for others. Participants were first asked a series of questions regarding what was good about the program including: 1) What moments or lessons stand out in your mind as the most valuable or important? 2) What aspects of REAL Pro have you carried forward into your life? 3) Do you have any reflections on how this program has affected your work community? The participants were then asked to share what they would change or improve: 1) Suppose that you were in charge and could make one change that would make the program better. What would you do? 2) What else could be improved? Any other suggestions for improvement? The participants were also asked how they would describe the program to someone else, a friend or family member.

The focus group was recorded and transcribed with participants’ names redacted for analysis with both facilitators reviewing the transcript for accuracy. Transcripts were coded and thematic analysis was conducted by the author and one research coordinator. Codes were developed through an iterative process by the two coders to ensure consistency in coding and themes were developed independently and finalized by consensus.

Preliminary Analyses

Missing data. Cases with complete data (n = 98), that is both pre- and posttest assessments, were compared with those missing data (n = 38) to assess the potential for bias introduced by attrition. There were no differences on pretest variables related to missingness. The magnitude of the effects of missingness were small for all variables (r = .01 to .11), indicating that little bias was introduced by missing posttest responses. To determine whether rates of missing data differed by provider group, χ² tests were conducted, and all tests were nonsignificant indicating that the provider groups completed surveys at similar rates.

Provider group related to pretest levels. We examined whether the provider groups differed in their pretest levels on study variables. Early childhood educators reported higher levels of self-compassion (r = .18, p = 0.034), whereas K-12 teachers reported lower levels (r = − .18, p = 0.038). Youth providers reported greater difficulties with emotion regulation (r = .19, p = 0.026) and higher perceived stress (r = .21, p = 0.018). Early childhood educators reported more use of denial coping (r = .22, p = 0.010) while providers in medical settings reported less denial coping (r = − .21, p = 0.017). To assess whether intervention effects depended on the provider groups, multiple regressions were conducted regressing posttest values on pretest levels and all the provider group status indicators. None of the effects of provider group status was significant indicating that rank order changes from pretest to posttest were not different across the provider groups.

Intervention Effects

The correlations among all study variables are provided in Table 2. Table 3 includes pretest (n = 136), posttest (n = 98) and follow-up (n = 11) means and standard deviations. Intent to treat analyses were conducted with sample mean replacement for missing posttest data. Dependent-sample paired t-test analyses tested differences from pretest to posttest, and Cohen’s repeated measures d provided an estimate of intervention effect sizes. Results showed significant improvements in self-compassion, active coping and emotion dysregulation, with moderate effect sizes. There was a trend towards improved resilience as well. There were no significant mean differences from pretest to posttest for perceived stress, denial coping, flourishing, burnout or secondary traumatic stress.

Table 2

Correlations among study variables at pretest.
	SC	PS	ED	AC	DE	FL	RE	BO
Reducing Stress
Self-compassion (SC)	--
Perceived Stress (PS)	-0.555**	--
Emotion Regulation
Emo Dysregulation (ED)	-0.620**	0.498**	--
Active Coping (AC)	0.549**	-0.305**	-0.274**	--
Denial (DE)	0.133	0.046	0.386**	-0.132	--
Well-being
Flourishing (FL)	0.635**	-0.355**	-0.427**	0.503**	-0.130	--
Resilience (RE)	0.661**	-0.503**	-0.572**	0.449**	-0.135	0.537**	--
Burnout (BO)	-0.035	0.291**	0.231**	0.187*	0.033	0.131	-0.096	--
Secondary Trauma (ST)	-0.418**	0.433**	0.515**	-0.150	0.289**	-0.395**	-0.377**	0.289**
p < .05; *p < .01

