Examining the Delivery of an Online Adaptation of ACT Training in the Workplace for Nursing Professionals: A Feasibility Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a highly relevant topic, as the mental well-being of healthcare workers deserves significant attention. The authors have provided adequate justification for employing ACT training, including appropriate consideration of its content and duration, supported by previous literature. The study objectives are clearly stated.

However, the sample selection process should also specify the exclusion criteria to enhance methodological clarity. The discussion section is well written and effectively highlights both the strengths and limitations of the study. The authors are encouraged to include a clear and concise conclusion to summarize the main findings and implications

Author Response

Thank you for your review and kind suggestions. The following statement has now been added to the manuscript in p. 162-163 "Individuals without current or previous UK-based nursing experience, and those unable to provide informed consent, were excluded" . Furthermore, a conclusion has been added at pages 795-808.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, I added comments in the document.

Comments for author File: Comments.pdf

Author Response

Comment 1:Recommendations:
•The abstract does not specify the number of participants, which makes it difficult to assess the sample and the generalizability of the findings. It is recommended to include basic demographic and numerical data (e.g., N = ...).
•It is also unclear whether the study employed a control group or only a pre-post design. Including this information would enhance the transparency and scientific value of the work.

Author Response:

Thank you for this suggestion. The abstract has now been updated to include the total number of participants (N=43) and a clarification that the study used a single-group pre–post feasibility design without a control group.

Changes made: Added: “A total of 43 participants enrolled in this single-group pre–post feasibility study…”

 

Comment 2: Introduction is dense; could be condensed

Reviewer Comment:

“The introduction is somewhat dense and could benefit from slight condensation… prevalence sections and the literature summary.”

Author Response:

We appreciate this feedback. The prevalence statistics and literature summaries have been streamlined, removing redundancies wherever possible, while retaining core evidence and the necessary context for occupational health readers.

 

Comment 3: 

3. The research gap should be more explicit

Author Response:

We agree. The introduction now clearly states the gap.

Change added: A sentence explicitly identifying the gap has been inserted before the study aims: “No previous study has examined the feasibility of online ACT training incorporating all six psychological flexibility processes for UK-based nurses, delivered via Moodle in a self-guided format”

 

4. Stylistic refinements needed (hyphen, transitions)

Reviewer Comment:

“Remove the hyphen in ‘Ac-ceptance’; improve transitions.”

Author Response:

All typographical artefacts have been corrected. Transitional sentences have been added to strengthen the flow of the manuscript.

 

 

5. Methods section too detailed

Reviewer Comment:

“The text is overly detailed… some parts more appropriate for supplementary materials.”

Author Response:

We acknowledge the concern and have selectively reduced descriptive detail, while retaining content required by the journal (Occupational Health requires Tables and Figures in-text). Technical and theoretical descriptions were shortened, and redundant explanations were removed, especially within the section referring to mechanisms of change.

However, because this is an early-phase feasibility study, detailed reporting of intervention components and feasibility indicators remains essential and aligns with MRC guidance.

 

6. Tables 1–2 contain too much lesson-level detail

Reviewer Comment:

“A concise summary would suffice.”

Author Response:

We have retained the tables in the main text because feasibility and intervention-fidelity documentation require transparency about content structure. However, the wording has been tightened and formatting improved.

 

 

7. Sample size and exclusion criteria not sufficiently clear

Reviewer Comment:

“A clearer explanation of the sample size and exclusion criteria is needed.”

Author Response:

This has now been clarified.

Sampling criteria: UK-based nurses, healthcare assistants, nursing associates, and second-/third-year student nurses with clinical placement experience.

Exclusion criteria: no current or previous experience in nursing roles and those unable to provide informed consent.

A concise explanation has been added to the Methods.

 

8. Data analysis lacks software clarification

Reviewer Comment:

“Include note on software used.”

Author Response:

Added. The manuscript now states that quantitative analyses were conducted using SPSS (Version 29) and descriptive analytics derived from Google Analytics and Moodle logs.

