This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
A growing body of research suggests that resilience training can play a pivotal role in creating mentally healthy workplaces, particularly with regard to protecting the long-term well-being of workers. Emerging research describes positive outcomes from various types of resilience training programs (RTPs) among different occupational groups. One specific group of workers that may benefit from this form of proactive resilience training is first responders. Given the nature of their work, first responders are frequently exposed to stressful circumstances and potentially traumatic events, which may impact their overall resilience and well-being over time.
This study aimed to examine whether a mindfulness-based RTP (the Resilience@Work [RAW] Mindfulness Program) delivered via the internet can effectively enhance resilience among a group of high-risk workers.
We conducted a cluster randomized controlled trial (RCT) comprising 24 Primary Fire and Rescue and Hazmat stations within New South Wales. Overall, 12 stations were assigned to the 6-session RAW Mindfulness Program and 12 stations were assigned to the control condition. A total of 143 active full-time firefighters enrolled in the study. Questionnaires were administered at baseline, immediately post training, and at 6-month follow-up. Measurements examined change in both adaptive and bounce-back resilience as well as several secondary outcomes examining resilience resources and acceptance and mindfulness skills.
Mixed-model repeated measures analysis found that the overall test of group-by-time interaction was significant (
The results of this RCT suggest that mindfulness-based resilience training delivered in an internet format can create improvements in adaptive resilience and related resources among high-risk workers, such as first responders. Despite a number of limitations, the results of this study suggest that the RAW Mindfulness Program is an effective, scalable, and practical means of delivering online resilience training in high-risk workplace settings. To the best of our knowledge, this is the first time a mindfulness-based RTP delivered entirely via the internet has been tested in the workplace.
Australian New Zealand Clinical Trials Registry ACTRN12615000574549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368296 (Archived by WebCite at http://www.webcitation.org/75w4xtrpw).
Poor mental health is the leading cause of absenteeism and long-term disability worldwide [
One proactive approach receiving increased attention from both public and private sectors is individual psychological resilience training. Resilience can be viewed as a dynamic process reflecting a person’s ability to adapt, manage, and recover effectively from stressful experiences and adverse circumstances [
Determining which RTPs are beneficial to groups such as emergency workers is particularly important for several reasons. First, these workers play a vital role in providing critical services that maintain the health and safety of our communities. Second, given the nature of their work, emergency workers are at higher risk of developing mental health conditions such as depression, anxiety, and alcohol misuse as well as posttraumatic stress disorder (PTSD) [
RTPs typically share the common aim of enhancing a person’s ability to manage stressful situations and adverse circumstances more effectively and with greater emotional insight. Although they may share this common goal, RTPs often differ considerably in terms of content, length, and delivery [
The growing emphasis on mindfulness training within RTPs is understandable, given the large body of research highlighting the positive benefits of this practice on mental health outcomes [
These specific strategies and skills require time to practice and attain proficiency. It is, therefore, unsurprising that most resilience studies completed thus far describe training programs that involve multiple face-to-face training sessions [
In response to these challenges, workplace mental health researchers have begun to develop and evaluate novel electronic health (eHealth) programs (online, Web-based training) to help improve accessibility and engagement. Results from a recent meta-analysis found that digital mental health interventions in the workplace can improve psychological well-being [
To address these issues, we developed an interactive e-learning program called the Resilience@Work (RAW) Mindfulness Program. This self-paced intervention aims to enhance psychological resilience among workers. It comprises 6 online training sessions, each taking about 20 to 25 min to complete on a tablet or computer. The program involves mindfulness training, psychoeducation, and a range of skills and strategies drawn from evidence-based therapies, including ACT, mindfulness-based cognitive therapy, and compassion-focused therapy. A more detailed overview of this program was published in a recent pilot study, and it was found that the RAW Mindfulness Program is feasible in a workplace setting and that those using the program showed a trend toward increased resilience and psychological flexibility [
The main aim of this study was to build upon the initial pilot research and examine whether the RAW Mindfulness Program can improve resilience among a group of high-risk workers, specifically emergency services personnel. Our primary hypothesis is that first responders receiving the RAW Mindfulness Program will have increased resilience following training, compared with the control group. In addition, we will examine the impact of this training on several secondary outcomes, including acceptance and mindfulness skills, as well as resilience resources such as coping, self-compassion, and optimism. To the best of our knowledge, this is the first time an entirely online mindfulness-based RTP has been evaluated via a randomized controlled trial (RCT) with active emergency services personnel.
