Evaluating the social return on investment of dance movement for wellbeing in the prevention of burnout among healthcare staff: a study protocol

Abstract

Introduction

Improvement in the National Health Service (NHS) employees’ mental well-being and staff retention are current key issues. Evidence indicates that dance movement therapy (DMT) has been effective in improving mental health and well-being; however, a social return on investment (SROI) evaluation on DMT interventions aimed at NHS staff has not been performed. This protocol for an SROI study will explore the social value generated from DMT, specifically ‘The Body Moving Self-Compassion’ programme, as measured by the increase in personal well-being and resilience experienced by participants. The SROI evaluation aims to measure the monetary and social value generated through DMT by placing a monetary value which is essential for sound policy in accessing investment while contributing evidence of dance/movement’s impact on health.

Methods

SROI is a pragmatic form of social cost-benefit analysis which uses quantitative and qualitative methods to value relevant costs, outcomes and associated impact. A mixed-methods approach design (focus group, online questionnaire and semistructured interviews) will be employed in this SROI study. SROI takes a societal perspective and considers relevant and significant outcomes for participants. Monetary values which often do not have a market price are then assigned to these outcomes. Contingent valuation is integrated into this study to estimate individuals’ choices, preferences and values associated with DMT. The social value generated by the identified outcomes will then be estimated in a similar way to cost-benefit analysis, and the ratio of social value generated per £1 invested is then calculated.

Ethics and dissemination

Ethical approval for this study has been granted by the Faculty of Life Sciences and Education Ethics Subgroup at the University of South Wales, with Reference No. 230 236LR. The findings from this SROI study will result in a report and academic publications.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Combines qualitative and quantitative data for a comprehensive view of outcomes and stakeholder experiences.

• Employs validated tools to measure mental well-being and self-efficacy, ensuring robust data.

• Data collection will occur retrospectively at the end of the dance movement therapy (DMT) intervention, allowing respondents to reflect and provide a considered opinion.

• Contingent valuation method questions are integrated within the social return on investment questionnaire as a rigorous approach to capture the proxy values and benefits of this DMT intervention.

• Financial proxies may not fully capture the qualitative impact or the long-term value of outcomes.

Introduction

The National Health Service (NHS) is the largest public sector employer in the UK¹; however, since the COVID-19 pandemic, the number of NHS staff leaving active service has been on the rise, with the risk that this could worsen in the future.^{2 3} In Wales, the latest data from the Nursery and Midwifery Council (NMC) showed that 1370 professionals living in Wales left the NMC permanent register in 2022–2023. Although this is a slight decrease from the previous year with 31 fewer leavers, the number of professionals leaving coupled with the ageing workforce due to retire in the near future is a concerning picture.⁴

Although relocation and retirement are the most common causes reported by staff, physical and mental health, burnout and exhaustion, issues around job satisfaction, work-life balance and working conditions were cited by clinicians.5,7 In addition, workplace culture along with experiences of bullying, harassment and discrimination were reported by respondents.5,7 This evidence highlights current pressing concerns regarding NHS staff well-being and retention in the UK.⁷ In response, the national implementation workforce Welsh Government’s (WG) plan was developed to address NHS workforce challenges with the aim to increase staff recruitment. The latter seeks to reduce the current pressure within the NHS along with improving retention and ensuring that staff health and well-being needs are met.⁸ Indeed, the WG aims to work with partners to deliver on the Staff Welfare Project in social partnership to enhance staff well-being, working conditions and learning and development opportunities.⁸

Therefore, finding ways to maintain and enhance staff well-being and decrease burnout that would improve staff retention is a key challenge for the NHS;⁷ as such, an innovative approach to address compassion fatigue and burnout is a body-focused therapeutic movement method.⁹ Movement therapy also referred to as dance movement therapy (DMT) is defined by the American Dance Therapy Association as ‘the psychotherapeutic use of movement to promote emotional, social, cognitive, and physical integration of the individual, for the purpose of improving health and well-being’.¹⁰ Along with the treatment of the mind and body, the European Association Dance Movement Therapy included ‘spiritual and social integration’ in the definition.¹¹ Current evidence shows that DMT has a significant positive effect on decreasing anxiety and depression levels and improving quality of life and interpersonal and cognitive skills in the individuals who take part.⁹ In addition, the meta-analysis by Koch et al supported the previous findings that DMT has persistent long-term effects.⁹

