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Grace under fire: Surviving and thriving in nursing by cultivating resilience

You’re in charge on a busy evening shift. While you struggle to fill an impending staffing deficit, a newly admitted patient begins screaming at a co-worker. As you move toward the patient, you notice that the rain hitting the windows is turning to ice, possibly making it difficult for the next shift to arrive. How will you cope with this small series of stressful events? How will you rally the troops and make a plan to get through the next hours with calm and grace?

This scenario is just a taste of the stressors nurses face on a daily basis; others include new technology, new protocols, alarms, high acuity, violence, and exposure to the suffering of those we are trying to help. As a team, nursing leaders and educators designed an evidence-based program to boost staff resilience and ability to cope in these types of stressful situations.

The nature of resilience

Why did we choose resilience as the foundation for our program? Resilience is defined as the capacity to keep functioning physically and psychologically in the face of stress, adversity, trauma, or tragedy. Adapting effective personal stress management techniques can translate into a better awareness of self and others, enhance supportive relationships, improve communication and teamwork, and increase personal health and well-being leading to a safer work environment for patients and staff.

Studies from business, education, and the military demonstrate that resilience isn’t a fixed concept but can be increased through education.

We used the following concepts in designing the program:

  • Stress inoculation, which better prepares staff to cope with a threat before it occurs.
  • Management of compassion fatigue such as building connections and support between team members, caring for oneself, and avoiding burnout.
  • Positive psychology, specifically optimism and building positive attitudes, used with success to assist the military and veterans to manage responses to conflict.

How the program worked

The program included a workshop taught by members of the Resilience Team, the authors of this article, followed by monthly education and activities to reinforce workshop content. The team believed a one-time approach would be less effective and that repetition and practice would yield more lasting personal and cultural change. Our target audience was the psychiatry staff, including registered nurses and nonlicensed clinical, clerical, and environmental employees. Over a span of 5 months, 162 individuals completed the training.


The workshop focused on the following seven elements to increase resilience:

  • Connectedness and support, which buffers individuals against the negative effects of stress. Staff identified support persons at work and home and developed strategies to connect with them.
  • Intentionality, which helps staff members to develop their own mission statement, professional or personal. The ability of a person to follow a mission helps one realize what is truly important and makes it more difficult to get derailed in challenging situations.
  • Self-validated care giving, stemming from one’s mission, strengthens the individuals’ ability to feel good about the work one does, regardless of the outcome. This element acknowledges that while recognition from others is important, self-acknowledgement is crucial.Exercises included having each person take time to create a “letter from the Great Supervisor” which recognizes the person’s own strengths, and contains thanks from this hypothetical person.
  • Self-efficacy is the belief that an individual is capable of performing in a certain way in order to achieve goals. Individuals are more inclined to take on a task if they believe they may succeed. Seeing how others succeed and experiencing personal mastery of new learning increases an individual’s motivation to take on new challenges. Staff was encouraged to identify goals and a mentor to assist with goal achievement.
  • Self-regulation is the ability to switch from the sympathetic (reactive) to the parasympathetic (calm, rational) nervous system through targeted relaxation techniques. Individuals shift to a state of sympathetic dominance when they are challenged or threatened. This activation is helpful in emergency situations, when one needs to respond quickly. The problem occurs when a person remains in a state of hyperexcitability, which may result in compromised higher brain functions like language, speech, motor activity, and compassion; loss of ability to make clear choices; and the inability to relax and enjoy the moment. This can lead to burnout, and is the source of many physical problems.Guided imagery exercises, meditation, deep breathing, relaxation of pelvic muscles, and even taking a short rest can help break the sympathetic activation cycle.
  • Positivity affects perceptions, attitudes, and expectations. Positive emotions have been shown to increase feelings of energy, help one cope with adversity, and feel more optimistic about life. Staff identified those things that brought joy to their lives, and learned about visualizing what they want rather than worrying about what they feared, remaining hopeful, and the importance of laughter.
  • Self-care and the importance of a healthy life style. As nurses we teach our patients the importance of self-care but often don’t practice what we teach.
    Strategies included getting enough sleep, healthy eating, regular exercise, rejuvenating hobbies, finding time for pampering, processing emotions though journaling or connecting with friends, maintaining a spiritual practice, and incorporating laughter into the day.
    After reviewing evidence to support each concept, staff wrote letters to themselves about what they wanted to change or add to their lives. These sealed letters were returned to them 3 months later as a reminder of their commitments to themselves.

