Interventions to foster resilience in nursing staff may help (a little) in the short-term

Research evidence consistently suggests that nurses suffer from impaired psychological wellbeing (Woo et al., 2020). With between 55% to 98% of nurses reporting that necessary patient care work remains incomplete at the end of their shift as a result of limited time and resources (Jones et al., 2015), nursing staff experience high levels of psychological distress on a daily basis due to the underlying need to ration nursing care (Lainidi & Montgomery, 2022).

A significant body of research has focused on resilience among healthcare professionals (Cheng et al., 2022; Huey & Palaganas, 2020) with resilience-focused interventions being developed as an attempt to enhance staff wellbeing. Resilience describes an individual’s ability to maintain balance in managing negative emotions when dealing with challenging experiences (Johnson et al., 2017). Despite the positive links between high resilience and better health outcomes, such as lower probability of stroke and coronary heart disease (Park et al., 2022) and lower levels of mental health symptoms (Hu et al., 2015), resilience-focused interventions in healthcare have been criticised for transferring the burden of improving working conditions to the healthcare staff, forcing them to “harden” rather than, for example, aim at a better staff-patient ratio that would allow for better workload management and more time for recovery.

To this end, Kunzler et al. (2022) reviewed the evidence on the effectiveness of interventions targeting resilience among nursing staff in terms of mental health improvement, and whether any improvement is maintained in the long-term.

Increasing resilience has been suggested as a potential way to improve the wellbeing and mental health of healthcare staff – but is it the right way to think about our current challenges?

Methods

Kunzler et al. (2022) conducted a systematic search of 11 databases to identify studies that included the following characteristics:

1. A psychological intervention aimed at fostering resilience;
2. Qualified nursing staff working across primary, secondary or tertiary care;
3. Randomised controlled trials (RCTs);
4. Intervention effectiveness measured as change in the most relevant outcomes (primary outcomes) such as resilience and mental health (e.g., anxiety, depression) and/or differences in variables that can help us better understand the effect of the interventions (secondary outcomes, e.g., self-efficacy, hardiness).

Studies were excluded if participants were student nurses, retired nurses, or belonged to other healthcare staff groups. Two reviewers independently double-screened all studies at title/abstract and full-text stages, before extracting relevant data.

For primary or secondary outcomes that were reported by more than two studies, effect sizes were computed, and separate effect sizes were calculated for the different time points (e.g., post-intervention; short term follow-up at < 3 months later; between 3 and 6 months; > 6 months after the end of the intervention). Effect sizes were calculated as the Standardised Mean Difference (SMD) in the scores of the outcomes pre- and post-intervention.

The authors used the Cochrane Risk of Bias Assessment Tool (Higgins et al., 2011) to assess the quality of the studies. Results generally indicated a moderate to high risk of bias, meaning that most studies were susceptible to bias, but probably not enough to invalidate the results.

Results

The authors identified 24 studies that met the inclusion criteria. The USA was the most frequent study location (n = 11). 21 of the studies comprised of nurses-only samples (n = 1,571 nurses), while 3 included mixed samples (nurses and other healthcare staff) from different departments and specialties (intensive/critical care, oncology, psychiatry, baby clinics and cardiology). Most participants were female (over 80%).

As two studies tested multiple interventions, a total of 26 resilience interventions were identified:

• 15 interventions were group-based
• 11 interventions were delivered face-to-face and 9 were hybrid, combining face-to-face and online contact
• Resilience-focused interventions were most often compared to either a no-intervention control group or a wait-list control group
• 12 interventions lasted between 5 and 12 hours; 7 interventions lasted > 12 hours; and 3 interventions lasted ≤ 5 hours; intensity information was not provided for 4 interventions.