Similarly, DMT can support NHS workers’ self-care. Indeed, the Body Hotel, a social enterprise offering dance movement sessions to all, delivered the Moving Respite employee well-being programme to Welsh NHS staff from November 2021 to April 2022. The programme’s objectives were to pilot and evaluate dance/movement-based burnout prevention for Health Education and Improvement Wales employees and understand the contributions of arts-based services to organisational development.¹² The evaluation of the pilot programme concluded that the Body Hotel: Moving Respite was perceived as a safe space where participants learnt skills and developed resources to prevent a reduction in well-being or recover from a physical or mental well-being experience. In addition, the evaluation recommended that a social return on investment (SROI) evaluation should be conducted for any new programmes.¹³ Therefore, following the Body Hotel: Moving Respite’s evaluation, a new programme of employee well-being workshops for NHS staff across Wales has been delivered by the Body Hotel. The Moving Self-Compassion programme aims to scale up its movement-for-employee-well-being model and is especially focused on staff who are coming back from maternity/paternity, stress, medical or compassionate leave. The programme targets staff sustainability, focusing on the transition from leave of absence and support to stay in work.¹⁴ In addition, the focus of this SROI evaluation, guided by stakeholder engagement, has identified that the key outputs of the intervention are team participation over its duration, and the key outcomes are improvements in mental well-being and increased self-efficacy among participants. To avoid overburdening participants with the SROI questionnaires, the study will concentrate on these outcomes within this cohort.

Currently, few arts in health programmes support the reintegration of staff into the workforce or help staff stay at work. The Moving Self-Compassion programme aims to provide a safe space to manage this difficult transition and promote well-being strategies to reintegrate while also providing spaces of positive engagement and self-care for all Welsh staff across the NHS. The programme uses a dance movement psychotherapy (DMP) approach which according to the Association of Dance Movement Psychotherapy UK is ‘a relational process in which client and therapist engage in an empathic and creative process using body, movement and dance to assist the integration of emotional, cognitive, physical, social and spiritual aspects of self’.¹⁵ However, this therapeutic approach is also referred to as DMT as this term is used across many countries, whereas DMP is used exclusively in the UK.¹⁶ In this paper, the terms DMT and DMP will be used interchangeably as terms to refer to body-focused therapeutic movement methods.

The evidence base of the effect of DMT on individuals’ overall well-being is limited and requires further research.¹⁷ Previous studies have found that DMT has positive effects on reducing psychological stress, increasing quality of life and well-being,^{9 18 19} reducing the likelihood of burnout among nurses,²⁰ reducing levels of depression^{9 21} and increasing resilience in people who have experienced trauma in their lives²² or are living with chronic pain.²³ Additionally, research on DMT interventions has shown positive impacts on team development and stress management, improving well-being and care for both staff and users.^{19 24} Bräuninger’s randomised controlled trial further supports these findings, demonstrating that DMT group treatment effectively reduces stress, enhances mental health and improves quality of life with lasting effects.^{25 26}

In light of these findings, evaluating the broader impact of DMT interventions requires a comprehensive approach. Cost-effectiveness analysis is a method used to compare the costs of alternative ways of producing the same or similar outputs; it measures the internal effectiveness and efficiency of the public health intervention outcomes. As an alternative, when there is a need to consider a full range of outcome measures, going beyond quality-adjusted life year social cost-benefit analysis (SCBA) is the default, preferred option. SCBA ensures that well-being outcomes are fully captured, and all the outcomes are affected by the public health intervention. SROI appraisal methods capture in a monetised form the value of a wide range of outcomes, create value for key stakeholders and provide a ratio that states how much social value (in £) is created for every £1 of investment.²⁷ Therefore, this SROI evaluation assessing the Body Hotel Moving Self-Compassion programme will be conducted to generate the associated social value linked with fostering staff well-being and mental health, staff retention and related costs. Additionally, this SROI protocol is the first evaluation conducted to generate the social value and effectiveness of DMT in improving well-being and resilience.

Aim

This protocol SROI study will explore the social value generated by the Body Hotel Moving Self-Compassion programme, focusing on its impact on participants’ well-being and resilience. The study will measure outcomes from the participants’ perspective to ensure a clear understanding of how the programme benefits them and the social value it creates.