Table 3

Observed means, standard deviations, dependent sample t-tests for complete cases for pretest to posttest change, pretest to follow-up change, and intervention effect sizes.
	Pretest M(SD) n = 136	Posttest M(SD) n = 98	Follow-up M(SD) n = 11	Pre/posttest Difference t-test, p-value (df = 135)	Cohen’s d Repeated Measures	Pre/Follow-up Difference t-test, p-value (df = 10)
Reducing Stress
Self-compassion	3.03(0.77)	3.20(0.56)	3.70(0.59)	3.30, 0.001	0.34	3.07, 0.012
Perceived Stress	2.15(0.57)	2.08(0.42)	1.86(0.33)	1.52, 0.131	0.12	1.09, 0.301
Emotion Regulation
Emo Dysregulation	2.53(0.73)	2.41(0.47)	2.02(0.36)	2.12, 0.036	0.27	1.08, 0.307
Active Coping	1.95(0.50)	2.03(0.42)	2.17(0.52)	2.17, 0.032	0.32	0.53, 0.607
Denial	0.38(0.63)	0.43(0.54)	0.45(0.65)	0.78, 0.437	0.10	1.30, 0.223
Well-being
Flourishing	5.72(0.79)	5.81(0.73)	6.15(0.60)	1.50, 0.136	0.22	1.27, 0.233
Resilience	3.16(0.79)	3.27(0.60)	3.83(0.78)	1.85, 0.067	0.29	1.00, 0.341
Burnout	3.36(0.39)	3.34(0.32)	3.14(0.18)	0.64, 0.523	0.06	2.72, 0.022
Secondary Trauma	2.48(0.66)	2.42(0.56)	1.91(0.40)	1.19. 0.236	0.16	3.01, 0.013

Dependent-sample paired t-tests were also conducted to examine change from pretest to follow-up in the small sample from which follow-up assessments were obtained. A significant difference on self-compassion from pretest suggests significant improvements at posttest were maintained. Significant differences from pretest to follow-up on burnout and secondary traumatic stress emerged when there were not significant differences from pretest to posttest. This might be an artifact of the small subsample of participants who were asked to complete a follow-up assessment, or it could suggest a delayed effect of the program on burnout and secondary trauma. To explore this, differences from posttest to follow-up were examined. There was a significant decrease in secondary traumatic stress from posttest to follow-up (t[10] = 4.908, p = 0.001) and a trend toward a decrease in burnout (t[10] = 1.785, p = 0.104).

Acceptability

The REAL Pro program also showed high acceptability, with participants reporting high levels of satisfaction and positive feedback. All participants in the program (193), not only those participating in the evaluation study, were invited to complete program feedback surveys, and 183 (95%) program participants completed the feedback survey. Responses showed that 98% (179/183) of respondents indicated the program content was useful and interesting; 97% (177/183) would recommend the program to colleagues; and 96% (175/183) reported the skills help with managing emotions and coping with challenging situations. Themes in feedback surveys indicated that staff have integrated coping skills into their workdays, enhanced their ability to model self-regulation skills with children, and that teams found a common language to discuss stress and well-being.

Qualitative

Themes emerged in three categories from the focus group:

Benefits of the program: Individual benefits to the participants themselves; practical tools or skills used with children and families; and strengthening a sense of community among staff at the center.
Aspects of the program that allowed for the above benefits to be realized included the space created by the facilitators felt safe; the program and facilitators were flexible, and adaptations were made to meet the needs of the group; and practices and concepts were introduced that provided valuable ongoing support.
Program Improvement suggestions included lengthening the program or having additional ongoing support.

In presenting the results, we are intentionally relying on quotes from the participants to honor the perspective and framing that they, personally, gave to their experiences in REAL Pro. Quotations are indented and led by the study identification number assigned to the participant being quoted.

1. Benefits of the program: Participants described the benefits of the program for them personally as a “release” from stress, anxiety and pressures with all participants agreeing with the ones who shared this. The sessions themselves provided time for release and the content provided support for participants to care for themselves.

103: ...it's helped me calm myself, help my anxiety, help my stress level, give me a release.

106: I think it was a good time for us to kind of just release and unravel from everything that's been going on.

109: Yes, I agree [with release] somehow teaching us how to let go of situations that are uncertain and remain focused on the here and now.

Participants also discussed practical ways they applied skills learned in REAL Pro when working with children, interacting with parents, or to support themselves in difficult moments.

101: …with REAL Pro we've been able to apply it to our daily life, like, whether it be our home life or work life, like it's something that's practical that you can change. You can use it not only with yourself but with your students as well.

103: ...when I am in the classroom with students, it is magical to see these 3–5 year olds close their eyes, and sit calmly and use this practice as a group.

104:...you know we're in a meeting and I'm thinking to myself okay you've got to, you've got to breathe yourself, you've got to remember, Just Like Me [a compassion-based practice]. And if my Window of Tolerance [a stress tolerance model] is closing, what am I going to do to change that?

