Nurses are called to join the mission of healthcare out of a deep desire to help others. Nurses promote health and execute the science of care by providing technically competent skills and practicing the art of presence as they provide whole-person care (Blackburn et al., 2020). However, the nursing profession is a stressful occupation for a myriad of reasons. Approximately one in three new nurses quits nursing within the first 24 months (Kovner et al., 2014). A 2022 survey of 2,500 nurses revealed that one-third expressed the intention to leave their positions (Landi, 2022). Regrettably, nurses are faced with stress, burnout, and compassion fatigue more than ever since the COVID-19 pandemic, leading to increased turnover (Cochran et al., 2020). Nursing students, even without the increased stress and hardships of a pandemic, face high demands during school (Rafati et al., 2017). Consider the following nurse's experience.
CASE STUDY IN BURNOUT
Nia was excited to graduate from a baccalaureate nursing program and pass her licensing exam. Her passion for the geriatric population led to her first nursing job at a nursing home. Over the preceding 21 months, due to the COVID-19 pandemic, she had experienced more changes, losses, and deaths than she ever anticipated. Nia described turnover in leadership as an impetus for the current dysfunctional work culture at her place of employment. She identified a lack of empathy as a formidable weakness in the new administration and felt devalued.
The nursing home had been understaffed since the pandemic began, and as a result, Nia was mandated to work overtime. She did not have time to exercise and could no longer attend her regular Bible study or maintain her garden. Nia felt overwhelmed, somewhat detached, and lacked the passion she had previously for her work. She avoided sharing her feelings with anyone because she did not want to be labeled as unprofessional.
Nia made a visit to her primary care physician with complaints of fatigue, insomnia, hopelessness, and depression. She denied suicidal ideation but added that she wonders if her life is "significant anymore." She disclosed trepidation about entering the nursing home each day and admitted to questioning her faith in God. She refused mental health referrals and expressed mixed feelings about seeking spiritual counsel. Nia was considering leaving the nursing profession.
Nia is not alone. A retrospective cohort study by Davis et al. (2021) examined 159,372 reported suicides between 2007 and 2018 and concluded that the risk of suicide among nurses is much higher compared with the general population. The greater concerns about nurses' mental well-being pre-COVID only magnify the concerns during these unprecedented times. It is heartbreaking that nurses, who are among the most caring professionals, struggle with the ongoing challenges they are facing. There should be a significant emphasis on nurses' well-being and holistic initiatives to support them (Davis et al., 2021). In addition, evidence indicates that the resilience attribute and religious and faith interventions could remedy burnout and help nurses thrive (Harris et al., 2021; Low et al., 2019). Unfortunately, the stigma surrounding mental health challenges most likely was a barrier for Nia in her hesitation to seek spiritual support.
When people demonstrate self-compassion, they show self-kindness and mindfulness during personal challenges and hardship instead of self-criticism (McRay et al., 2018). There is a positive correlation between nurses' ability to care for their patients and their own self-compassion. Nia wasn't enjoying going to the work she was once passionate about because she struggled to take care of herself. Nurses who are kinder toward themselves during hardships are less likely to experience burnout and more likely to sustain passion for giving care over a long period (Dev et al., 2018).
Limited literature is available regarding incorporating resilience education and training in nursing curricula. This raises important questions about what will help nurses thrive and the benefits of resilience-building education and training for nurses and nursing students alike. Furthermore, how do believers in Christ, like Nia, press forward, thriving and learning through the experience of burnout? What might help prioritize and equip nurses with the psychological personal protective equipment (PPE) needed to soar in their profession from a biblical perspective? This article discusses the importance of resilience education and training and how self-awareness and self-compassion are quintessential to maintaining resilience.
RESILIENCE
A plethora of definitions for resilience is found throughout the literature, with nearly all definitions including the concepts of adversity and adaptation. Resilience is a psychological construct that involves innate and/or modifiable capacities that allow an individual to adapt positively to adverse situations while remaining hopeful about the future (Cochran et al., 2020; Wei et al., 2019). It is a multidimensional concept that includes physical, social, spiritual, and emotional aspects and involves both intrapersonal and environmental factors (Low et al., 2019). Cochran et al. (2020) notes that the common characteristics of resilience are "optimism, faith/spirituality, cognitive flexibility, regular exercise, goal-setting, moral integrity, autonomy, humor, and the ability to engage with support systems" (p. 105).