Methods and analysis

Study design

This study will employ an SROI methodology that includes a mixed-methods approach design (focus group, online questionnaire and semistructured interview). The first stage of the data collection will consist of an online semistructured focus group interview with 8 to 10 stakeholders which will involve the participants and those taking part in the development, delivery and administration of the Body Hotel Moving Self-Compassion programme. At the end of the programme, participants who have attended the sessions delivered by the Body Hotel will be invited to complete an online questionnaire which will capture participant demographic data along with information regarding current levels of mental well-being and self-efficacy. Finally, six to eight one-to-one online interviews with the stakeholders will be carried out. The participants will receive a participant information sheet and consent form for each stage of the study.

Social return on investment

SROI approach is proposed to evaluate the Body Hotel Moving Self-Compassion programme. SROI analysis aims to develop a programme-level theory of change to establish how inputs (eg, costs, staffing) are converted into outputs (eg, number of participants attending, return to work transition, job retention) and subsequently into outcomes that matter to participants experiencing the Moving Self-Compassion programme (eg, improved mental well-being). The social value generated by the identified outcomes will then be estimated in a similar way to cost-benefit analysis, and the ratio of social value generated per £1 invested will be calculated.²⁸

The SROI analysis will be operationalised through the six stages outlined in the guide to social return on investment analysis²⁹:

1. Identifying stakeholders

2. Developing a theory of change

3. Calculating inputs

4. Evidencing and valuing outcomes

5. Establishing impact

6. Estimating the SROI ratio.

Identifying stakeholders

The stakeholders who will be involved in consultation throughout the analysis are the individuals or organisations (ie, those affected or who affect the activity) that may experience change as a result of the activity and will be best placed not only to describe the change but also to inform what is the added value of the activity and how it should be measured.³⁰

In this protocol, SROI study participant eligibility will include adults (aged over 18 years old) working in Wales in one of the Health Boards (Cwm Taf Morgannwg, Aneurin Bevan, Betsi Cadwaladr and Cardiff and Vale) who attended any of the activities delivered as part of the Body Hotel Moving Self-Compassion programme. It will also include those taking part in the development, delivery and administration of the Body Hotel Moving Self-Compassion programme. In addition, the protocol will incorporate an equity analysis to examine whether the Body Hotel Moving Self-Compassion programme impacts different demographic groups (eg, age, gender, ethnicity) equitably. This analysis will ensure that any disparities in outcomes are identified and addressed. Engagement with diverse staff and other stakeholders has been integral to the intervention and will also be a key part of the evaluation. Feedback from NHS staff and those involved in the programme’s development, delivery and administration will be collected through a focus group and interviews. This inclusive approach ensures that diverse perspectives are considered and that stakeholder contributions are integrated into the programme’s evaluation and refinement. The findings may inform future NHS policies related to staff well-being and retention, offering evidence-based recommendations for similar interventions.

Developing a theory of change

The theory of change for the Moving Self-Compassion programme is a crucial framework for understanding and measuring the impact of the initiative. It helps clarify how the programme is expected to bring about specific changes and benefits for its stakeholders. The theory of change outlines the logical sequence from programme activities to desired outcomes, helping to ensure that the programme meets its goals and provides value to participants.²⁹

Evaluating stakeholder experiences involves understanding their involvement and contributions to the programme, as well as the changes they have observed as a result of the intervention. It also includes assessing how these changes align with their expectations and considering what alternative supports they might have explored. Understanding whether participants feel they need to sacrifice anything to participate or if they are receiving similar support from other sources provides valuable insights into the programme’s value and its comparative effectiveness. Systematically collecting and analysing this feedback allow us to make informed adjustments, ensuring that the programme remains responsive to the needs and expectations of all stakeholders.

Calculating inputs

The SROI study will examine the total costs for the Body Hotel Moving Self-Compassion programme which will include both administration costs along with costs related to the run of the workshops. Administration costs involve the time for Body Hotel’s staff to monitor, manage and promote the programme along with any other activities required to support the delivery of the programme. Session costs involve the costs related to the running of the workshops.