This study was prospectively registered with the Australian New Zealand Clinical Trial Registry (ANZCTR no: 12615000574549). We conducted a cluster RCT comprising 24 NSW Primary Fire and Rescue and Hazmat Stations. Fire and Rescue New South Wales (FRNSW) is the seventh largest urban fire service in the world and responds to firefighting, rescue, and hazardous material emergencies in Sydney, Australia, and surrounding regional areas. Given the nature of their work, employees are known to have an elevated risk of depression, anxiety, and PTSD [
Potential participants were full-time firefighters working in the 24 Primary Rescue and Hazmat Stations involved in this trial. Participants were informed about the study during a standard well-being talk facilitated by members of the FRNSW Peer Support Team. These talks are performed several times a year as part of FRNSW’s employee well-being initiative. The Peer Support System within NSW Fire and Rescue is a successful and long-running nonhierarchical support service for firefighters. From November 2015 to April 2016, the Peer Support Officers provided a brief presentation on the topic of resilience as well as the aims of the research study and highlighted that participation in the study was voluntary. The presentation slides were provided by the researchers. Following the presentation, firefighters were provided with a participant information sheet and consent form, the study questionnaire, and a stamped address envelop to return their information to the research team if they chose to be a part of this study. Potential participants in the 12 stations randomly assigned to the intervention group were also asked to provide their email address in the consent form to receive information to access the online program. Log-in details were then emailed directly to the participant. When a participant logged into the online RAW program, this was considered as final consent and enrolment in the intervention group. Participants could withdraw at any time from the study. Participants were not aware of the study hypotheses and were blinded to intervention versus control status. Potential participants who were currently engaged in any form of regular psychological therapy with a psychologist and/or psychiatrist were excluded from this study.
Firefighters assigned to the intervention group received the RAW Mindfulness Program. FRNSW granted firefighters who were enrolled in the study permission to access the program at work. Tablets (iPads) were made available in the stations for firefighters to complete the online program. The RAW program is a mindfulness-based intervention, which also draws on ACT and has a significant emphasis on self-compassion and acceptance skills. The intervention comprises 6 online training sessions. Each session takes about 20 to 25 min to complete. A combination of interactive exercises, audio, and animation is used to teach resilience skills. An overview of the core strategies and skills taught in the RAW program is outlined in
Overview of skills and topics covered in the Resilience@Work Mindfulness Program.
Session | Resilience topic and skills focus | Mindfulness tracks |
1 | Introduction to mindfulness, resilience and psychological well-being | Drop anchor; Take 10; Leaves on a stream |
2 | Mindfulness skills, understanding your reactive mind versus wise mind, recognizing unhelpful mind chatter and managing uncomfortable and unhelpful thoughts (cognitive defusion); Recognizing your values exercise | Mindful Breathing; Defusion Technique; Notice it, Name it, Let it Go (I’m having the thought that…); Defusion technique 2: Thank you Mind |
3 | Revision of Cognitive Defusion; Introduction to Mindfulness with Emotions, The Reactive Mind and Avoidance, Understanding how values are linked to Emotions; Valued Action check | Creating Space (Mindfulness with emotions); Mindful Body Scan; The Golden Room |
4 | The problem with Avoidance, Recognizing avoidance strategies versus adaptive strategies | Creating Space; A Mindful Break (mindfulness with words) Surfing Waves |
5 | Self-care and support, the Compassion myth, barriers to accessing compassion, compassion fatigue, self-compassion actions & resilience, Identifying Mindful Support (compassionate, nonjudgmental and mindful); Valued Action check | A kind and gentle hand (loving-kindness practice); A Safe Place (compassion-focused mindfulness); A bird’s eye view |
6 | Compassion focused Mindfulness; Gratitude practice, optimism and resilience, identify and celebrate the milestones; creating a personalized action plan to practice skills | Breathing in the Present Moment; A Golden Moment exercise; Being Kind to your old wounds |
Along with the standard FRNSW well-being talk, firefighters who were assigned to the control group received access to the Healthy Living Program (HLP). FRNSW granted permission to firefighters enrolled in the study to access the program while at work. The HLP comprises 6 modules that provide helpful information on a range of health and well-being topics, for example, healthy skin, healthy home environment, and mobile phone use. The self-paced program was available on tablets (iPads) within the station, with each module taking about 20 min to complete.
