Bedside nurses work in a stressful and ever-changing hospital environment, with little time to recover between shifts. The American Nurses Association reported 79% of nurses surveyed ranked workplace stress as the top workplace hazard.1 Nurses have some of the highest levels of occupational stress among healthcare professionals.2 Direct care nurses must manage and attend to the emotional and physical demands of patients, as well as the emotional burdens of families and other healthcare team members.3 The level of stress perceived by direct care nurses has dramatically increased recently because of the coronavirus disease 2019 (COVID-19) pandemic.4,5 Not only has the pandemic resulted in abrupt changes in work duties and job status, but it also has disrupted all aspects of life. For a profession already reporting high levels of stress, the COVID-19 crisis has pushed many nurses to their limit, and some have left the profession or plan to leave soon.4 The United Nations reported that the pandemic has highlighted the important role of nurses as the backbone of healthcare.5 The reported global deficit of 7.2 million skilled health professionals is projected to increase to 12.9 million by 2035.6 Before the pandemic, the United States was projected to need an additional 11 million nurses to maintain the current workforce.6 This projected number may have increased in light of the effect of the pandemic on nurses. The nursing profession cannot afford to lose any highly skilled, licensed nurses who are fundamental to patient care. Finding ways to help nurses recognize and cope with stress may be essential to retaining them in the workplace.7
Resilience is the ability to adapt and thrive in face of a challenging work environment.3 Resiliency-building activities can address the effects of emotional dissonance found in nursing work. The presence of high resilience reduces job stress, burnout, compassion fatigue, and turnover intent, as well increasing overall well-being, quality of life, and job satisfaction.3,8-10 Resilience is maintained through environmental factors and personal characteristics such as self-efficacy, flexibility, problem solving, emotional stamina, and level-headedness.11 Two recent reviews of stress reduction and resilience building activities for healthcare professionals encouraged further research on ways care organizational leaders can incorporate these activities consistently into daily routines.10,12 This work addresses a gap in the literature by engaging nurses in stress reduction and resilience-building activities, termed microrestorative practices,13 during their work hours, rather than outside of work. This pilot study investigated the feasibility of increasing nurse resiliency over 4 to 6 weeks through a toolkit of evidence-based stress-reducing interventions on medical-surgical units. A variety of interventions were selected for ease of use during work. Although this study was completed before the COVID-19 pandemic, there is significant and relevant information that can be applied to the resilience of bedside medical-surgical nurses today.
The framework for this study was based on a concept analysis of resilience.14 “The concept of resilience, the capacity to transcend adversity and transform it into an opportunity for growth, offers a valuable framework for working with diverse individuals and challenging situations.”14(p125) Gillespie et al14 identified the antecedents to resilience as adversity, trauma, a realistic worldview, and a capacity to interpret adversity both cognitively and socially. The interrelationship of the defining attributes of resiliency (self-efficacy, hope, and coping) contributes to the overall measure of resilience. Resilience allows individuals to bounce back from stressors by using a repertoire of coping skills. Stress coping skills may be conscious or unconscious and learned in response to exposure to difficult situations. The outcomes of resilience were integration, development of personal control, psychological adjustment, and personal growth.14 Thus, the more resilient person is better able to cope with adversity. Importantly, resilience is not static, but rather can be developed or enhanced. Resilience grows as coping skills are applied over time. Resilience and stress coping vary between individuals based on life experience and other individual factors.
Stress and Resilience in Nurses
Recent studies show a relationship between stress and resiliency.15,16 Work stress mediates resilience, and resilience moderates work stress.16 Resilience appears to be related to job satisfaction, coping skills, and job retention. Increased resilience therefore ameliorates work stress, which should decrease job dissatisfaction and turnover.