Participants discussed the importance of the sense of community and authenticity that REAL Pro supported among the organization’s staff with all participants in agreement that REAL Pro built trust among staff. Participants shared:

106: …[REAL Pro] was a great opportunity for us to be real and be authentic with each other in terms of, like, how we were feeling with our emotions and our struggles and I think that that in itself, like, it helped generate a lot of, like, trust and respect within each other.

105: I think [REAL Pro] has given us techniques that help with communication among ourselves.

104: I think [REAL Pro] helped foster a sense of community that wasn't there when some people were at home, some people were in the building, there were a lot of external forces that were putting pressure on people…

When asked what aspects of REAL Pro they had carried forward into their lives, participants identified four in-the-moment coping skills (ranging from breathing to sensory practices), two compassion-based practices, and a mindfulness-based body scan.

2. Aspects of the program that allowed for the above benefits to be realized:

The positive regard for the program shared by participants was attributed largely to the facilitators’ ability to create an environment that felt safe and supportive to the participants. One participant described the program as “genuine and real” and said the facilitators “are like one of us” (participant 103). Other participants noted:

108: I truly believed that they accepted me right where I was. There was no prerequisites… I didn't have to show up any kind of way, I didn't have to filter myself in any kind of way…

I always felt [I was] an equal participant…they were just so inclusive - so inclusive.

104: Like you were really heard and listened and valued and that carried over each week.

One participant specifically identified the importance of having a facilitator of color leading the program contributing to the sense of safety.

106: I think that it was really helpful that we had a person of color kind of lead us into this, because I think you know as a [ethnicity removed to protect identity] woman, like, I'm not really raised on the idea of emotion. I'm not really raised to, you know, talking about, like, my anxiety and stuff and having, like, just that representation there … And every time that I shared I felt seen in that sense…we have a lot of POC and BIPOC… People were just more comfortable in that sense, and it made everyone feel heard and seen…it's super important that we're talking about certain things and that we’re being represented in that way.

Another aspect of building a sense of safety that participants described was the facilitators’ ability to be responsive to the participants and situations unfolding at their center and in society. For example, a participant noted that the facilitators were mindful of when to have Zoom breakout groups by teams or have managers in a different group due to power dynamics.

101: I remember one day when stuff happened there was like a whole bunch of us that just, we were drained and did not want to talk and so they said, private message me if you don't want to talk. And they put us in separate groups, of groups that wanted to talk with each other and groups that just sat there and were silent for a little bit.

3. Program Improvement: When asked for ways they would change the program to make it better, participants were quick to indicate how much they appreciated the program, including expressing deep appreciation for the facilitators. There was agreement that they want more of this programming in an ongoing way and one also speculated that it may have been even better in-person if that had been a possibility given the pandemic.

107: I wish we meet them on weekly basis

101: …if it was available it'd be awesome if we could have that resource at our Center, like, have someone there in the moment or maybe even have them available through zoom I guess… in the moment (when you are) needing help, or that day needing help.

One participant also indicated they would like more direct support for implementing mindfulness with the families they work with.

104: We want to bring a parent group together … I am pretty new at this whole mindfulness thing so like it would have been helpful if it was kind of pre-packaged like, this is how you would present it or, this is what you would present instead of having to think to myself, like, how would I change it an adapt it if I was talking to parents…

This study aimed to establish preliminary evidence for an intervention that can reduce STS and burnout and improve well-being in providers across various care settings. This study evaluated the effectiveness of the REAL Pro intervention in reducing STS and burnout and improving well-being through increased capacities for self-compassion, emotional regulation and effective coping in professionals who work with children and families. Reduced stress and burnout ultimately would be expected to improve services received by children and families (e.g., Salamehe et al., 2021). The findings for intervention effectiveness were mixed. Participants demonstrated significant increases in self-compassion, active coping and emotion regulation and a trend towards improved resilience. However, significant improvements in perceived stress, STS or burnout were not observed at posttest. Exploratory follow-up analyses with a small subset of the sample suggests there might be delayed effects of the intervention on reduced STS and burnout, suggesting the possibility that, as participants’ capacities for self-compassion, coping and emotion regulation improve, they may experience reductions in STS and burnout over time.

