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Building nurse resilience

Kester, Kelly, BSN, RN, CCRN, NE-BC; Wei, Holly, PhD, RN, CPN

Nursing Management (Springhouse): June 2018 - Volume 49 - Issue 6 - p 42–45
doi: 10.1097/01.NUMA.0000533768.28005.36
Feature

Examine current evidence-based literature that addresses how to promote resiliency in nurses.

Kelly Kester is a cardiothoracic ICU operations nurse manager at Duke University Medical Center in Durham, N.C. Holly Wei is an assistant professor at East Carolina University College of Nursing in Greenville, N.C.

The authors have disclosed no financial relationships related to this article.

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Defined as the ability to face adverse situations, remain focused, and continue to be optimistic for the future, resilience is a vital characteristic for nurses in today's complex healthcare system.1 The competing priorities and challenges with which nurses are confronted may make it difficult to develop resilience characteristics.2 Therefore, it's important for nurse leaders to educate nurses about self-care and techniques to build resilience.

An online literature review, primarily using PubMed, was conducted to gather evidence-based articles that address strategies to promote nurse resilience. The following search terms were used: nurse, nursing, nurse leaders, resilience, resiliency, and their combinations. The literature review was restricted to articles published between 2015 and 2017 to ensure that the recommendations were up-to-date and relevant to current healthcare needs.

Much of the literature about nurse resilience describes high-intensity areas, such as the ED, oncology, and critical care environments. The literature indicates an urgent need to support nurses in becoming resilient to decrease burnout, stress, and compassion fatigue, especially for nurses working in high-intensity areas. This article summarizes the findings of nine studies about common contributing factors to nurses' dissatisfaction at work and strategies for nurse leaders to boost nurse resilience.

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Contributing factors to nurse dissatisfaction

Nurse dissatisfaction at work can lead to feelings of distress and a negative professional quality of life. Several factors are described that contribute to altered nurse satisfaction. Three of the factors are compassion fatigue, burnout, and secondary trauma.3

Compassion fatigue is a tense feeling that develops when a nurse experiences stress related to repeated exposure to high acuity and high patient volumes.4 Gradually, the fatigue starts to impact the quality of care that nurses can provide, leading to decreased patient safety and organizational outcomes.3 In addition, compassion fatigue can lead to increased job dissatisfaction and nursing turnover.

Burnout is defined as a response to physical or emotional stressors that leads to exhaustion, self-doubt, cynicism, and ineffectiveness.5 It's commonly reported in high-stress areas, including critical care, pediatrics, and oncology.6 Moral distress, emotional stress, and spiritual demands may contribute to burnout and create a perception of excessive workload.6 A Robert Wood Johnson Foundation study found that 18% of nurses experience depression, which is twice the rate of the general public and may develop from burnout.5 Nurses are often exposed to ethical dilemmas, particularly when the beliefs of caregivers and patients don't match. One study found that when caregiver and patient values conflict, caregivers' sense of integrity may be compromised.6 Caring for patients in these situations can create an internal conflict for nurses, leading to burnout and secondary trauma.

Secondary trauma creates feelings of misery and may manifest through anxiety, sleeplessness, depression, and lack of job satisfaction.4 These symptoms, combined with compassion fatigue and burnout, can impact patient safety and outcomes. In addition, when multiple team members are experiencing factors related to compassion fatigue, burnout, and secondary trauma, the impact on patient safety and care delivery may compound, potentially leading to increased turnover and cost, decreased efficiency, and poor patient outcomes.

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Leadership strategies

After reviewing the literature, three strategies for building nurse resilience consistently emerged: formal education programs, social support, and meaningful recognition. In addition, participating in self-care, fostering relationships, and establishing boundaries help support nurse leader resilience, which, in turn, allows leaders to foster opportunities for nurses' well-being.7 Building strong relationships is a key factor in caring and building resilience.

One study introduced how the military is leading the way in building resilience, shifting from treatment to prevention of traumatic symptoms, including burnout and secondary trauma.8 Master Resilience Trainers teach active duty military members to prepare for and sustain resilience through adversity.8 This training is provided through a formal program that ensures consistent education, support, and leadership engagement. A second program for Navy personnel, Operational Stress Control, promotes engagement through education about sleep, fitness, eating habits, and other self-care techniques.8

The healthcare industry may benefit from using the military as guidance for educating nurses about maintaining resilience.8 Implementing formal and consistent resilience education for nurses to identify stressors, be aware of personal triggers, and take part in preferred self-care activities can help move the healthcare industry toward supporting a culture of wellness.9 Providing education for charge nurses, preceptors, and nurse leaders to identify behaviors caused by compassion fatigue and burnout may also be helpful for supporting new nurses.