The R.E.S.T. mnemonic (Rajamohan et al., 2020) consists of the essential components of resilience and offers a holistic approach to formulating a definition and a framework for building resilience, encompassing intrapersonal, interpersonal, and environmental factors. The acronym represents the following: Relationships (to self and others), Exercise (care of the mind, body, and spirit), Soul (compassionate self-care), and Transformative thinking (leading to thoughtful actions; Rajamohan et al., 2020, p. 53; Table 1). We define resilience as the mental ability to seek value and meaning in life's hardships by embracing them and intentionally growing holistically, allowing one to persevere with hope in Christ to a functional state as opposed to giving up. Christian nurses are called to use their gifts of service to others by depending on God's strength and power (1 Peter 4:10-12). To view the self holistically, a relationship with God becomes the catalyst to building the spiritual strength required for building resilience. R in this mnemonic must include the relationship with God, self, and others. Each of the concepts of R.E.S.T. can be developed into practical interventions and offered as workshops in resilience training. Later in this article, a brief application of R.E.S.T. to Nia's situation is presented.
WORK ENVIRONMENT STRESSORS
The healthcare environment lends itself to inherent stress. Nurses experience bullying, physical threats, and assault-which can make the workplace feel unsafe, as well as medical errors, all adding an undue amount of stress (Blackburn et al., 2020). According to Hetzel-Riggin et al. (2020), the two principal environmental stressors are lack of sufficient staffing and too high of a workload. Other various demands of the profession also add to the stress experienced by nurses. These include conflicts with coworkers, problems with leadership, long hours, physical demands, and exposure to the suffering of patients. Moreover, when nurses become overwhelmed with high levels of occupational stress, they may question their ability to manage the stress and may even question their fit in the profession (Hetzel-Riggin et al., 2020).
Likewise, high levels of stress can lead to higher levels of absenteeism, turnover, and even burnout. Burnout, or the state of emotional, physical, and mental exhaustion resulting in high levels of depersonalization and low levels of satisfaction in one's work, can lead to depression and unnecessary suffering (Blackburn et al., 2020). Hetzel-Riggin et al. (2020) noted that there appears to be a direct relationship between occupational stress and all three components of burnout in nurses. Burnout can increase the likelihood of nursing turnover. Among hospital nurses, burnout is correlated with a greater intent to quit and is associated with lower patient satisfaction (Bamonti et al., 2019). Burnout can affect the overall quality, safety, and performance of the nurse, as well as impact the capacity to build therapeutic relationships with patients (Cleary et al., 2018).
Although burnout is a concern for nurses working in any environment, faith-based organizations could encourage employees to explore faith to help mitigate the effects of burnout. Harris et al. (2021) found a consistent inverse relationship between religion/spirituality and negative mental health outcomes (including burnout) in nurses. Nurses offer emotional and spiritual support to their patients; when depleted, nurses need the same support themselves (Harris et al., 2021). The work culture needs to be conducive to nurses developing their spirituality, finding meaning in their work, and therefore experiencing better job and personal satisfaction (Harris et al., 2021). Administrators and those in positions of authority have the responsibility of providing a work environment that fosters positive mental health strategies and one of those includes spirituality and faith.
The COVID-19 pandemic added to the already existing high levels of occupational stress in the nursing profession. Nurses are exposed to stress and trauma routinely and nurses' well-being was adversely affected by COVID-19. Reactions to trauma are varied and do include the opportunity for posttraumatic growth. Posttraumatic growth refers to transformation following trauma and informs meaning-making, an essential step in transforming old (negative) patterns of thinking into a more positive view, resulting in a growth mindset (Liu et al., 2021). Posttraumatic growth and growth mindset need to be employed in order for nurses to flourish personally and professionally. Spirituality practices, including prayer, meditation, Bible reading and study, and fellowship with other believers, have long been recognized as a powerful coping mechanism for dealing with life-changing and traumatic events. From a Christian perspective, suffering produces perseverance, character, and hope (Romans 5:3-5). For Nia, having access to her spiritual resources, including her Bible study, and reliance on her pastor may have assisted her to cope better with the impact of her work-related stress and avoid burnout.
Resilience informs personal change that allows for growth, and individuals higher in resiliency are viewed as being better equipped to rebound from adverse events (Blackburn et al., 2020). Liu et al. (2021) found that resilience positively affected posttraumatic growth as well as a person's intent to stay. The pandemic also caused rapid changes in healthcare practices and nurses were asked to execute protocols that changed daily. LoGiudice and Bartos (2021) noted that nurse stress, frustration, and feelings of anger during the pandemic were correlated to not having evidence-based practice recommendations. Rapid changes placed nurses in an environment that had the potential to generate not only physical distress, but psychological distress as well.
