Healthcare workers and institutions are facing turbulent and challenging times. The cruel realities of the COVID-19 pandemic further magnified these challenges over the past 2 years. Even when not in a pandemic, the nursing profession is inherently exposed to chronic and traumatic stressors contributing to burnout, compassion fatigue, and job dissatisfaction, which can negatively affect patient care.1-4
Work-related stressors include the emotional strain of caring for dying patients, shifts of 12 hours or more, rotating between day and night shifts, excessive workload demands, ineffective teamwork, value conflicts, and high-stress work environments.2,3,5 The prevalence of these stressors affects nursing retention and absenteeism.3 High turnover rates continue to be a challenge with 20% of nurses leaving their position within their first year of employment and hospital turnover rates as high as 30.7%.3,6 This creates a cost burden for hospitals, impacting financial security, in addition to patient safety and quality of care. Studies have found significant correlations among burnout, job performance, patient safety, and high-quality care.6,7 Faced with unprecedented healthcare practice changes and patient volumes, bedside providers' level of emotional exhaustion and stress has continued to intensify.
Although researchers continue to heavily investigate the impact of the global healthcare crisis, it isn't well understood yet, and nurse leaders have a tremendous responsibility to enhance the well-being of nursing staff. As such, the Institute for Healthcare Improvement's Triple Aim has evolved into the Quadruple Aim to emphasize the importance of promoting healthcare workers' well-being.6 Finding ways to enhance nurses' well-being is imperative to reduce turnover and promote mental health. Thus, building resilience among the nursing workforce has been proposed as a way to strengthen nurse longevity.
Background and rationale
Resilience by definition is "the ability to face adverse situations, remain focused, and continue to be optimistic for the future."8 Studies illustrate that individuals, groups, and systems can develop resilience.9,10 Researchers describe resilience as a set of dynamic attributes that includes an ability to face and recover from adversity, adapt to change, and adjust oneself and/or the environment while maintaining a positive attitude and optimism.9-11
All individuals have the capacity to develop resilience, which is influenced by internal and external factors, including individual experiences, personal characteristics, the environment, and the person's balance of risk and protective factors.10 Known as psychological capital, internal resilience-promoting qualities encompass a sense of purpose and self, faith, empathy, creativity, humor, high self-efficacy, flexibility, emotional intelligence, hope, and optimism. Moreover, training programs and improvement of individual well-being can help develop psychological capital.9,10,12-17 External promoting factors are found in workplace and practice environments. Evidence from the literature positively correlates autonomy in practice, strong nursing leadership, empowerment, supportive social networks, availability of resources, and encouragement of self-care with healthy, resilient work and practice environments.6,9-12,15,16,18,19
Interventions aimed at supporting internal and external factors to help build individual and group resilience have been shown to improve psychological health, work relationships, professional quality of life, and job satisfaction.6,9,12,18-20 Developing strategies to foster and promote resilience should be a key priority for nurse leaders because nurse leaders' attributes have an impact on nurses' work performance and resiliency.6
Purpose
The purpose of this inquiry was to review existing evidence and interventions aimed at encouraging and supporting resiliency among nurses. Although resilience can improve one's ability to thrive in adversity, a survey of nurses showed that only one-fifth were highly resilient.6 As the pandemic has caused increased stress and burnout among bedside clinicians, leaders must implement strategies to aid in the process of developing resilience. The literature synthesized in this article will provide nurse leaders with practical evidence-based practices to encourage the development of individual and group resiliency.
Methods
An integrative review of relevant literature was conducted to examine existing evidence related to building resilience among nursing staff. Although a significant amount of research exists regarding techniques for building resilience, limited literature is available on implementable strategies for nurse leaders. Recommendations for encouraging and supporting resilience will be offered here with specific suggested strategies for nurse leaders.
To identify and examine existing literature on this topic, a search was conducted of several databases, such as PubMed, CINAHL, and Scopus. When searching PubMed, search terms used were: nursing leadership, nursing, nurse leaders, resilience, resiliency, and their combinations. The search was limited to articles from 2010 to 2020 to provide the most current evidence. Only English-language articles were reviewed, and articles focusing on leadership strategies were given preference. Initially, article titles and abstracts were scanned in the search result to identify applicable content. Remaining articles were then reviewed in full and critically appraised for quality and applicability to the review's purpose. Preference was given to articles that focused on nursing leadership strategies; however, other articles were included to enrich the content and themes related to building resilience. Studies that focused on nursing students, allied health, and patients' or families' resilience were excluded.