Levels of stress, STS and burnout are high among professionals who provide services to children and families (Gallup, 2014; Lamson et al., 2014; Mulyani et al., 2021; Sinclair et al., 2017). While it is critical to address structural and organizational factors that contribute to this, there are also individual level factors that can be promoted to potentially reduce STS and burnout (e.g., Brigham et al., 2018). A strength of the REAL Pro intervention is the combination of mindful self-compassion practices with cognitive-behavioral coping and emotion regulation skills that have been shown to reduce perceived stress, symptoms of anxiety and depression, and improve well-being on other populations (e.g., Ferrari et al., 2019, Long et al., 2023). Although the quantitative results of this study were mixed, class feedback surveys and qualitative findings suggest that participants made use of and experienced the intended benefits from the mindfulness and coping skills, indicating that participating in the intervention provided stress relief.

In addition, in qualitative feedback participants reported that they will be able to utilize the practices and skills in their work with children and families. Professionals need tools both for their own well-being and for supporting the social, emotional and behavioral well-being of the children and families they serve, and the skills taught in REAL Pro may accomplish both. Having practical tools for managing stress and difficult work-related situations can improve provider-client relationships and services. For example, one study showed that being trained in an effective social-emotional learning program mitigated the negative association of teacher burnout with the quality of teacher-child interactions and instructional support in Head Start classrooms (Sandilos et al., 2020). Given high rates of stress, STS and burnout in child- and family-serving professions and the impact those have on the quality of services (e.g., Salamehe et al., 2021), interventions that can address both are needed.

Another strength of this study lies in its effort to address STS, burnout and well-being among a variety of professionals in child and family services, whereas most studies focus on one profession only (e.g., Ormiston et al., 2022). Our results indicated that the program effects were equivalent across professions, suggesting that it can be applicable to a variety of professionals working with children and families. By recognizing the interrelated nature and common experiences of various professions that serve children and families, the REAL Pro intervention has the potential to reach many groups of crucial service providers to boost their resilience and effectiveness. REAL Pro attempts to alleviate symptoms of stress and burnout across a range of care providers through streamlined and universally applicable methods, including learning more appropriate ways to understand and respond to stress, strengthening tools for tuning into oneself and the clients with whom one works, and cultivating a culture of compassion for self and others at work. These methods can reduce reactionary responses in providers and help them respond to difficult situations in a balanced way. In addition, these methods support providers’ capacities to respond to their own emotional needs and learn key skills that support them in their day-to-day lives.

This study evaluating the REAL Pro intervention shares some of the same limitations as other similar intervention studies mentioned earlier (Hazen et al., 2020; Luthar & Mendes, 2020; Orsi et al., 2023). In this preliminary evaluation, the sample size was limited impacting the ability to detect small intervention effects. In addition, we were unable to include a control group for comparison, and participants self-selected into the study introducing potential bias relative to all the individuals who participated in the intervention. However, the REAL Pro intervention is scalable such that it may be universally applied to address staff well-being across a diverse spectrum of caring professionals. By improving well-being and emotional regulation, the REAL Pro intervention addresses both distinct and common challenges related to STS and burnout that are experienced in a variety of caregiving professions. As such, despite the limitations of this pilot study, the REAL Pro intervention shows promise for succeeding in its intended purpose and reaching a broad population.

This study lays a foundation for further investigations of the REAL Pro intervention that aims to foster a thriving and resilient workforce that can deliver high-quality services to children and families. Future evaluations of REAL Pro would benefit from use of a more rigorous research design that includes a comparison group, randomized assignment to groups, and follow-up assessments. In addition, future evaluations could examine the impact of the intervention on organizational factors, such as contributing to a supportive, collegial environment that values staff well-being. Nonetheless, the results of this study suggest promising directions for REAL Pro to support the well-being of child and family serving professionals and quality of care they provide.

Author Contribution

L.L. and R.L. developed the intervention and designed the study. R.L., R.C., and M.A. implemented the intervention and oversaw data collection. L.L and K.S. conducted data analyses. L.L., R.C., I.B., and R.L. wrote the manuscript. All authors contributed to the interpretation of the results and to the final manuscript.

Conflict of Interest

The authors have no conflicts of interest to disclose.

Data availability

The dataset included in this study is not publicly available due to not having participant consent or IRB approval to make it publicly available. Data are available from the corresponding author upon reasonable request.

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No competing interests reported.

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A Well-being Promotion Program Increases Self-Compassion, Resilience and Active Coping among Providers Who Work with Children and Families

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