The primary outcome of this study was resilience. The means by which resilience is best measured remains a topic of considerable discussion in the literature. In their review of resilience scales, Windle et al [
Psychological resilience was measured using the validated short-form 10-item version of the Connor-Davidson Resilience Scale (CDRISC_10) [
Bounce-back resilience (the ability to recover from stress) was measured using the 6-item BRS [
A number of secondary outcomes were included to examine the processes by which the RAW Mindfulness Program may enhance resilience. Measures of acceptance and mindfulness skills and several resilience resources were administered.
Mindfulness was measured using the short version of the Freiburg Mindfulness Inventory (FMI-14) [
The CFQ is a measure of cognitive fusion and defusion, a core component of the ACT model [
The Acceptance and Action Questionnaire (AAQ-II) is a measure of experiential avoidance and psychological inflexibility. Previous research has found the AAQ-II to be a reliable and valid measure, with a Cronbach alpha of .84 and test-retest reliability of .81 at 3-month follow-up [
The 12-item short form of Self-Compassion Scale (SCS-SF) [
The Life Orientation Test-Revised (LOT-R) was used to assess levels of optimism [
A total of 3 subscales of the Brief-Coping Orientation to Problems Experienced (Brief-COPE) [
The extent to which participants value their daily activities and have a sense of life purpose was examined by the 6-item Life Engagement Test (LET) [
As outlined in the a priori analysis plan recorded in the online trial registry (ANZCTR no: 12615000574549), the primary analysis was undertaken within an intent-to-treat framework utilizing mixed-model repeated measures (MMRM). This approach is recognized as a reliable method of analyzing RCT data [
This study was conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement and guideline for transparent reporting of RCTs.
Demographic details of firefighters enrolled in the study are shown in
Consolidated Standards of Reporting Trials flow diagram. RAW: Resilience@Work.
Demographics of enrolled participants at baseline.
Demographics | Intervention group (n=60) | Control group (n=83) | |
Male | 56 (93) | 81 (98) | |
Female | 4 (7) | 2 (2) | |
Age (years), mean (SD) | 43.9 (7.8) | 41.1 (9.2) | |
1 to 5 years | 5 (8) | 9 (11) | |
6 to 10 years | 13 (22) | 27 (33) | |
11 to 15 years | 11 (18) | 24 (29) | |
16 to 20 years | 6 (10) | 6 (7) | |
More than 20 years | 25 (42) | 17 (20) | |
1 to 5 | 3 (5) | 14 (17) | |
6 to 10 | 7 (12) | 17 (21) | |
11 to 15 | 5 (9) | 10 (12) | |
16 to 20 | 6 (10) | 5 (6) | |
More than 20 | 37 (64) | 37 (45) | |
CDRISC_10a | 28.4 (5.3) | (5.5) |
|
BRSb | 22.1 (3.4) | 23.0 (3.6) |
aCDRISC_10: 10-item version of Connor-Davidson Resilience Scale.
bBRS: Brief Resilience Scale.
The majority of participants (38/60, 63%) completed more than half the RAW program (mean number of sessions completed was 3.5 out of a possible 6; SD 2.0), equating to 60 to 75 min of training. A total of 22 participants (22/60, 37%) went on to complete 5 to 6 sessions (a total of at least 100 to 120 min of training).
For the primary outcome, the overall test of group-by-time interaction was significant (
No significant differences were found between the intervention group and the control group in terms of change in bounce-back resilience as measured by BRS (
A per-protocol analysis examined the dose response to the RAW intervention program at 6-month follow-up (
Test of group-by-time interaction (
Analysis of primary outcome (change on the 10-item version of the Connor-Davidson Resilience Scale) by number of Resilience@Work sessions. Statistical difference test of significance compared with control group obtained from mixed-methods repeated measures models. RAW: Resilience@Work; CDRISC_10: 10-item version of the Connor-Davidson Resilience Scale.
Mixed-model repeated measures with secondary outcome variables change at 6 weeks and 6 months for intervention and control groups.