After themes were identified, an additional search with each theme and resilience was conducted. The following search terms were used: mentorship and nursing resilience, shared governance and nursing resilience, and debriefing and nursing resilience. The search resulted in 23 articles reviewed for this inquiry. Levels of evidence were identified and scored based on the rating tool by Ackley and colleagues.21 (See Table 1.)
A review of these 23 articles yielded a variety of evidence. Quantitative evidence was reflected through cohort studies whereas multiple qualitative studies provided depth and insight into personal understanding of resilience attributes. The literature review also included expert opinions from nurse leaders who added valuable perspectives, practical knowledge, and personal experiences, and offered specific leadership strategies to implement. Overall, most studies reviewed were Level IV-Level VII. The Oxman, Cook, and Guyatt Index was used to critically appraise the systematic review conducted by Zhang and colleagues.22 It was rated with only minor flaws and strong scientific quality. Using the guideline from DiCenso and colleagues, a critical appraisal was performed of the meta-analysis completed by Zhang and colleagues.4,23
Conceptual framework
Through this evidence review, five themes emerged regarding leadership strategies to help build resilient nurses and teams: shared governance, debriefing, social support, mentorship, and education. A concept map was designed to highlight these strategies. (See Figure 1.) The main concept of resilience is at the center of the map, and the five themes are indicated with black arrows. The effects of each leadership strategy on individual ability to develop resiliency are depicted in the colored sections. Each colored rectangle summarizes internal and external promoting factors of resilience. It's important to note that all internal and external factors influencing resilience are related and directly affect one's overall resiliency.
Implications for nurse leaders
Developing resilience is a dynamic nonlinear process influenced by internal and external factors. Individual ability to develop resilience plays an important role in responding to workplace adversity.
Faced with challenging situations when caring for patients in their most vulnerable moments, nurses support people through emotional extremes, from the highest joys to fear, pain, and loss.24 Developing and maintaining resilience may serve to mitigate the workplace stressors faced by clinical nurses. Prioritizing the well-being and mental health of the nursing workforce is essential given the combined challenges of the global COVID-19 pandemic, documented high levels of burnout and compassion fatigue, and high nursing turnover rates.1-6 As improvements in healthcare continue to help those with acute and chronic illnesses survive longer, the need for and use of health resources will simultaneously continue to rise.
Nurse leaders play a vital role in shaping and supporting the frontline nursing workforce. Building a resilient workforce requires not only maximizing the use of personal resilience strategies but also creating, fostering, and maintaining a supportive and healthy work environment.
Recommendations and strategies
Multiple techniques to encourage and support resiliency can be implemented to ensure that the preference and use of such strategies meet the needs of all nurses. Based on the literature review, here are five key recommendations and associated strategies nurse leaders can use to boost resilience in their team members.
1. Shared governance
A core component of resilience-building is staff engagement and empowerment, and using shared governance serves as a leadership strategy to empower clinical staff.4,25,26 Shared governance places problem-solving capabilities in the hands of those who provide direct care.25 Eliminating hierarchies is a successful technique for nurse leaders to create a culture of partnership.27 Brainstorming solutions and seeking staff input places value on nursing ideas and reinvigorates bedside staff.28 Shared governance allows staff to participate in bidirectional communication to ensure that the voices of frontline staff are heard, which can support an active partnership between leaders and staff.26
Engagement and empowerment are linked to several nursing outcomes, including job satisfaction, decreased burnout, decreased intention to leave, fewer nurse-reported patient safety events, and increased quality of care, all of which support and encourage individual and team resilience.4,25,27,29 Researchers found that when nurses work in an empowered environment, relationships among colleagues are stronger, leading to lower stress and emotional fatigue, thus supporting both internal and external drivers of resiliency.4 Specific strategies from the literature include using shared governance to:
* Ensure bidirectional communication among clinical staff and nurse leaders.7,25,27,28
* Enhance empowerment and engagement by seeking staff input for solutions to practice problems.4,25,27,29
* Encourage open and honest communication when issues arise to create transparency and partnership and validate nurses' values.7,27,28
2. Debriefing
Debriefing consists of critical conversations that help reframe the context of a situation, clarify perspectives and assumptions, include techniques to build trust among the group, and serve as a supportive outlet for staff.10,30 Scheduling regular formal debriefing sessions is one leadership strategy that encourages empathy and enables a mutual understanding among the team. Structured sessions offer the nursing staff a safe space and group dialogue that encourage critical reflection and validate feelings.31