Results from the meta-analysis found that:

• Resilience-focused interventions resulted in a moderate increase in resilience post-intervention (SMD = 0.39, 95% CI [0.12 to 0.66], p = .004); however, the effect was not maintained at any of the follow-up timepoints.
• No significant changes were identified for anxiety symptoms post-intervention; interestingly, though, there was a moderate decrease in anxiety symptoms at the short-term follow-up (SMD = -0.59, 95% CI [-1.09 to -0.10], p = .02).
• Similarly, no significant changes were identified for stress post-intervention, but there was a moderate decrease in stress at the short-term follow-up (SMD = -0.49, 95% CI [-0.84 to -0.14], p = .006). However, this effect faded out at any time point over three months after the end of the intervention.
• No significant changes were identified in depressive symptoms at post-intervention or any of the follow-up timepoints.
• For wellbeing, a moderate positive change was identified post-intervention (SMD = 0.44, 95% CI [0.15 to 0.72], p = .003) and a smaller change was maintained within three months (SMD = 0.30, 95% CI [0.03 to 0.56], p = .03), but there was no evidence of significant changes in the long-term.

From reviewing 26 interventions, the authors found evidence for moderate reductions in anxiety and stress, and improvements in resilience and wellbeing in nurses, but only in the short-term.

Conclusions

The authors concluded that the meta-analysis:

revealed small to moderate positive effects of resilience training on resilience and other mental health outcomes immediately post-intervention (resilience, wellbeing) and in the short-term (anxiety symptoms, [perceived] stress), while there was a lack of evidence for training effects on depressive symptoms or any outcome at later follow-ups.

The meta-analysis found some positive changes in resilience, wellbeing, anxiety and stress over the short-term, but found no evidence for improvement in depressive symptoms or any long-lasting effects.

Strengths and limitations

The strengths of this study included adhering to the Cochrane Collaboration methodological guidelines to increase transparency and quality, and employing a rigorous systematic search strategy; making it is less likely that relevant studies were omitted.

Importantly, by combining the methods of a systematic review and a meta-analysis, the authors highlighted the clear need for further research on the effectiveness of resilience-focused interventions for nursing staff and the lack of consistent long-term data. Additionally, the authors emphasised the importance of transparency in describing the interventions in detail, as this will allow to better identify what does and what doesn’t work.

However, there are some limitations:

• As the review only included interventions that made explicit mention of targeting resilience, more generalised interventions that might improve resilience indirectly were excluded.
• The authors make it clear that the findings of this meta-analysis should be interpreted with caution due to the limited pool of studies identified, especially as far as long-term follow-up in concerned. For example, even though no evidence of significant effects on depression were found, this does not mean that there is the complete absence of this effect among nurses in general.
• Despite the narrow focus, the included studies were still considerably heterogeneous (e.g., high variability in the interventions), which may have also affected the findings of the meta-analysis.
• The authors acknowledge the certainty of evidence being low, and that the small number of studies on each outcome and the predominance of specific characteristics (e.g., face-to-face delivery) did not allow for meaningful sub-group comparisons. As such, there is no evidence on whether interventions with different characteristics could affect the outcomes differently (e.g., group versus individual interventions).
• Similarly, the authors explained that for the same reasons, risk of bias due to missing results was not assessed further than quality appraisal, due to funnel plot asymmetry (although the Cochrane Handbook does suggest ways around this; Page et al., 2019.

The effectiveness of resilience-focused interventions for nursing staff was explored; however, the insufficient evidence of long-term effects, the low number of included studies, and lack of meaningful sub-group comparisons imply significant limitations.