An exploratory study by Lanz and Bruk-Lee9 further illuminated the relationships between resilience and other salient variables in nurses. The study examined the relationship between interpersonal work conflict, burnout, workload, and intent to leave in relation to resiliency in a sample of medical-surgical nurses.9 Interpersonal work-related conflict predicted turnover intention and burnout. However, resilience mediated the relationship between conflict and job outcomes (turnover, burnout, and injuries). Nurses with low resiliency felt the effects of conflict more strongly, causing negative affect and negatively influencing job outcomes. Highly resilient nurses coped with work conflict effectively, and their job outcomes were not affected.
From the review of the literature, because stress is related to resilience, it is important to measure and compare both of these variables. Stress in nursing appears to be a variable that can be influenced in a variety of ways. Stress affects us in everyday life, but it is heightened in the hospital environment where nurses work. It is widely recognized that stress exists at home as well as in the workplace. There is much discussion about the differences between acute versus chronic stress in the nursing literature with chronic stress leading to burnout.17 The focus of this study is on acute work-based stress, which was thought to be most impacted by the interventions proposed; however, a baseline survey of stressors confronting nurses outside of work was also included. Therefore, interventions toward decreasing acute work-related stress were proposed, while measuring potential changes in resiliency.
Interventions to Decrease Stress and Increase Resilience
Resilience-building activities are interventions used to decrease nurses' feelings of stress, increase coping, and address emotional dissonance. In the literature, resilience-building activities take a variety of forms and are aimed at such constructs as mindfulness, life balance, and other self-improvement exercises. These activities are time consuming and done outside work hours. A 2020 integrative review of evidence on work stress and resilience reported nurses experience moderate to high levels of stress at work.10 Despite that, resiliency scores were increased through use of a variety of activities.10 Sources of stress included the job, patient, and personal factors. Resiliency-building activities offered in these studies were predominantly mindfulness courses, work-life balance, increasing positive thinking, or enhancing emotional intelligence.10 Worth noting were 3 studies that addressed leadership practices thought to enhance resiliency. Suggestions included nurse leaders giving nurses positive feedback, treating staff with respect, and development of self-awareness among leaders.10
A 2017 systematic review of resilience in nurses addressed the emotional labor of hospital-based nursing.3 Four studies detailed resiliency-building interventions, including 2 that used detailed educational activities, such as workshops, to learn specific techniques. One study used interventions including workshops, cognitive behavioral therapy, meditation, and aerobic exercise, and another used education and mindfulness activities. All reported diminished stress and improved resiliency.3
A delivery method investigated for presenting resilience-building activities used an online format. Nurses completed 12 modules over 20 weeks, including exercises and group discussions.8 A variety of scales measured happiness, stress, anxiety, mindfulness, resiliency, and burnout. At the end of the study, happiness, mindfulness, and resiliency scores increased, whereas anxiety, stress, and burnout decreased. A time commitment to a 20-week experience during personal time seems extreme for a work-based intervention.
A 2013 study used an 8-week self-care program, taught in 3- to 8-hour sessions.11 Participants continued practicing the techniques on their own time for 8 weeks. Techniques included Reiki, guided imagery, yoga, toning, meditation, intuitive scanning, and creative expression. The study found decreased stress and increased coping with job roles at 8 weeks; the effect continued a year later with a follow-up questionnaire. Once again, the time commitment seems excessive for a work-based intervention.
In summary, the majority of interventions studied were lengthy intensive educational programs, which were costly in money and personal time. Although the results of each show a positive impact on resilience, do the cost and time involved justify the intervention? None of these studies occurred on the job, where nurses experience work stress and need an immediate intervention.