 

9. Terminology (“proximate outcomes”, etc.) may be confusing

Reviewer Comment:

“Could be simplified for international readers.”

Author Response:

Terminology has been clarified, and definitions are provided at first use. This preserves the integrity of the MRC framework while improving readability.

 

10. Results section too detailed, esp. lesson-level engagement

Reviewer Comment:

“Move detail to supplementary appendix… summarise key statistical findings.”

Author Response:

We have summarised the narrative in the main text, emphasising key findings (e.g., improvements in vigour and absorption). Moodle/Google Analytics details are included in the manuscript because  fidelity-reporting is central to such an early phase intervention. However, the section is less condensed and has greater readability and allows the reader to see how usage statistics from Moodle and Googly analytics complement each other as means to understand user engagement patterns.

 

11. Limitations could be more concise with concrete recommendations

Reviewer Comment:

“Highlight key points (Moodle constraints, attrition, sampling)… concrete guidance for future research.”

Author Response:

The Limitations section has been reorganized to address: workload pressures in nursing contexts, Moodle constraints for guest-access courses, high attrition after Session 2, structural recommendations (embedded recruitment, integrated reminders, role-protected time)

 

12. 

 

9. Clarity of statistical results: Emphasizing the key findings (e.g., which results are statistically significant and their implications) would help the reader, rather than listing all correlations in detail.

Author Response:

Clarification about the quantitative analysis was added highlighting the  aim was to see measures’ sensitivity to change rather than statistically significant differences per se.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. I appreciate the authors' work in addressing an important topic and developing an online adaptation of ACT training for nursing professionals. 
Supporting nurses in managing psychosocial demands is highly relevant, and the manuscript contains several promising elements. At the same time, several substantial conceptual and methodological issues currently limit the clarity, interpretability, and scientific value of the study. I summarise my remarks below to help the authors further strengthen the paper.

The manuscript would benefit from a more precise conceptual positioning. Psychosocial risks in the workplace, including stress, should be approached primarily through preventive organisational measures. Individual-level interventions such as training and education form the lower tier of the prevention hierarchy and should be presented as complementary to system-level actions. The paper does not currently discuss what organisational interventions exist or could exist for stress prevention, nor does it situate the online ACT course within a broader prevention framework. Omitting stronger interventions makes it difficult to understand how the evaluated intervention fits into real-world workplace practice.

The study's overall aim needs more precise articulation. It is unclear whether the paper evaluates the usability and acceptability of the online course or whether the goal is to test the intervention's impact on psychological flexibility or other ACT-related outcomes. If psychological flexibility is the primary outcome, the introduction should define the construct precisely, explain how it is measured, present typical reference values from the literature, and clarify its relevance to nurses. The methods should then explain in detail how the construct was assessed in this study, and the results and discussion should show whether any meaningful changes occurred. At present, Table 5 does not show improvement on the psychological flexibility scale, while some change appears in the last rows, whose interpretation remains unclear due to insufficient methodological detail.

We can assume that the paper examines the feasibility of online ACT training, yet throughout the text, the description of psychosocial risk factors, ACT principles, the general aims of training programmes, and the specific features of the Moodle-based course are interwoven. It is essential to separate the characteristics of the developed online course (content, structure, exercises, internal feedback mechanisms) from the methods used to evaluate its feasibility. For example, section 2.5 describes the course itself and would logically belong in the introduction, where the authors define the object of the study. Conversely, the methodological section should provide full details on the evaluation tools, including the specific use of Google Analytics, the platform's learning analytics functionality, and the measurement instruments introduced in section 2.7.3.
It would help the reader to know which components belong to the course's built-in pedagogical and feedback mechanisms, and which were added specifically for research purposes. Without this distinction, the feasibility findings cannot be interpreted reliably.

From a methodological perspective, the extremely low sample size is a significant limitation. Only 31 participants completed the pre-intervention questionnaire, and only four participated in the follow-up interviews, rendering the qualitative evaluation practically inconclusive. This limitation is acknowledged, but its implications are substantial: the core findings on feasibility cannot be generalised, and the intervention effects cannot be meaningfully interpreted.