During the pandemic, moral distress occurred as nurses were unable to provide optimal compassionate care, resulting in burnout and compassion fatigue. The apostle Paul, in Galatians 6:9, emphasized the promise of staying committed to good work and not giving up. This is easier said than done, but Paul reminds us that in due season, the harvest will be evident if we do not give up (Galatians 6:9). When experiencing hardships, "in due season," may feel unceasing. When living by faith, the experiences of trials develop perseverance to the point of reaching posttraumatic growth where one feels spiritually mature, lacking nothing (James 1:2-4). Trials in life may be viewed as compliments from God because he gives us the strength to bear difficulty (Philippians 4:13).
RESILIENCE BUILDING
Resilience building can be operationalized as developing positive coping skills and the ability to self-regulate and move forward during challenging situations (Low et al., 2019). The THRIVE Program, developed after an extensive literature review by two clinical nurse specialists, was created to teach self-care strategies to oncology nurses. The program focused on building resilience through participation in an 8-hour retreat, followed by a 6-week private group study on social media, and a final 2-hour wrap-up session (Blackburn et al., 2020). The goal was for participants to engage in an assortment of self-care experiences and develop a routine of self-care. According to Blackburn et al. (2020), the THRIVE program identified self-care as a joint responsibility of both the worker and the institution, with self-care being viewed as another form of PPE. God's Word as found in the Bible endorses self-care, reminding us to take care of ourselves in addition to taking care of others. We are to love our neighbors as we love ourselves (Matthew 22:39), noting that we must love ourselves first.
The literature review by Cleary et al. (2018) systematically reviewed studies that sought to evaluate resilience interventions either qualitatively or quantitatively among health professionals. The primary outcome measure of interest for the review was the effectiveness of resilience interventions. Study findings reported that resilience workshops were beneficial not only for understanding professional resilience but also for identifying personal triggers for stress and the significance of self-care. According to Cleary et al., resilience-building interventions require a substantial time requirement; the authors note that short interventions for resilience may be ineffective. In fact, resilience interventions were more likely to have a sustained effect where the interventions had more sessions, longer interventions, and extended duration with a deliberate effort to support ongoing practice. Resilience interventions involving additional training sessions were more likely to demonstrate significant improvements in resilience postintervention (Cleary et al., 2018).
The utilization of interventions that predominantly focus on the individual is not adequate for the long-term management of workplace stress. A combination of person-centered interventions, including cognitive behavioral approaches targeted at enhancing coping skills, and organization-centered interventions addressing issues such as task restructuring, job demands, and collaborative decision-making, produce better outcomes than a singular approach (Bamonti et al., 2019). Researchers have reported that management must remain supportive of ongoing resilience promotion. Wei et al. (2019) discussed how instrumental nurse leaders are in building a resilient nursing workforce. Seven core strategies for fostering nurse resilience identified in their study included facilitating social connections, promoting positivity, capitalizing on nurses' strengths, nurturing nurses' growth, encouraging nurses' self-care, fostering mindfulness practice, and conveying altruism (Wei et al., 2019).
From a biblical perspective, taking care of the temple of God (one's body) is a divine responsibility (1 Corinthians 3:16). Modeling self-care and offering spiritual guidance and support for nurses on how to make self-care decisions are crucial in creating a supporting and thriving environment. These simple strategies can shape nurse resilience by making a shift in nurses' focus, connecting and reconnecting with others, practicing moment by moment awareness, and giving overall attention to their physical, emotional, and spiritual well-being.
Another organizational intervention involves organizational empathy, or the ability of an organization to understand what can make the lives of the staff better (Taylor et al., 2020). It is the job of the organization as a whole to understand the needs of its employees and to meet those to the best of the organization's ability. Creating an empathetic work culture where nurses' well-being is supported will influence the way the organization handles burnout and stress. Leadership must recognize there is a gap in the educational emphasis on resilience for emotional regulation and self-awareness. This is especially important considering the challenges nurses have faced with the pandemic. There needs to be a balance between the cultivation of empathy and the creation of personal and professional boundaries so that burnout does not occur (Taylor et al., 2020).
We have found that faith in God and reliance on the Bible offer hope and encouragement. The Old Testament prophet Isaiah wrote, "But those who hope in the LORD will renew their strength. They will soar on wings like eagles; they will run and not grow weary, they will walk and not be faint" (Isaiah 40:31, NIV). This word picture inspires us to have hope in God, which is the remedy to renew our strength, so we can continue to soar like eagles and not experience exhaustion. When nurses are experiencing burnout, they are at the point of fatigue, so encouraging them to have hope in God to renew their strength can be challenging. This is where the Christian community and spiritual resources must support them.