Moreover, debriefing is considered a means to enhance morale among individuals and the group, shape a sense of self, and build emotional intelligence. Sharing work experiences among peers is positively correlated with improved mental health and well-being, ultimately leading to more resilient individuals and teams.11,19,32 Ultimately, all these components strongly influence the resilience-building process. Specific strategies from the literature include:
* Offer frequent structured debriefing sessions held by trained debriefing mentors.7,10,19,31,33
3. Social support
Another suggestion frequently found in the literature is for nurse leaders to take a personal interest in staff, allowing the leader and nurse to get to know each other and support the growth of a trusting interpersonal relationship. Learning about individuals on their team will help nurse leaders recognize when a staff member may be overburdened and need coaching to return to a balanced state.18 Participating in conversations with frontline nursing staff allows leadership to better understand their concerns and needs and learn what they value.32 With that information, nurse leaders can connect the work nurses are performing with the values of the team and the organization.34
Building positive connections among staff can also enhance altruism and gratitude between colleagues.6 Creating opportunities to develop relationships among peers can establish positive social connections and enhance resilient team-building. Specific strategies from the literature include:
* Plan and participate in social events.6,19
* Get to know the nursing staff; spend time learning about the nurses to gain a better understanding of their needs and values.6,18,32,34
* Encourage and plan team-building activities among peers and other nursing units and interdisciplinary teams.6,35,36
4. Mentorship
Nurse leaders are in a unique position to nurture nurses' growth. Implementing a mentorship program is a leadership technique that will directly affect the resiliency of the nursing workforce. Participation in a work-based mentorship program enhances both the mentors' and mentees' professional development, self-confidence, and ability to approach workplace challenges.14,22,37,38
Imitative learning through mentorship can be viewed as a leadership strategy to role-model personal resilience.14 Mentorship promotes internal resilience-building elements, including a sense of self, self-efficacy, emotional intelligence, and hope.39 Mentorship also capitalizes on supportive work environments through enhancement of social support and empowerment. Specific strategies from the literature include:
* Implement a mentorship program for experienced and novice staff members.7,22,37-39
* Role-model resiliency by embodying self-confidence, self-efficacy, emotional intelligence, hope, and optimism.12,14,39
5. Education
Incorporating education on resilience building is a leadership strategy that can positively affect nurse well-being and job satisfaction. The critical need for resiliency training and education is very relevant for healthcare professionals today.14 Education tailored to defining the process of resilience-building with evidence-based techniques, exploring the attributes and behaviors of resilient individuals and teams, and discussing the relevance of resilience will serve as a useful approach in developing healthy workforces.9
Implementing resilience education will help nurses identify stressors, encourage participation in self-care techniques, and foster emotional intelligence. Ultimately, these activities can move the healthcare industry toward a supporting culture of wellness.8 Specific strategies from the literature include:
* Implement education in nursing orientation/onboarding that includes the definition of resiliency and the relevance of the topic, attributes associated with resilient individuals and teams, and interventions that foster resilience for frontline staff.7,9,12,17,33
* Offer online education modules for all staff members that encourage self-care and well-being and promote individual factors that enhance personal resiliency.8-10,12,16,33
Limitations
Due to the high heterogeneity noted among the articles included for analysis, the authors could only calculate the summary effect size, subsequently decreasing the overall strength of the analysis.
Additionally, there's a lack of higher level evidence that would help illustrate the impact of the previously discussed resiliency-building techniques. Only two articles reviewed were Level 1 and no randomized or nonrandomized controlled studies were found to support the clinical question. The cohort studies reviewed included small or self-selected convenience sampling, which limits generalization to a larger population. Further research is needed using rigorous methods to examine the impact of resilience-building and more research is needed on the longitudinal impact of resilience-building among healthcare workers.
Armed against adversity
The nursing profession is physically, mentally, and emotionally demanding.24 Documented high levels of compassion fatigue, burnout, and turnover rates have driven researchers to look at resilience as a way to protect nurses against adversity in the work environment. Nurse leaders are instrumental in setting the tone of a healthy work environment and thus building resilient nursing workforces. By implementing the five evidence-based techniques outlined in this article, nurse leaders can help cultivate and foster nurse resilience, positively impact nursing staff members, and improve patient outcomes.
INSTRUCTIONS Leadership strategies to support resilience
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