Concerning the feasibility outcomes, the results in section 3.4 indicate that most participants discontinued the course after the first lesson. The manuscript does not provide sufficient information to understand why this occurred. The paper does not indicate how much time participants devoted to the course, whether they followed the intended weekly structure, how they engaged with the videos, the quality of their submitted tasks, or whether they received feedback on assignments. The course logs and Google Analytics data could have provided helpful information, yet the manuscript does not include a detailed analysis of these sources.

The discussion does not convincingly relate the study's findings to existing knowledge, likely because the aims, methods, and results are not consistently aligned earlier in the paper. In addition, the paper unexpectedly lacks a conclusion, making it impossible to evaluate the study's overall message or contribution. A clear concluding synthesis would be needed to show how the findings support (or do not support) the feasibility and usefulness of the online ACT course.

Comments on the Quality of English Language

The clarity of communication throughout the manuscript requires improvement. Several sentences contain grammatical or typographical errors; jargon and abbreviations are used without explanation; and various conceptual elements are presented together without clear justification. Improving the language and structure would significantly enhance readability.

Author Response

1. Conceptual positioning of psychosocial risk prevention

Reviewer comment:

Psychosocial risks should primarily be addressed through organisational measures. The paper does not situate the ACT intervention within a broader prevention framework.

Response:

We fully agree. We have now strengthened the Introduction to explicitly situate individual-level ACT training within a multi-level prevention hierarchy. We added recent evidence (Aronsson et al., 2023; Bernal et al., 2022; Schill & Chosewood, 2019) showing that organisational/system-level interventions remain the primary mechanism for psychosocial risk prevention, with individual-level programmes serving as complementary support. This contextual positioning directly addresses your concern. (Revised in Introduction)

 

2. Clarification of the study aim and the role of psychological flexibility

 

Reviewer comment:

It is unclear whether the aim is to test psychological flexibility outcomes or feasibility. Psychological flexibility results are ambiguous and insufficiently justified.

 

Response:

We have clarified throughout the manuscript that this is an early-phase feasibility study, not an effectiveness study. Psychological flexibility was included only to test measurement suitability and sensitivity for a future feasibility trial, not as an outcome test.

 

Revisions include:

Explicitly stating the feasibility aim at the end of the Introduction.

Refining the Methods to describe psychological flexibility measurement and its interpretive purpose.

Revising Results to remove any implication of outcome testing.

Re-iterating in discussion noting that all pre–post patterns are preliminary and not evidence of effectiveness.

 

3. Separation of course content from feasibility evaluation methods

Reviewer comment:

Descriptions of risks, ACT principles, Moodle features, and methods are interwoven. Section 2.5 belongs in the introduction. The distinction between intervention content vs. research evaluation tools is unclear.

Response:

We have addressed this by restructuring and clarifying:

The relationship between ACT principles and feasibility outcomes and their place with an intervention’s theory of change and created a new table that summarizes previous information

A new paragraph clearly referring Moodle’s built-in pedagogical features (e.g., progress tracking, resource structure, multimedia layout constraints)

This separation ensures that feasibility interpretations are unambiguous.

 

4. Low sample size and limited qualitative findings

Reviewer comment:

The sample is small, and the qualitative evaluation cannot be generalised.

Response:

We agree, and this limitation is now stated more prominently. The qualitative data are presented explicitly as exploratory signals intended to identify usability issues, contextual barriers, and areas for refinement. A strengthened paragraph in the Limitations clarifies that results cannot be generalised and that interpretation is bound to early-phase feasibility design constraints. (Revised in Limitations section)

 

5. Disengagement after Session 1 requires clearer explanation

Reviewer comment:

Participants primarily discontinued after the first lesson; the manuscript does not explain why.

Response:

We have expanded both the Results and Discussion to interpret this pattern:

Results section 3.4 now views separately and then synthesises Moodle logs and Google Analytics to show engagement trajectories.