The Role of Nurse Leadership
Stress at work is a real concern in today's healthcare settings. Prolonged stress is harmful to organizational efficiency as well as nurses' health.18 Therefore, nurse leaders actively seek to promote less stressful environments and improve nurse well-being. The World Health Organization's Healthy Workplace Framework and Model19 recommended a work environment where there is an absence of harmful conditions and encouraged leaders to advocate for healthy supportive spaces. This model addressed 4 areas of influence including physical work environment, psychosocial work environment, personal health resources, and community involvement. Balancing all 4 of these areas assisted in creating a positive work environment that is less stressful and more supportive and encourages commitment to the organization to decrease turnover. Emphasized is the impact that quality, compassionate leadership has on dramatically improving the well-being of nurses.10 Programs should be aimed at promoting long-term resilience in employees and be actively encouraged and supported by leadership.10
In the literature, a single resiliency-building intervention has not emerged as effective for every nurse. Therefore, a variety of strategies were offered that were either portable or downloadable applications (apps) accessible by smartphones. The interventions, supporting citations, and descriptions are located in Table 1.
Table 1 -
||Findings to Support
||Decreased stress,20 heart rate, blood pressure, and stress measures21
||Lipstick-sized lavender inhaler
|Adult coloring books
||Relaxation, mindfulness,22 decreased stress,23 increased positive affect, self-efficacy; decreased negative affect, anxiety, perceived stress, and burnout24
||One 5.5 × 8.5-inch high-quality adult coloring book with colored pencils
||Balanced autonomic nervous system and reduced anxiety; decreased hemodynamic changes that occur under stress; can decrease fatigue and anxiety25; long used as nursing intervention for pain distraction (eg, women in labor)
||Instructional card detailing a deep-breathing exercise augmented with a free app for smartphones
|Relaxation through guided meditation
||Decreased blood pressure, decreased heart rate, slowed breathing, and movement out of the flight-or-fight stress response25,26
||Instructional card detailing how to access a free guided meditation relaxation app for smartphones
||Elevated mood, decreased stress27,28; Bejeweled, a matching game, decreased stress levels and heart rate, while elevating mood; Tetris, a puzzle game, decreased stress in some populations28
||Instructional card with directions to access free Bejeweled and Tetris apps for smartphones
|Mind activity book
||Distracts from current situation, allows change of mental focus, makes player feel life is more ordered and under his/her control29
||One 5.5 × 8.5-inch high-quality booklet with Sudoku, crossword puzzles, and word search games
Setting and Sample
Four affiliated urban and suburban hospitals were included in the study: 2 Magnet®-recognized facilities with 463 beds and 2 facilities on the journey to Magnet designation with a total of 886 beds. Funding for this study was provided by the 4 hospitals within the health system. Each hospital selected nurses to be part of a Nurse Scholar Program (Program). The nurses met 5 times with 2 nurse researchers from an academic health sciences center to create the study protocol. The Program promoted evidence-based practice and research education by active collaboration on the study. The nurse scholars were engaged in all aspects of the study. The research team consisted of the nurse scholars, 1 of the hospital Magnet directors, and 2 university-based nurse researchers.
Institutional review board (IRB) approval was obtained through the health system's Clinical Research Institute and the university affiliated with the nurse researchers. A convenience sample of 150 volunteer nurses on medical-surgical units were included. Subjects were recruited by nurse scholars who attended team huddles on units and by posted flyers and word of mouth during November 2017 to February 2018.
This quasi-experimental pretest and posttest interventional pilot study used a within-subjects design. Nurse scholars obtained informed consent from nurses at designated medical-surgical units at each hospital; showed a video about the study protocol, how stress and resiliency are related, and use of the toolkit items; and then provided subjects with toolkits. Toolkits included written instructions to carry out the study. Subjects accessed all electronic surveys housed on the Qualtrics platform by a unique link sent to work email accounts. Subjects completed electronic surveys at baseline, at 10 time points over a 4- to 6-week period, and lastly at the conclusion of the study.