Measure | Description | Change at 6 weeks Mean (SE) | Significance test of difference at 6 weeksa | Change at 6 months Mean (SE) | Significance test of difference at 6 monthsa | |||
Control | RAW | Control | RAW | |||||
Cognitive Fusion (CFQ) | Level of thought entanglement | −0.18 (1.07) | −0.85 (0.74) | .25 | 0.06 (0.89) | −1.65 (1.18) | .40 | |
Experiential Avoidance(AQQ_II) | Psychological inflexibility/ reactivity, tendency to avoid experiencing internal events | −0.29 (1.38) | −0.83 (0.56) | .31 | −0.27 (0.81) | −0.94 (0.81) | .27 | |
Self-Compassion (SCS-SF) | Level of self-compassion during difficult times | 0.89 (1.66) | 1.31 (0.95) | .42 | 0.71 (1.24) | 1.47 (1.08) | .99 | |
Mindfulness (FMI) | Level of mindfulness and present moment awareness | 0.38 (1.06) | 1.18 (0.87) | .79 | 0.37 (0.99) | 4.16 (1.05) | .09 | |
Life Engagement Test (LET) | Sense of purpose in Life | 0.00 (0.64) | 0.11(0.57) | .83 | −0.69 (0.66) | −0.60 (0.53) | .89 | |
Life Orientation Test- Revised (LOT-R) | Level of optimism | −0.83 (0.55) | 1.2 (.43) | .05a | −0.86 (0.48) | 0.38 (0.68) | .14 | |
Active Coping (AC) | Personal effort and actions to change and improve current situation | 0.11 (0.46) | 0.40 (0.43) | .09 | −0.56 (0.44) | 0.21 (0.43) | .046a | |
Use of Emotional Support (ES) | Emotional, empathic and comfort from others | −1.35 (0.48) | 0.30 (0.36) | .05a | −0.40 (0.34) | 0.24 (0.30) | .10 | |
Use of Instrumental Support (IS) | Advice/help from others on what actions to take | −0.47 (0.43) | 0.43 (0.36) | .05a | −0.29 (0.37) | 0.03 (0.38) | .32 |
aSignificant at
Analyses of change for secondary outcomes are shown in
Finally, we examined how mindfulness (FMI) and cognitive defusion (CFQ) skills changed over time for partial completers (1-4 sessions) and completers (5-6 sessions). Change in scores was examined across 3 time points: baseline, 6-week follow up, and 6-month follow-up. The differences between baseline and different follow-up for partial completers and completers were analyzed using paired
Analysis of change in mindfulness and cognitive fusion scores over time for partial and full program completers. RAW: Resilience@Work; FMI: Freiburg Mindfulness Inventory; CFQ: cognitive fusion questionnaire.
This study is the first ever RCT to test the ability of an entirely online training program to enhance psychological resilience. Our results demonstrate that the RAW Mindfulness Program enhanced adaptive psychological resilience among active firefighters, increasing their ability to adapt successfully in the face of adverse circumstances and situations. Our per-protocol analysis found that the greatest improvements were seen among those who completed all 6 RAW sessions—at least 2 hours of training over a minimum of 3.5 weeks. The results support previous findings that mindfulness-based RTPs can create improvements to individual resilience [
This study utilized 2 of the most commonly used measures of resilience, along with several measures of resilience-related factors. This approach was in response to the absence of a current gold standard resilience measure [
In terms of the secondary outcomes examined in this study, the RAW program resulted in significant improvements in overall optimism, use of emotional support (seeking empathy and emotional support from others), and use of instrumental support (actively seeking advice and help from others on what actions to take) post training. At 6-month follow-up, there was a significant improvement in the level of active coping (personal effort and actions to change and improve the current situation). This may further explain why improvements were observed on the CDRISC_10 and not the BRS, as the RAW program focused heavily on the acquisition of skills directly aimed at enhancing resilience resources that are more directly measured by the CDRISC. Surprisingly, although an overall trend of improvement in acceptance and mindfulness skills was observed in the RAW group, when compared with the control group, these changes did not reach statistical significance. As this study’s power analysis was based on our primary outcome of resilience, it may have been underpowered to detect a difference on measures of mindfulness and acceptance skills.