Implications for practice

The authors link the findings to potential practical implications relevant to interventions. In particular:

• For researchers, organisations and funders, there is a need to rethink whether resilience-focused interventions in the current format are appropriate; changes in certain aspects might be needed to achieve better outcomes. For example, team-level interventions need to be further considered and explored as a growing body of literature suggests that the interplay between individual and team resilience is key when addressing the wellbeing and mental health of employees (Hendrikx et al., 2022).
• The effect of individual-based resilience interventions might be also restricted by organisational-level factors, such as a lack of participatory leadership practices and shortages of staff and resources; thus, for organisations, funders and researchers, there is a need to consider organisation-directed or structural approaches to foster resilience by also addressing workplace factors.
• Researchers and funders should consider further exploring online interventions, which could simultaneously help to reduce the costs and resources required to deliver face-to-face interventions, while also interventions more accessible to nursing staff (read Chris O’Sullivan’s Mental Elf blog on digital tools for employee wellbeing to learn more).
• Nursing education should consider integrating resilience training as part of the curriculum, as being proactive might be more effective in terms of preparing nursing staff to deal with difficulties at work, rather than just a post-hoc attempt to mitigate the impact of work-demands on nurses’ mental health.

Future research is needed to better integrate resilience training within organisations, as well as within the nursing education curriculum.

Statement of interests

I have no competing interests to declare.

Links

Primary paper

Kunzler, A. M., Chmitorz, A., Röthke, N., Staginnus, M., Schäfer, S. K., Stoffers-Winterling, J., & Lieb, K. (2022). Interventions to foster resilience in nursing staff: a systematic review and meta-analyses of pre-pandemic evidence. International Journal of Nursing Studies, 104312.

Other references

Cheng, C. K. T., Chua, J. H., Cheng, L. J., Ang, W. H. D., & Lau, Y. (2022). Global prevalence of resilience in health care professionals: A systematic review, meta‐analysis and meta‐regression. Journal of Nursing Management, 30(3), 795-816.

Hendrikx, I. E., Vermeulen, S. C., Wientjens, V. L., & Mannak, R. S. (2022). Is Team Resilience More Than the Sum of Its Parts? A Quantitative Study on Emergency Healthcare Teams during the COVID-19 Pandemic. International Journal of Environmental Research and Public Health, 19(12), 6968.

Higgins, J. P., Altman, D. G., Gøtzsche, P. C., Jüni, P., Moher, D., Oxman, A. D., … & Sterne, J. A. (2011). The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ, 343.

Hu, T., Zhang, D., & Wang, J. (2015). A meta-analysis of the trait resilience and mental health. Personality and Individual Differences, 76, 18-27.

Huey, C. W. T., & Palaganas, J. C. (2020). What are the factors affecting resilience in health professionals? A synthesis of systematic reviews. Medical Teacher, 42(5), 550-560.

Johnson, J., Simms-Ellis, R., Janes, G., Mills, T., Budworth, L., Atkinson, L., & Harrison, R. (2020). Can we prepare healthcare professionals and students for involvement in stressful healthcare events? A mixed-methods evaluation of a resilience training intervention. BMC Health Services Research, 20(1), 1-14.

Jones, T. L., Hamilton, P., & Murry, N. (2015). Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. International Journal of Nursing Studies, 52(6), 1121-1137.

Lainidi, O., & Montgomery, A. (2022). Untangling Difficult Emotions on the Job. In H. Blake & G. Stacey (Eds.), Health and Wellbeing at Work for Nurses and Midwives-E-Book (pp. 37-42). Elsevier Health Sciences.

O’Sullivan, C. (2017). Are digital tools the answer to improving employee wellbeing and effectiveness? #WorldMentalHealthDay. The Mental Elf.

Page, M. J., Higgins, J. P., & Sterne, J. A. (2019). Assessing risk of bias due to missing results in a synthesis. In J. P. T. Higgins, J. Thomas, J. Chandler, M. Cumpston, T. Li, M. J. Page, & V. A. Welch (Eds.), Cochrane Handbook for Systematic Reviews of Interventions. Cochrane.

Park, J. W., Mealy, R., Saldanha, I. J., Loucks, E. B., Needham, B. L., Sims, M., … & Howe, C. J. (2021). Multilevel resilience resources and cardiovascular disease in the United States: A systematic review and meta-analysis. Health Psychology.

Woo, T., Ho, R., Tang, A., & Tam, W. (2020). Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. Journal of Psychiatric Research, 123, 9-20.

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