Resilience was measured at baseline and at conclusion using the 10-item Connor-Davidson Resilience Scale-10 (CD-RISC-10).30 The CD-RISC-10 has been used in multiple settings and has undergone rigorous validity and reliability testing across a variety of ages and populations including healthcare personnel and nurses and within numerous countries with solid and consistent psychometric properties (α > .80).30,31 Subjects completed a demographic questionnaire at baseline. The research team created shift surveys that asked subjects to record their stress levels on a Likert-type scale of 1 (low) to 5 (high) preuse and postuse of the interventions and to identify sources of work stress. Subjects recorded the number of times interventions were used and length of time each was used during a shift. These were completed at 10 time points over 6 weeks. Lastly, subjects were asked to complete a postsurvey that included the CD-RISC-10.
Descriptive analyses, exploratory statistics, regressions, and analysis of variance were used to analyze the data using SPSS 27 (IBM SPSS, Armonk, NY) and SAS 9.4 software (SAS Institute, Cary, NC). The baseline questionnaire was completed by 148 subjects. Seventy percent of subjects were between 25 and 44 years of age (Table 2). Subjects selected all sources of stress at work and home from a list of 10 items. The main sources of stress outside of work were family including caregiving (70%). Figure 1 shows the most common sources of work stress were patient acuity (43%) followed by patient interactions (37%).
Table 2 -
Baseline Demographics and Sources of Stress Outside of Work
|Age, n (%)
||n = 148
| 18–24 y
| 25–34 y
| 35–44 y
| 45–54 y
| 55–64 y
||n = 145
||n = 149
| 7 am to 7 pm
| 7 pm to 7 am
||n = 149
| Licensed practical nurse/licensed vocational nurse
||n = 150
| Black/African American
| Indian/Alaska Native
|Sources of stress outside work
| Spouse/intimate partner
| Personal health
The breathing exercise was the intervention used most often by the most subjects (Table 3). The next most used interventions were the lavender inhaler and the coloring book. Other interventions not part of the toolkit but selected by subjects included taking a break off the unit, prayer, and singing. There were no significant differences found for effectiveness of intervention types. More than 50% agreed the intervention used was either very effective or extremely effective for stress relief.
Table 3 -
Effectiveness of Interventions for Stress Relief
||Not Effective at All
|Active mind activity book
Self-reported stress level was reported before and after use of the intervention for each shift. The difference between preuse and postuse stress level defines level of stress relief. As shown in Figure 2, the level of stress relief progressively increased over time from the 1st through the 10th shift significantly, indicating the more participants used an intervention, the more improvement in stress level after each use. For deep breathing, the frequency and length of time increased significantly over time (P = .022 and P < .001, respectively). There were upward trends in frequency and time spent using the interventions as the study progressed. Initially, interventions were used for 1 to 2 minutes, increasing over time to 7 to 8 minutes. Most subjects (97.1%) indicated a desire to continue using the interventions beyond the study.
Resiliency scores increased significantly after use at follow-up (df77 = −2.141, P < .02). Older participants used breathing exercises more frequently (P = .031). Younger participants used the lavender inhaler for a progressively longer time as the study continued (P = .003). There was no statistical significance in resiliency scores related to non–work-related stressors or any other demographic variables at baseline.
The top work-based sources of stress reported by the nurses were patient acuity and patient interactions. Direct care nurses spend most of their time performing patient care. Hospitalized patients may feel bad or confused, and the more severe the illness, the more complex the care, involving increased coordination with other providers. The top 2 sources of stress from outside work were not unexpected, as family/caregiving and financial concerns would be considered typical stressors of most working adults. With increased resiliency, one expects both work and home stress to be better managed. Although one cannot always separate work and home stress, statistics did not bear out any causal effect of home or outside stressors. Other than within the initial demographics, data about non work-related stressors were not collected. The focus of this study was on work stress.
Deep breathing and the use of the lavender inhaler were most popular, possibly because they were easy to use during minutes-long breaks from patient care, and while doing other things, such as documentation. Nurses have long helped patients cope with anxiety by advising the use of deep breathing, so it is interesting that nurses have not routinely used this to decrease their own stress. Nurses need to use their own judgment as to when and where deep breathing is safe and appropriate, taking into consideration the potential presence of infective agents in the environment.