Discussion provides an evidence-informed explanation: workload demands, post-pandemic fatigue, absence of reminders or embedded pacing mechanisms, and guest-access limitations in Moodle

These explanations are grounded in literature on digital intervention attrition in healthcare.

(Revised in Results 3.4. and Discussion)

 

6. Lack of detail on time spent, engagement with tasks, and feedback

Reviewer comment:

Insufficient information about time spent, video engagement, task completion, and feedback mechanisms.

Response:

We now include:

Average time per page and views per user from Google Analytics.

Summary of access patterns to worksheets, exercises, and mindfulness practices.

A clarification that Moodle’s guest-access mode does not allow tracking of video completion, worksheet uploads, or graded tasks, which constrained evaluability.

This explanation is now integrated into Methods and Limitations.

 

7. Analytics and logs require more detailed analysis

Reviewer comment:

Logs were not analysed in sufficient detail.

 

Response:

We have added clearer, structured reporting:

Main text includes two summary figures (Figures 3 and 4).

A comprehensive Appendix Figure A presents full page-by-page data (users, views per user, cross-system comparison).

 

8. Discussion lacking alignment with aims; missing conclusion

Reviewer comment:

The Discussion is not fully aligned with the aims, and the paper lacks a conclusion.

Response:

We have restructured the Discussion to map directly onto feasibility objectives and integrated a new Conclusion section. The conclusion synthesises feasibility signals, contextual limitations, and refinements required for a future feasibility trial. (Revised Discussion; new Conclusion added)

Reviewer 4 Report

Comments and Suggestions for Authors

The authors, who recently published a bibliometric analysis of the literature on Digital Interventions for Mental Well-Being Promotion in this journal, developed a method for online mental health promotion and evaluated its applicability. The experience is interesting and worthy of publication, although the methodology has significant and unavoidable limitations. In my opinion, the authors should explicitly acknowledge these limitations and use this initial experience to improve their intervention.

1. Study design. The authors adopted a before-and-after single-arm comparative method. This design prevents us from knowing whether the observed changes are due to the intervention or any other factor. The experimental method requires the presence of a control group. This is an unavoidable limitation of this manuscript; the authors should acknowledge this point and include it in the limitations. Consequently, they should avoid making claims in the manuscript about the effectiveness of the intervention, which cannot be demonstrated with this method, limiting themselves to stating that the observed improvement "might" be due to the intervention, but this has not been proven.
2. Observation time. Parameters were measured before and after the intervention; no follow-up measurements were planned. It is well known that, due to the placebo effect, all interventions are immediately effective. The authors should highlight and discuss this limitation.
3. Follow-up. Future improvements to the study could include longer observation periods and the division of participants into two randomized groups, with treatment periods separated by time intervals; this could serve as an internal control group.
4. The authors did not conduct a preliminary assessment of the necessary sample size. This led them to work with an insufficient sample size and likely to miss significant differences. This limitation should also be discussed.
5. The convenience sample is excessively heterogeneous: "registered nurses, healthcare assistants, and nursing associates employed in any setting, as well as postgraduate and second- or third-year undergraduate students." The occupational risk factors in these categories are profoundly different; it is not possible to expect that a program developed for one category will be valid for all. This limitation also needs to be discussed.
6. The authors should reflect on the high percentage of workers who did not complete the project. Perhaps the course was too demanding, and its feasibility is therefore questionable. These considerations should be included in the article. It should also be considered that very few people participated in a course that was presumably free. The percentage of healthcare workers with stress and mental health issues is quite high, as the authors know. Therefore, one wonders why they found so few, and perhaps not even motivated, participants, given that they did not complete the program.

Author Response

We thank the reviewer for their thoughtful and constructive comments. Below we respond point-by-point.

 

1. Study design and absence of a control group

Reviewer comment:

“A before–after single-arm method does not allow determination of whether changes are due to the intervention… avoid making any claims about effectiveness.”

 

Author response:

We agree fully. This study was not designed nor powered to evaluate effectiveness, and we have now emphasised this clearly throughout the manuscript. All language implying effects has been revised to reflect preliminary signals only, consistent with feasibility-study reporting standards.

