Creating Nurse Resilience Programs That Work

To move the needle on burnout, resilience programs must be designed to meet nurses' specific needs.

Meredith Mealer, PhD, RN, assistant professor, department of physical medicine and rehabilitation at the University of Colorado, Denver, understands challenges bedside nurses face.

"I was a bedside nurse for a number of years and the stress was just overwhelming at times," she says.

"When I decided to get out of bedside nursing, I started to notice that a lot of the really good nurses were leaving. When I asked, 'Why are you leaving the bedside?' they said, 'I’m just stressed out. I can’t handle this work anymore. I’m having anxiety attacks. I'm having nightmares,' " Mealer says.

This experience inspired Mealer to study the prevalence of psychological distress in nurses, specifically those in critical-care, to help them develop coping skills.

"Once I identified that this is a big problem, I started thinking about what can we do to help mitigate some of these symptoms," she says.  

One strategy studies have found to be effective in combating issues such as anxiety, depression, post-traumatic stress disorder, and burnout syndrome is resilience—the ability to cope with and recover from stress or adversity.

But, before healthcare leaders dive headfirst into launching a program to promote resilience and prevent burnout among nurses, they should query their staff to identify barriers and concerns that could thwart a program's success, says Mealer.

Mealer did just that for the study "Designing a Resilience Program for Critical Care Nurses." Here's what she found.

What a Resilient Nurse Looks Like
 

What characteristics do highly resilient nurses possess that others do not? Some of Mealer's prior work helps answer that question.

In a 2012 national qualitative study, Mealer interviewed 13 randomly selected ICU nurses defined as highly resilient on the Connor-Davidson Resilience Scale and 14 nurses with a diagnosis of PTSD, based on the posttraumatic diagnostic scale.

There were four major areas where differences were identified:

• Worldview
   
• Social network
   
• Cognitive flexibility
   
• Self-care/balance

The highly resilient nurses identified that they were able to cope with stress in the work environment through their spirituality, supportive social networks, optimism, and resilient role models.

The nurses with PTSD on the other hand, reported:

• A poor social network
   
• Lack of identification with a role model
   
• Disruptive thoughts
   
• Regret
   
• Lost optimism

"The highly resilient nurses had so many more positive coping skills to draw from. They exercised. They had rituals before they would go into work or when they would come home from work. They understood that death was part of life, and they didn’t hold on to the regret and the guilt that some of these nurses that weren’t highly resilient had," Mealer says.

"[Among] the nurses that were not highly resilient there tended to be negative coping skills. So, for example, 'I come home from my shift and I can’t sleep. I’m worried about whether I did something wrong and whether I was part of the reason why this person coded. So, I got home, and took sleeping medication, or I went home, and I had a few glasses of wine.' [They used] these less-than-desirable coping strategies," she says.

Fortunately, there is a body of research that shows resilience can be learned.

Mindfulness-Based Cognitive Therapy
 

There are various ways to develop resiliency skills, but Mealer chose to focus on Mindfulness-Based Cognitive Therapy for her study.

MBCT uses mindfulness practices such as breathing and meditation exercises to help people identify and become aware of negative thoughts and feelings. The MBCT techniques help interrupt negative thought patterns. 

"MBCT was originally developed as a treatment of relapsing depression but since then it has been modified for anxiety, and for PTSD," Mealer says.

Based on her prior work, Mealer knew nurses were open to MBCT to develop resilience, but for the purposes of this study, she wanted to assess whether nurses wanted the program delivered in the traditional 8-week MBCT format or if needed to be modified.

For the study, she moderated 11 focus groups with members of the American Association of Critical-Care Nurses. There were a total of 33 participants working as critical care nurses in the U.S.

Results
 

Based on the participants' feedback, it was determined the traditional 8-week course of two hour sessions needed modification.

"We found that was too much for the nurses. They just didn’t have the time to commit to two months of classes," Mealer says. "We have modified it, and now we have four weekly 4-hour sessions and that seems to be working well."

While there is no one-size-fits-all approach to resilience training, healthcare leaders can address their staff's needs by getting their input to design a program that works for them.

"No single design was accepted, suggesting that institutions will need to modify interventions to fit the needs of their staff," Mealer said. "We know that positive coping skills can be learned, but more research is needed to understand which interventions and resources are effective and feasible."

Researchers will use the results to refine a pilot MBCT resilience program, which will be evaluated to identify additional modifications needed. They then plan to conduct a larger trial to determine effectiveness.

3 Barriers to MBCT
 

During her study, Mealer discovered the following barriers for nurses using the MBCT program:

1. Session timing

Nurses had different preferences on the best time to offer the program. Some reported childcare would be an issue that would prevent them from coming in on their day off to attend a session. Others said because of the mentally taxing nature of their job, they preferred training on a day off rather than directly after a shift because they would be more alert and engaged.  

2. Homework assignments

 Daily homework assignments are a part of MBCT but participants said shift length, consecutive shifts, and physical fatigue at the end of a shift would make completing daily homework assignments difficult. They suggested homework would be more doable if the assignments were short and if mindfulness practices could be done at work.

3. Travel

Nurses also cited travel distance to the group sessions as a potential barrier.

"It was interesting because we interviewed critical care nurses from around the country and, depending on where they were working, they had specific requests. So, if it was in a rural-type setting, they would be fine coming in on their days off and participating in the intervention. But then if you talked to someone who worked in Washington, D.C., the traffic is so terrible, they didn’t want to have to drive back to work on a day off and battle with traffic," Mealer observed.

Improving Adherence
 

In conducting the study, Mealer found that the following participant suggestions would improve nurse adherence to the MBCT program:

1. Hybrid model. Participates felt a combination of online and face-to-face sessions would help with adherence to the program.
    
2. Short exercises. Nurses said short mindfulness practices that could be done while working would help with adherence.
    
3. Instructor background. Participants said having multiple instructors lead a session would be helpful, but they also wanted consistency that the same instructors would be at subsequent sessions to facilitate a connection between the nurses and teachers. They also preferred the instructor be a nurse with an ICU background rather than a physician.