Evidencing and valuing outcomes

Questionnaires and interview data will be collected to identify the changes experienced by the stakeholders as a result of taking part in the Body Hotel Moving Self-Compassion programme as described below. Financial proxies are then used to provide the value of the outcomes where there is no market value. Many outcomes are not traded in markets, and as a result, their value is not recognised. Financial proxies should be used to recognise the value of these outcomes and to give a voice to those excluded from markets but who are affected by activities. Hence, monetary values will be assigned to mental well-being and self-efficacy outcomes using sources such as the HACT Social Value Bank, the Social Value Calculator and the Mental Health Social Value Calculator.³¹ In addition, in this SROI evaluation, proxy values will be captured by means of the inclusion of a contingent valuation (CV) method question within the SROI questionnaire. CV is a stated preference technique rooted in neo-classical economics and applied in SROI analysis as a financial proxy to capture the value or willingness to pay (WTP) that participants place on the value and benefits associated with the proposed DMT intervention.³²

Questionnaire

The SROI protocol will gather data from all the participants taking part in the Body Hotel workshops who will be invited to complete a postintervention questionnaire using a direct link to a secure questionnaire via JISC Online Surveys. The questionnaire will feature questions about participant demographics (gender, age, ethnicity and occupation) and reasons for attending the programme along with information on participants’ mental well-being, self-efficacy and the value placed on the Body Hotel Moving Self-Compassion programme.

The questionnaire includes validated scales for assessing mental well-being and self-efficacy. The Short Warwick–Edinburgh Mental Wellbeing Scale (SWEMWBS) which was developed to monitor mental well-being in the general population uses seven positively worded statements with five response categories from ‘none of the time’ to ‘ all of the time’ to measure mental health. Overall scores can range from 7 to 35, with higher scores indicating higher levels of mental well-being.³³ The General Self-Efficacy Scale (GSES) is a 10-item self-reported measure of self-efficacy. It assesses the perceived self-belief to respond to novel or difficult situations and to cope with any obstacles or setbacks that may present. The score ranges from 10 to 40 with a higher score indicating greater self-efficacy.³⁴

Interviews

In this mixed-method SROI protocol, the stakeholders will be invited to attend online semistructured one-to-one interviews. The proposed qualitative interviews will explore stakeholders’ experiences, expectations and outcomes of the Body Hotel Moving Self-Compassion programme.

Social value analysis

In this SROI study, the SWEMWBS will be used to assess mental well-being, and the GSES will be applied to measure the change in self-efficacy. Well-being valuation can be applied using two value sets: Social Value Bank and the SWEMWBS value set for measuring mental well-being. In addition, this SROI study protocol will apply the eight principles outlined in conducting SROI analysis as advised by Social Value UK³⁵ which will allow for the adoption of integrated social, environmental and economic accounting reporting systems which is supported by the evidence on the challenges and limitations in applying a blended value proposition approach.³⁶

Establishing impact

To establish the impact of this SROI protocol, it is necessary to reduce bias and decrease the risk of over-claiming the benefits of the Body Hotel Moving Self-Compassion programme. The proposed questionnaire and interviews will include specific questions to determine deadweight (the proportion of observed outcomes that may have happened anyway), displacement (the proportion of outcomes that may have been displaced from one sector to another), attribution (the amount of outcome directly attributed to Body Hotel Moving Self-Compassion programme) and drop-off (the length of time that outcomes last for Body Hotel Moving Self-Compassion programme participants).³⁷

Estimating the SROI ratio

The SROI ratio in this protocol will be calculated by dividing the total value of inputs by the total value of outcomes. The proposed resulting ratio is the amount of social value generated for every £1 invested in the Body Hotel Moving Self-Compassion programme. In addition, to calculating a proposed base case scenario, a range of sensitivity analyses will be performed to explore how the SROI ratio could be affected if different financial proxies were used and if varying levels of outcomes were achieved than those used in the base case scenario. A checklist for quality assessment in SROI analysis will be used as a framework to guide the reporting of the SROI findings.³⁸

Data collection and management

Following ethical approval from the University of South Wales (USW), Faculty of Life Sciences and Education Ethics subgroup, primary data will be collected as described in the study design. The online semistructured focus group interview with the stakeholders will be carried out first followed by the online questionnaire data collection which will take place at the end of the programme. The online one-to-one interviews with stakeholders will then be conducted.

Each participant will be identified by a personal identification number (PIN). This PIN will be used to identify the participant once recruited into the study. The list of identity numbers linked to names will be stored securely and separately from the research data. The record of participant PIN will be stored on a university computer using a password-protected spreadsheet. Confidentiality will be maintained throughout the study.

Questionnaire data and consent forms will be stored on an online questionnaire platform; only the research team will have access to the data. The questionnaire will be presented to participants using the JISC online survey tool specifically designed for academic research that is fully compliant with the General Data Protection Regulation (GDPR), data protection law and in line with USW protocol. Each survey created in the tool has its own uniquely generated URL which can be easily shared with the participants. The number of respondents can be monitored, and once the survey is closed, data can be downloaded in an Excel file that can be analysed offline.