 

Statement has been added to the Methods, Results, and Limitations noting that:

the design does not permit causal inference

observed changes may reflect  expectancy effects or spontaneous fluctuation

psychological flexibility outcomes were collected only to examine measure suitability for a future feasibility trial

Changes made:

Explicit clarification added in the Introduction, end of Methods, and Limitations.

 

2. Absence of follow-up period; need to discuss short observation time

Reviewer comment:

“Parameters were measured only before and after; the placebo effect may produce short-term improvements. This limitation should be highlighted.”

 

Author response:

We appreciate this point and have now made this limitation explicit. The Limitations section now acknowledges that:

only immediate post-intervention data were collected

 

short-term changes may reflect non-specific factors

a follow-up period would be essential in a future feasibility trial to assess persistence of any change

 

3. Suggestion for future study design: randomised groups and staggered treatment

Reviewer comment:

“Future improvements could include two randomized groups with staggered intervention timing.”

 

Author response:

We agree. The Limitations and Future Research section now notes that a future study should include a fully randomized feasibility trial should

 

4. No preliminary sample size assessment

Reviewer comment:

“No sample size assessment was conducted.”

Author response:

Correct—this was an intentional feature of the study design. As an early-phase feasibility study, the objective was to estimate recruitment, retention, and procedural uncertainty rather than detect statistically significant differences.

 

The purpose was to generate parameters to inform sample-size estimation for a subsequent feasibility trial

This clarification now appears in the Methods and Limitations.

 

5. Heterogeneity of participant roles

Reviewer comment:

“The convenience sample is excessively heterogeneous… risk factors differ… unclear whether a single programme is suitable for all.”

 

Author response:

We acknowledge this and have strengthened the explanation. The revised manuscript notes that:

the heterogeneity was intentional at this early stage to maximise recruitment reach for engagement analysis

 

recruitment was not conducted through employers, making occupation-specific sampling impractical

 

a future feasibility trial should recruit occupationally homogeneous groups (e.g., only registered nurses or mental-health nurses) to evaluate contextual fit

 

We now also discuss how occupational differences may influence acceptability and engagement.

 

6. High attrition and low completion rates

Reviewer comment:

 

“Reflect on the high percentage of workers who did not complete… was the course too demanding?”

 

Author response:

We agree this is important. The Discussion and Limitations sections now explicitly address:

high workload and post-pandemic fatigue among nurses

the absence of automated reminders or employer-endorsed participation

the likelihood that nurses experiencing greater distress may be less able to complete digital training

We also added recently published references showing that:

digital mental health interventions for healthcare workers have consistently high attrition

lower engagement is common when training is self-guided and not embedded in workplace routines

These additions clarify that attrition reflects contextual constraints rather than the inherent “demand” of the material.

 

7. Small number of participants despite the course being free

Reviewer comment:

“Few people participated despite the course being free; this should be explained.”

Author response:

We have added text explaining that:

uptake of voluntary, self-guided digital wellbeing interventions is typically low among nurses unless organisationally integrated

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Best regards

Author Response

Thanks, no other reviewer comments to address.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the revised version of this manuscript. The paper has clearly undergone substantial development, and the study design and the authors’ intentions are now more understandable. However, this improved clarity also reveals fundamental contradictions in the study’s conceptual and methodological structure that require further attention.

The manuscript appears to combine at least three major components, all of which are presented in considerable detail. The first component concerns the content and theoretical background of ACT training, including its applicability for nurses and examples of acceptance and commitment therapy in practice.

The second component concerns the development of the Moodle-based online course, including its structure, content and methodological elements.

The third component concerns the feasibility assessment itself and the indicators used to evaluate course usability.

Alongside these three elements, a fourth component is also present: the Professional Quality of Life (ProQOL) questionnaire, introduced in Sections 2.4 and 2.7. This instrument appears intended to measure the effect of the online ACT intervention. Its results occupy a disproportionately large part of Section 3.3 and appear again in the conclusion as if they provided validated evidence of intervention impact. However, in the current design, the use of ProQOL is methodologically unsupported. Despite the removal of lines 528–539, the problem remains that the data are not strong enough to substantiate any claims about training effectiveness.