A positive and supportive work environment lowers burnout, and both leaders and the organization play crucial roles in cultivating a safe workplace (Gensimore et al., 2020). Burnout can be minimized by observing, addressing, and identifying the signs and symptoms in the staff. Contributing factors to staff burnout can be identified by providing a survey with key questions on what keeps staff motivated. What is the climate of the unit? What stage of burnout is identified in the staff? Do staff feel valued and supported, and what issues prompt feelings of frustration with their work and resource allocations? What helps them cope and experience hope?
Leaders must focus on the root causes of burnout in both their units and within the organization. Recognizing the stages of burnout from low to high risk can support efforts to deal with stress levels. According to Murat et al. (2021), the higher the level of burnout, the lower the sense of personal achievement, as well as increased levels of emotional exhaustion. Nurse leaders also struggle with increased mental health needs and burnout due to higher work demands, including mediating personnel conflicts, living with time constraints, and experiencing a lack of higher leadership support. Leadership is a 24/7 job, and leaders must demonstrate high levels of emotional intelligence and serve as role models. The organization must take accountability and responsibility to provide support for their leaders and frontline workers. Organizational interventions to build resilience are summarized in Table 2.
RESILIENCE EDUCATION
Resilience strategies can be taught to nurses to help them mitigate occupational stress and thrive in the face of adversities at work. Additionally, personal resilience interventions that are taught and then employed consistently and effectively may prevent burnout (Blackburn et al., 2020). It is imperative that nursing students are taught resilience skills in nursing school. A national survey of college students found that about half were diagnosed with a mental health issue within the past year (Kim et al., 2021). Studies of previous coronavirus outbreaks have found that the symptoms of anxiety and depression lasted long after the worst of the outbreaks (Brooks et al., 2020). During the COVID-19 pandemic, students who had parental and spiritual support had lower levels of anxiety and depression. In addition, novice nurses are likely to lack resilient protective factors and are at risk for leaving the profession within the first year. Literature published during the last decade identified that resilience must be fostered for newly licensed nurses to remain at their current jobs (Concilio et al., 2019).
As resilience training offers positive outcomes, it is imperative to examine current nursing curricula. Cochran et al. (2020) examined the prevalence of resources and resilience education in nursing curricula in the United States. According to a convenience sample of 155 nursing schools, only nine percent (9%) of schools integrated resilience training in the curriculum. Cochran et al. urge nursing schools to incorporate resilience education and training to remedy burnout and turnover challenges. The COVID pandemic disrupted the education and training of new nurses. Nursing students still need the practical application of working with patients which, during the pandemic, added to students' stress and anxiety levels. Kim et al.'s (2021) survey of nursing students indicated that student's stress levels increased 6-fold and anxiety levels 3- to 4-fold from the prepandemic period. However, resilience, family support, and spirituality were all factors that helped ameliorate these problems. Nursing education programs are uniquely situated to offer training programs or courses that integrate resilience. Nurse educators must take advantage of this and develop and integrate resilience training programs into their curriculum to help train nursing students in these much-needed skills (Kim et al., 2021).
RECOMMENDATIONS
Nurses choose nursing as a calling, and their self-sacrificial care for others makes the profession noble. Still, the personal cost nurses pay is immeasurable. This cost is challenging the healthcare workforce more significantly than ever before. Nurses need to serve others from a full cup, meaning they must care for themselves in order to care for others. Self-awareness and self-compassion are quintessential to developing and maintaining resilience. Self-compassion research is widely known, but integrating self-compassion as a foundation for resilience education/training is limited and not utilized in the nursing curriculum. Instilling the need for reflective practices can lead to transformative thinking in nursing schools and healthcare institutions (Rajamohan et al., 2020). Proverbs 23:7 reminds us, "For as [a person] thinks in his heart, so is he" (NLT). Without regular reflective thinking, nurses may lack self-awareness and could continue to face barriers to everyday self-care practices that are foundational to thriving. Christians are instructed in Romans 12:2 to be transformed by the renewing of our minds. When we allow God's Word to transform our thinking, we become sensitive to the leading of the Holy Spirit. Having and experiencing an intimate and authentic relationship with God is vital for Christian nurses to persevere and become the best version of who God called them to be. Reflective thinking may include journaling, thought tracking, and examining one's heart and mind and can be incorporated into nursing curricula that encourage spiritual formation. As compassion fatigue and burnout have been an ongoing challenge for nurses, focusing research on barriers to self-compassion practices personally and professionally may provide insight into possible solutions. Nursing schools should screen students for burnout on a regular basis to identify students who are at risk and to provide additional support and encourage self-compassion activities.