Interview audio recordings and transcriptions will be uploaded to a secured network that only the research team will be able to access. Research records will be held securely at USW according to the GDPR and by USW research data management guidelines. Data will be stored on a secured, password-protected university computer server. The computer is password-protected and encrypted and so will any document files.

Patient and public involvement

Participants will be actively involved in both reviewing and disseminating the findings of this SROI study. The development of the research question and outcome measures was directly informed by stakeholders’ priorities and experiences. Results will be shared through detailed reports, feedback sessions and summary materials to ensure they are clear and accessible. Participants will have opportunities to review draft findings, engage in discussions and receive updates on how the results are being used.

Advisory team

The advisory team for this study is comprised of the Director and Arts Management Officer of the Body Hotel, researchers from USW and the Royal College of Surgeons in Ireland. The advisory team will meet weekly for meetings to discuss recruitment, data collection progress and the write-up of the stakeholder report.

Discussion

This SROI protocol aims to explore the social value associated with the Body Hotel Moving Self-Compassion programme by measuring the changes in well-being and self-efficacy experienced by the participants especially focusing on staff coming back to work from leave or who are considering leaving the profession. It aims to measure the monetary and social returns of the programme and offer evidence to policymakers along with contributing evidence of dance/movement’s impact on health.

The effectiveness of the Body Hotel Moving Self-Compassion programme will be compared with current literature evaluating dance/movement interventions to support staff mental health and staff retention. Evidence suggests that applying art therapy interventions which include DMT aimed at supporting NHS team development could support performance along with staff well-beingwell-being, increasing staff retention and ultimately patient care.^{9 20} This DMT offered a different approach to team development providing a creative, inclusive and accessible environment concluding that this approach could be considered an option for teams that are experiencing low control and high-pressure working environments.²⁴ Similarly, Garcia-Callao et al’s study with staff working in a prison identified that the DMT training programme could be an effective tool to help staff cope with stressful situations and improve well-being. The participants reported having learnt strategies to deal with burnout which in turn led to better care for staff and users.¹⁹ In addition, Bräuninger’s randomised controlled trial concluded that DMT group treatment showed a reduction in stress levels, improved mental health, improved quality of life and better stress management strategies compared with the control group that received no treatment. The author also concluded that the intervention had long-lasting effects.^{25 26} Although the methodological quality of the studies in this area varies with a limited number of high-quality studies, the result shows a positive impact on clinical practice and policymaking²¹; hence, this SROI evaluation would be able to add to the existing body of knowledge by measuring the change in a way that is relevant to the participants who experience it or to the organisations that contribute to it.

The strengths of this study are underscored by its utilisation of a mixed-methods approach, which integrates qualitative and quantitative data to offer a comprehensive view of outcomes and stakeholder experiences. The use of validated tools for measuring mental well-being and self-efficacy further strengthens the reliability of the collected data. Retrospective data collection at the end of the intervention allows respondents to provide considered reflections on their experiences. CV questions are specifically designed to assess tangible and meaningful WTP values and benefits associated with DMT intervention. Nonetheless, potential limitations of this evaluation include the reliance on financial proxies, which may not fully capture the qualitative impact or long-term value of the outcomes. Moreover, while the use of specific, realistic, closed-ended questions is strength, it may constrain the scope of responses and limit insights into participants’ experiences. Despite these limitations, this novel study aims to assess whether the Body Hotel Moving Self-Compassion programme can generate positive social value for participants. Additionally, the mixed-methods approach within the SROI methodology will facilitate the determination of whether participants experience improvements in mental well-being and self-efficacy as a result of their involvement in this innovative DMT programme.

Ethics and dissemination

Ethical approval of this study has been granted by the Faculty of Life Sciences and Education Ethics Subgroup at USW (Reference No. 230 236LR). It is proposed that the participants’ data will remain anonymised and no participants will be identifiable in the results. Participants will be reminded that they can withdraw from the study at any time without explanation.

Participants will be actively involved in reviewing and disseminating the findings of this SROI study. A comprehensive report detailing the study’s results will be provided to participants and funders, using accessible formats tailored to their needs. Additionally, participants will have opportunities to engage in feedback sessions to discuss the findings. An academic paper will also be prepared and submitted for publication in a peer-reviewed journal, ensuring that the study’s outcomes contribute to the broader academic discourse while keeping participants informed in ways that are clear and understandable to them.