For these reasons, the manuscript still lacks structural coherence. Despite the title and the abstract, the empirical core of the paper is in fact the analysis of user engagement in a Moodle course based on Moodle logs and Google Analytics. The feasibility study rests almost entirely on these platform-derived indicators. These analyses are heavily marked by limitations—primarily the small number of participants and severe constraints on available data—but the methodological description of these limitations remains fragmented and is scattered across multiple sections rather than integrated coherently at the end of the discussion.

A further problem arises in the newly introduced “program theory of change” in line 286. This framework is presented as the foundation for constructing feasibility indicators, yet it lacks any literature grounding, is not justified conceptually, and its validity for evaluating an online Moodle course is not demonstrated. Nor is there any clear connection between this framework and the actual Moodle and Google Analytics indicators used. The disconnect between the conceptual model and the empirical data significantly weakens the methodological foundation of the study.

In addition, there is a conceptual gap between the content of ACT therapy and the platform usage data. The mechanisms of ACT, its psychological processes and its intended impacts on workplace functioning remain entirely unrelated to the analytics-based indicators. These two domains operate on fundamentally different levels, and the manuscript does not provide a bridge that would meaningfully connect them. Without such integration, the feasibility indicators cannot be interpreted in relation to ACT outcomes.

As a consequence, the abstract still cannot accurately reflect the methodological structure or the actual results of the study. Other points also remain unclear. The reference to “promotion” in line 107 is not explained. The central conceptual question—how a group-based intervention such as ACT can be meaningfully delivered individually in an online asynchronous format—remains unresolved. The transformation of the course material mentioned in line 207 has no documented foundation in the manuscript. The categories presented in line 272 are overlapping and have no clear analytic purpose. Nothing demonstrates the validity of the components included in Table 2.

The purpose of Section 2.6 is also uncertain, as the course content was already described in Section 2.4. Table 3, which spans three pages of demographic variables, is disproportionate to the importance of these data and could be summarised in a few lines. The constantly repeated references to low sample size and limited data collection are appropriate, but these observations should be synthesised into a single, coherent limitations section rather than appearing throughout the text. Figures 2 and 3 are essentially variations of the same information, though they use inconsistent terminology (“sessions” versus “lessons”). If these values were presented in course order, the essential finding would be immediately visible: participants gradually lost interest, and dropout increased steadily after the first lesson. This is also clear in Figure 4. It remains unclear whether this decline reflects the time sequence, the content progression, or both. Because data on video viewing and activity completion were unavailable, several important aspects of course engagement cannot be evaluated.

These limitations leave very little substantive material for the discussion. The paragraphs beginning at line 724 represent the only true discussion grounded in the presented empirical data, but the content is too limited to support the broader conclusions of the paper. The conclusion reflects all three major thematic strands—the ACT content, the development of the Moodle course, and the feasibility analysis—but the empirical evidence does not substantiate claims about course usability or intervention potential based on Moodle and Google Analytics alone.

Comments on the Quality of English Language

Repeated rounds of revision have left the manuscript with several inconsistent sentences, unclear expressions, and irregular use of abbreviations. Although the language is generally understandable, the accumulation of structural and conceptual inconsistencies makes interpretation difficult.

Author Response

We would like to thank the reviewer for their careful reading of the revised manuscript and for their detailed and constructive feedback. We have addressed each point below and have revised the manuscript accordingly.

1 Reviewer comment:  The manuscript appears to combine at least three major components, all of which are presented in considerable detail.

Response:

We agree that earlier versions created conceptual overlap. In the revised manuscript, we have now clarified that the primary empirical focus of the study is the feasibility and engagement evaluation of an online Moodle-based ACT training programme, using platform-derived indicators and participant feedback and we have deleted / moved sections about ACT theory

To address this comment:

We reframed the role of ACT theory as background underpinning the intervention content.