Social support can be implemented in many ways and may vary depending on the culture of an individual department. One option is hosting scheduled debriefing sessions in which nurses can bond and learn from each other while sharing stories and experiences.4 The debriefing sessions are educational, focused, and led by individuals who are trained to structure reflection, learning, and healing.4 Ensuring that staff members are comfortable in this setting and have access to the sessions on all shifts is important for maintaining engagement. Regular sessions can create a supportive, educational outlet for nurses; as-needed sessions can also be held for situations that occur unexpectedly. Other options for social support may include activities such as potluck dinners and holiday crafts, and out-of-work events.

Meaningful recognition can be challenging to sustain because even though providing recognition isn't necessarily difficult or expensive, individuals may interpret recognition differently. Participating in a formal program, such as the DAISY Award for Extraordinary Nurses, can demonstrate that the organization is invested and interested in recognizing staff members for the work that they do. In addition, informal and spontaneous recognition can be made meaningful for staff, such as small tokens of appreciation for nurses who have a challenging day, perform well on quality metric audits, or demonstrate strong teamwork. Nurses who receive recognition may have improved compassion satisfaction and decreased impact from secondary trauma.3 Also of note in the literature is that the highest level of stress for nurses is during their first year of practice, so recognition by preceptors is an impactful way for new nurses to feel valued.10 Developing tools to identify methods of recognition that nurses prefer can help nurse leaders be effective in giving meaningful recognition, utilizing resources, and better understanding what recognition strategies impact nurse resilience.

Nurse leaders aren't specifically trained to build a resilient team; however, combining formal education, social support, and meaningful recognition is an achievable strategy that promotes the well-being of nurses in the patient care environment. Implementing one intervention at a time and engaging staff in the planning, rollout, and maintenance of the interventions can provide a sense of camaraderie, teamwork, trust, and ownership, which, in turn, can positively influence the work environment.

Financial resources are often limited, leading to potential restraints when planning education, social activities, and recognition. Nurse leaders can advocate for funds in their operational budgets using the current evidence that supports the need for building resilience and justify the need over time by trending nurse retention and work culture survey scores. Regardless of the resources available, creative solutions can be developed by individual teams to promote resilience.

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Building blocks

Building nurse resilience through formal education, social support, and meaningful recognition is an important focus for nurse leaders in establishing a healthy work environment and maintaining a stable nurse workforce. Prioritizing the well-being of caregivers is necessary for patient safety, quality of care, and the patient experience.

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REFERENCES

1. Dyer JG, McGuinness TM. Resilience: analysis of the concept. Arch Psychiatr Nurs. 1996;10(5):276–282.
2. Rutter M. Resilience in the face of adversity. protective factors and resistance to psychiatric disorder. Br J Psychiatry. 1985;147:598–611.
3. Kelly LA, Lefton C. Effect of meaningful recognition on critical care nurses' compassion fatigue. Am J Crit Care. 2017;26(6):438–444.
4. Schmidt M, Haglund K. Debrief in emergency departments to improve compassion fatigue and promote resiliency. J Trauma Nurs. 2017;24(5):317–322.
5. Magtibay DL, Chesak SS, Coughlin K, Sood A. Decreasing stress and burnout in nurses: efficacy of blended learning with stress management and resilience training program. J Nurs Adm. 2017;47(7–8):391–395.
6. Rushton CH, Batcheller J, Schroeder K, Donohue P. Burnout and resilience among nurses practicing in high-intensity settings. Am J Crit Care. 2015;24(5):412–420.
7. Dyess SM, Prestia AS, Smith MC. Support for caring and resiliency among successful nurse leaders. Nurs Adm Q. 2015;39(2):104–116.
8. Crabtree-Nelson S, DeYoung LP. Enhancing resilience in active duty military personnel. J Psychosoc Nurs Ment Health Serv. 2017;55(2):44–48.
9. Klein CJ, Riggenbach-Hays JJ, Sollenberger LM, Harney DM, McGarvey JS. Quality of life and compassion satisfaction in clinicians: a pilot intervention study for reducing compassion fatigue. Am J Hosp Palliat Care. [e-pub Jan. 1 2017]
10. Meyer G, Shatto B. Resilience and transition to practice in direct entry nursing graduates Nurse Educ Pract. 2018;28:276–279.
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