At the end of the workshop, staff created a plan for improving their functioning in all seven elements. An evaluation showed that staff enthusiastically appreciated the opportunity to focus on themselves, their health, and building resilience.

Return on investment

Stress costs the American work force about 300 billion dollars per year. What stress costs a nursing organization is more difficult to calculate. The resilience project required 8 hours of workshop time per staff member and meal costs spread over 5 months. Books, CDs, CD players, and DVDs associated with resilience themes used to support resilience education were relatively inexpensive (about $100 for each unit). Ongoing reinforcement sessions were built into pre-existing, budgeted education, such as monthly Nursing Grand Rounds.

The goal of the program was to help staff strengthen their internal coping mechanisms, bolster pre-existing resilience, and build a healthier work environment by empowering staff to become stronger as individuals and as a team. Although the return on investment is not easy to calculate, perceived stress is a strong predictor of general health, number of sick days, health limiting activities, and ratings of the work environment. Providing healthcare staff with the ability to perform more effectively in stressful situations can ultimately improve patient care outcomes, staff satisfaction, and the healthcare environment.

Maintaining momentum

The main challenge in implementing a resiliency program is maintaining staff involvement. Nurses expressed great enthusiasm during the initial workshop day, and there was buzz across the units about resilience principles. The class included laughter yoga sessions, creation of personal vision boards, commitments to return to school or hobbies they loved, pledges to start weight loss programs, and re-commitment to family and social connections. To sustain staff energy and enthusiasm, similar sessions related to resiliency and wellbeing continue to be offered throughout the year.

Creating an engaged workforce

It’s crucial to realize that resilience training is a long-term commitment to creating a more positive work culture. The investment in staff well-being will have positive outcomes in staff and patient satisfaction, patient safety, and recruitment and retention of an engaged workforce.

Back to that icy night when you were in charge…

Tapping into your resilience stores, you took a few deep breaths (self-regulation). You remembered that you had gotten through equally difficult staffing problems (self-efficacy.) You knew that you could count on your teammates to help you problem solve (connectedness/support.) Perhaps you prayed (maintaining a spiritual practice/self-care.) and maintained a positive attitude, imagining the best outcome (positivity.) The point is that you got through the difficult situation with calm and grace. We all can imagine the possible consequences should a less resilient nurse have been in charge that night.

Patricia Sullivan is a nurse manager for psychiatry, Kim Bissett is an assistant nurse manager for psychiatry, Mary Cooper is a nurse manager for psychiatry, Sandra Dearholt is assistant director of nursing for neurosciences and psychiatry, Kristine Mammen is an assistant nurse manager for psychiatry, Joyce Parks is a clinical nurse specialist, and Kathleen Pulia is a nurse manager for psychiatry. All authors work at The Johns Hopkins Hospital in Baltimore.

Selected references

Cohn MA, Fredrickson BL, Brown SL, et al. Happiness unpacked: positive emotions increase life satisfaction by building resilience. Emotion. 2009;9(3):361-8.

Gentry E. Compassion fatigue: a crucible of transformation. Journal of Trauma Practice. 2002;1(3/4):37-61.

Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. J Adv Nurs. 2007;60(1):1-9.

Kaminsky M, McCabe OL, Langlieb AM, et al. An evidence-informed model of human resistance, resilience, and recovery: the Johns Hopkins’ outcome-driven paradigm for disaster mental health services. Brief Treatment and Crisis Intervention Advance Access. 2006. doi:10.1093/brief-treatment/mhl015. Accessed October 14, 2012.

Nucifora F Jr, Langlieb AM, Siegal E, et al. Building resistance, resilience, and recovery in the wake of school and workplace violence. Disaster Med Public Health Prep. 2007;1(1 Suppl):S33-7.

Pipe TB, Buchda VL, Launder S, et. al. Building personal and professional resources of resilience and agility in the healthcare workplace. Stress Health. 2012;28(1):11-22.

Seligman ME. Building resilience. Harv Bus Rev. 2011;89(4);100-6.

Shirey MR, Ebright PR, McDaniel AM. Sleepless in America: nurse managers cope with stress and complexity. J Nurs Adm. 2008;38(3):125-31.

Steinhardt M, Dolbier C. Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symptomatology. J Am Coll Health. 2008;56(4):445-53.

Tucker SJ, Harris MR, Pipe TB, et al. Nurses rating of their health and professional work environment. AAOHN J. 2010;58(6):253-67.

Waite PJ, Richardson GE. Determining the efficacy of resiliency training in the work site. J Allied Health. 2004;33(3):178-83.

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