We clarified that the Moodle course development constitutes the intervention object, while feasibility assessment (via Moodle and Google Analytics) represents the empirical core.

We adapted phrasing to clearly shown that all outcome measures  should only be viewed as exploratory sensitivity checks for future trial design, not as evidence of intervention effectiveness.

The Conclusion and Abstract have been edited to remove any interpretation that would suggest effectiveness testing.

 

2. Alongside these three elements, a fourth component is also present

Response:

We have now clarified explicitly that ProQOL was treated in exactly the same way as the work engagement and psychological flexibility measures, as exploratory tools to examine measurement sensitivity, not intervention effects.

Revised the Results and Discussion sections to consistently describe all outcomes as preliminary and non-confirmatory.

Removed all language that could be interpreted as effectiveness claims.

Added explicit statements that this study was not designed or powered to assess effectiveness and that all measure-related findings are indicative only for future feasibility trial design.

 

3. Weak link between ACT mechanisms and platform analytics

To address this:

We clarified that this study does not attempt to operationalise ACT mechanisms through analytics data, but rather evaluates whether an ACT-informed intervention can be delivered, accessed, and engaged with via a digital platform in a real nursing workforce context.

The manuscript now distinguishes clearly between:

Clinical mechanisms of ACT (theoretical)

Implementation mechanisms (engagement, access, usage, retention)

We explicitly state that engagement metrics  provide feasibility indicators for whether training in psychological flexibility processes could be delivered so that those processes can then be studied in a later trial.

 

 

4. Program Theory of Change (ToC)  creates confusion

Response:

We accepted this critique and have now taken decisive steps:

The simplified ToC framework has been removed to avoid conceptual overreach.

Relevant discussion of psychological flexibility processes has been retained and integrated into the background section instead.

 

5.  limitations are fragmented

We have now consolidated all study limitations into a single structured subsection in the Discussion “. Limitations and future directions”

 

6. The central conceptual question—how a group-based intervention such as ACT can be meaningfully delivered individually in an online asynchronous format—remains unresolved

Response: In the introduction section, we note that there is evidence of a small number of online ACT-based interventions showing positive effects on healthcare professionals', including nurses, mental health.

We have clarified that ACT training in workplace settings is frequently delivered by workplace psychologists or trainers, not exclusively therapists, and that its adaptation here involved. Finally, we explicitly acknowledge the limitations of the absence of synchronous facilitation and position this as an important consideration for future modality-comparison studies.

 

7. Overly long demographic table

Response:

We have summarised demographic information more concisely in text and reduced table complexity accordingly, while retaining necessary transparency for journal standards.

 

8.Redundancy and inconsistency in figures

Response:

We have: Standardised terminology across all figures (consistently using sessions vs lessons).

Reordered figures to follow the chronological order of course delivery.

Additional details were added about the interpretation of the user metrics “All sessions and lessons were made available to participants from the outset. Consequently, the observed engagement patterns reflect access and navigation behaviours across the full course rather than a strictly linear progression from one session to the next, as individual learning pathways and sequencing could not be confirmed”

 

9.  ACT is a traditionally group-based intervention; its online translation requires justification.

Response:

We have clarified that ACT training in workplace settings is frequently delivered by workplace psychologists or trainers, not exclusively therapists, and that its adaptation here involved:

We explicitly acknowledge the limitations of the absence of synchronous facilitation and position this as an important consideration for future modality-comparison studies.

 

9. Abstract still cannot accurately reflect the methodological structure or the actual results of the study. 

Response:

The abstract has been rewritten to explicitly reflect that this is:

A feasibility and engagement study of a digital intervention

 

10. Language and clarity issues

We performed a language review to improve clarity, remove redundancy, and standardise terminology throughout the manuscript.

Reviewer 4 Report

Comments and Suggestions for Authors

The authors have revised the manuscript to introduce possible changes and to alert readers to the limitations of the study.

Author Response

Thanks, manuscript has now been updated.