APPLICATION OF THE R.E.S.T. FRAMEWORK
If Nia had been educated about building and sustaining resilience utilizing a simple framework such as R.E.S.T. (Table 1), her relationship with God, herself, and others would be foundational to her identifying and coping with her own high levels of stress and subsequent burnout. Self-awareness is the key to having a healthy relationship with self, and it paves the way for transformative thinking and positive behavioral change. Reflecting on and processing her true feelings, Nia could recognize the need to seek help and utilize resources available to her. The benefit of physical exercise is widely known, but balancing exercising the body, mind, and spirit is imperative in developing a growth mindset, allowing the self to learn through hardships and challenges, as the apostle Paul cited in James 1:2-4. Suppose Nia had the opportunity to practice reflective thinking; she might be able to take her thoughts captive, as Paul directs in 2 Corinthians 10:5. She may have been able to shift her focus, practice moment-by-moment awareness, and be attentive to her body, mind, and the Holy Spirit, which would help strengthen her spiritual resilience. Nurses can take control of their thinking and focus on a growth mindset with appropriate spiritual support, and encouraging and meaningful resources.
Research supports that self-compassionate people are more resilient and experience less anxiety, stress, burnout, and depression than less self-compassionate people (McRay et al., 2018). Self-care is a daily decision that should become a routine for nurses and nursing students. Self-care, including exercise, counseling, hobbies, spiritual activities, and the like, may have mitigated Nia's stress. Participating in her small group Bible study and praying with others could have helped Nia cope. Hebrews 10:25 highlights the importance of intentionally gathering with other believers, which helps build relationships with God and others. By prioritizing self-care as a sacred responsibility, resilient nurses can continue to thrive despite the tremendous pressure and demands. Nurses are excellent decision-makers, and they must be empowered by leadership to make choices about caring for themselves.
Nia's employer could have utilized organizational empathy and demonstrated an understanding of the needs of employees, working to meet those needs to the best of the organization's ability. Nia's employer could have equipped nurses with resilience strategies to promote utilization of resilience consistently and effectively. As unprecedented times continue, individuals experiencing life challenges need to focus on what is happening around them and what is in their control to change. Reflective questions suggested by Rajamohan et al. (2020) such as "What might have gone wrong, what went well, what might have been a barrier to utilizing available resources, and what can be done differently moving forward?" may offer insight for shaping nurses' growth mindsets. These personal insights are powerful in providing self-development and growth opportunities. Psalm 46:10 wisely recommends, "Be still and know that I am God" (NIV). When we get to the surrendering place with God and let go of the cares of this world and cause ourselves to be still, we can experience the peace from God that passes all understanding (Philippians 4:7). Researching and learning from the life experiences of nurses who embrace challenges and grow in their faith to rise above the circumstances would contribute valuable insight into how to support colleagues like Nia.
CONCLUSION
To build a resilient work culture that prioritizes empathy and resilience as a form of a psychological PPE, nurses and nursing students need to be trained in resilience building and self-care skills. Interventions that solely focus on the individual are not adequate for the long-term management of stress. A combination of person-centered and organization-centered interventions produces better outcomes than a singular approach (Bamonti et al., 2019). In addition, the current gap that exists in nursing curricula is the lack of screening students for burnout, with few schools participating in proactive resilience training (Cochran et al., 2020). By screening nursing students for burnout, nursing schools could tailor their training programs to the stressors that students experience in clinical training. This screening tool could provide valuable data to create resilience-building programs. Churches and faith communities should embrace and offer spiritual support for students and nurses and encourage them with God's promises. Individuals also need to take accountability for caring for themselves holistically and seek support as needed. It is the responsibility of both the nursing schools and healthcare organizations to strategically integrate resilience training into their curricula and organizational culture to mitigate stress and burnout and promote the well-being of all nurses. Let us remind ourselves that "... all things God works for the good of those who love him, who have been called according to his purpose" (Romans 8:28, NIV).
Web Resources
* Spiritual Care FOR Nurseshttps://ncf-jcn.org/resource/spiritual-care-nurses
* American Association of Critical-Care Nurseshttps://www.aacn.org/clinical-resources/well-being
* American Psychological Associationhttps://www.apa.org/topics/resilience
* Oncology Nursing Associationhttps://www.ons.org/onf/47/1/thrive-program-building-oncology-nurse-resilience-t
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