Overall, our findings suggest that the RAW program can improve specific resilience resources and aspects of resilience such as distress tolerance, positive adjustment, and perseverance, as measured by the CDRISC_10. It may have less impact on the concept of
Limitations to this research include that the workforce was a male-dominated high-risk group, thus limiting the generalizability of the findings to lower-risk and gender-balanced occupational groups. It is also important to acknowledge that during the trial period, the self-reported resilience of the control group reduced. It is unknown whether this may be related to their ongoing trauma exposure or whether it may be the natural trajectory of resilience among firefighters over a 6-month period. The latter may be the case, given that participants enrolled in this study were all active, full-time firefighters based at Primary Rescue and Hazmat Stations. These stations are the busiest across the state of New South Wales and frequently respond to serious emergencies, critical incidents, and disaster situations, including motor vehicle accidents, suicide, structural fires, hazard material, and body recovery. In light of these environmental factors and the workplace setting, it is perhaps unsurprising that the overall resilience of firefighters in the control group declined over a 6-month period. Importantly, this highlights the significance of the temporal elements of resilience and the value of measuring it over several time points [
It is important to also acknowledge the adherence issues in this trial. Although the majority of firefighters (63%) in our study completed over half the program (3.5 out of 6 modules), only 37% of firefighters went on to complete the entire program. Unfortunately, we did not gather specific follow-up information from participants regarding their reasons to stop training. Some potential reasons include poor internet connection within the station, the program being accessible only on tablets or computers, reduced motivation, or limited available time because of competing work responsibilities. It is also possible that a participant may have found certain skills in the early modules helpful and, therefore, felt they did not require additional training. Alternatively, some participants may have found some aspects of the training repetitive and restrictive (each module had to be completed to unlock the next one) and, therefore, lost interest in the program. In future evaluations of the program, it will be important to examine why participants stop engaging in the RAW program and whether having access to the program on other personal devices such as smartphones may increase program adherence. In addition, as noted by recent research [
A final limitation is that the primary outcome of resilience was measured by self-report. Although the measures used are the most validated and widely used measures of resilience available, it is important that future studies are able to assess whether changes in self-reported resilience from interventions such as RAW translate into fewer incidents of mental illness over time. It is important to note that the RAW program was specifically aimed at enhancing personal resilience rather than reducing mental health symptoms. Given the emerging literature on the relationship between low resilience and increased risk of future mental health difficulties [
Despite these limitations, our study’s findings have important implications. First, mindfulness-based resilience training delivered in an online format can create improvements in adaptive resilience and related resources among high-risk workers, such as firefighters. This is particularly significant, given recent findings that low baseline resilience may be a risk factor for increased mental health symptomology in emergency workers [
In conclusion, the RAW Mindfulness Program is an effective, scalable, and practical means of delivering online resilience training to high-risk groups such as first responders. With the benefit of further research and development, this form of online resilience training may serve to enhance mental health on a broad scale, protecting workers who perform some of our society’s most challenging roles.
Acceptance and Action Questionnaire version 2
acceptance and commitment therapy
Brief-Coping Orientation to Problems Experienced
Brief Resilience Scale
10-item version of the Connor-Davidson Resilience Scale
cognitive fusion questionnaire
electronic health
Freiburg Mindfulness Inventory
Fire and Rescue New South Wales
Healthy Living Program
Life Engagement Test
Life Orientation Test-Revised
mixed-methods repeated measures
New South Wales
posttraumatic stress disorder
Resilience@Work
randomized controlled trial
resilience training program
Self-Compassion Scale
This publication was made possible by an Australian Government Research Training Program Scholarship and the University New South Wales Brain Sciences PhD Grant in aid awarded to SJ for her doctoral studies and funding for SH from NSW Health and the icare foundation (grant number: RM09708). RTP, icare foundation, or NSW Health did not have a role in the study design, collection, analysis, or interpretation of the data; writing the manuscript; or the decision to submit the paper for publication. The researchers would like to express their sincere gratitude to the NSW firefighters who generously gave their time to participate in this study. The authors would also like to thank the FRNSW Peer Support Officers and staff who provided invaluable logistical support throughout the research project, in particular, Tara J Lal, Brendan Mott, Mark Dobson, Brett Farmer, and Bruce Fitzpatrick. Finally, the authors wish to thank and dedicate this paper to the NSW firefighters and first responders globally who choose to be of service in our communities every day and by doing so make our world a safer, kinder, and more compassionate place.
SJ and SBH devised the study. SJ developed the RAW Mindfulness Program; the internet-based format; and collected, scored, and entered the data. TJL assisted with data collection. SJ and SBH analyzed and interpreted the data, and SJ wrote the first draft of the manuscript. All authors read and contributed to subsequent versions and approved the final manuscript.
SJ and SBH are associated with a company that offers resilience training (RAW Mind Coach). SBH and FS work for the Black Dog Institute, a not-for-profit organization that provides mental health and resilience training to various other organizations.
CONSORT-EHEALTH checklist (V 1.6.1).