Nearly all subjects expressed an interest in continuing to use the interventions. This validates our finding that nurses used the interventions more often and for longer periods, while reporting increased benefits over the course of the study. Therefore, it can be inferred that the nurses identified some positive change in themselves after using the interventions. An additional inference is that the interventions most used were those most feasible in a fast-paced healthcare environment.
Role of Nurse Leadership
Nurse participants anecdotally shared a sense of being valued and supported by the leadership due to being provided the self-care strategies and information presented within this study. When managers support such interventions and encourage nurses to take time during their shift to practice stress management, it may make the work environment feel less stressful and more supportive. These strategies could be a part of an initiative building toward a healthier work environment, with the goals of decreasing acute stress and building a resilient workforce over time. Offering and encouraging interventions within the work environment, as opposed to before or after work, allow nurses to feel more in control over their work environment. By providing these interventions, the intention of management was to empower nurses in their choice of stress management tool, ultimately giving them a sense of control and feeling valued.
Although 149 nurses enrolled in the study, 59 subjects dropped out after the baseline survey, (attrition rate, 39.5%), leaving 90 who completed surveys for at least 8 shifts. There were further losses over time, and 77 subjects, resulting in a total attrition rate of 48%, completed posttests at 4 to 6 weeks. Several factors contributed to the attrition rate. The IRB approval process took 3 months, delaying recruitment and enrollment; thus, data were collected during winter holidays. The hospitals also experienced a record amount of absenteeism from flu, causing a loss of subjects. The initial rollout of this study also coincided with an overhaul of the email security system at all 4 sites, causing a substantial bounce-back of email containing study information. This additional delay resulted in decreased participation until the issue was resolved. There were also some issues inherent in individual subjects. Although subjects were informed of the expectations and requirements of this longitudinal study at enrollment, both verbally and in writing, some subjects said the shift surveys were lengthy, cumbersome, and difficult to complete during work. Unexpected was learning that substantial numbers of nurses did not use their work email consistently, where the study information was sent, leading to further attrition.
Because the focus of this study was to assess the relationship of work stress to resiliency, outside sources of stress were not measured throughout the study. It is unknown whether measuring non–work-related stressors would have made a difference to the outcomes. Conversely, the effect of increased resiliency on the level of non–work-related stressors is also unknown.
This study was conducted at 4 hospitals. Some sites had higher participation than others. The differences might have been due to the cultures and demographics of the hospitals. A unit at 1 site underwent a managerial change, interfering with adoption of the study. Conversely, when a nurse scholar was part of 1 of the selected medical surgical units, the participation was greater than when a unit member was not a nurse scholar. Taking all of these factors into consideration, a 2nd study of these interventions was performed using paper-and-pencil data collection and will be reported in the future.
This study sought to investigate the feasibility of stress reduction and resiliency enhancement interventions applied across a multisite hospital system among nurses during work hours.
Statistically significant results were reported for increased resilience. Previous studies have concentrated on ways to reduce stress and increase resilience-building activities outside of the work setting, while this study focused on integrating simple, brief, and portable interventions for use during work hours. Health systems may be able to retain nurses through actively supporting adoption of strategies to promote stress reduction and build resilience. Especially with the COVID-19 crisis, it is imperative that nurse leaders offer ways for staff nurses to mitigate their stress during work hours. Further studies need to evaluate the long-term impact of nurse resilience and overall well-being with continued use of selected stress relief interventions while at work.
The authors acknowledge and thank the following: Methodist Health System-Dallas, Texas, and the following nurse scholars for their participation and assistance with this study: Fawn Rojas, Cheri James, Cheyenne Ruby, Ashley Attaway, Debra Harper, Laurine Ndlovu, Kristen Caldwell, Elaine Mueller, and Terri Daugherty. Additionally, they also thank Michelle Knight, Lead Wellness Coach with Methodist Health System-Dallas, Texas.
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