The United States is experiencing a shortage of registered nurses with job openings estimated to exceed one million by the year 2022. The shortage is related to many factors including the increased need for health care by the aging Baby Boomer generation, the expanded infrastructure demands on nursing schools related to increasing healthcare need,s and the psychological stress associated with working in the healthcare environment. The nursing shortage is most pronounced in specialty areas such as the intensive care unit (ICU), with reported annual rates ranging from 13-20%.
It has been reported that the prevalence of psychological disorders such as anxiety, depression, burnout syndrome, and posttraumatic stress disorder (PTSD) are high in the ICU nurse because of the stressful work environment.
The Role of Resilience on Psychological Distress
Resilience is a psychological characteristic that enables one to thrive in the face of adversity. It has been identified as one of the most important factors in adjusting after trauma or life disruptions. While there are many innate attributes of resilience, it can also be learned through cognitive behavior therapy.
Researchers studying resilience believe that individuals can be inoculated against stress by adopting protective coping mechanisms associated with resilience. Ten traits of resilience, which can all be learned, may play a pivotal role in adaptation following major stressors. These ten psychological characteristics that individuals can work toward to increase resilience are: optimism, cognitive flexibility, a personal moral compass or set of beliefs, altruism, finding a role model/mentor, being adept at facing fears, developing active coping skills, establishing and nurturing a supportive social network, exercise and having a good sense of humor.
Qualitative interviews with highly resilient ICU nurses identified the coping mechanisms and characteristics they employed to enable them to continue working in the stressful work environment without developing symptoms of PTSD, anxiety, depression, and burnout syndrome. These skills included a positive social network personally and professionally, using emotional intelligence to guide decision-making and incorporate methods such as positive reframing, critical reflection and optimism to process the stressors of the work environment.
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In addition, the highly resilient nurse incorporated self-care into their daily living that included good sleep habits, exercise, journaling, laughter, spiritual rituals, and nutrition. The positive coping skills and psychological characteristics that were identified by highly resilient ICU nurses embodied the modifiable traits of resilience and were therefore used to develop a resilience training intervention for ICU nurses.
A Multi-Modal Resilience Training Intervention
ICU nurses at a single academic institution were randomized to either the resilience training intervention or a control group if they were currently working at least 20 hours in the ICU and had lower than average resilience scores.
Validated surveys were used to measure resilience, PTSD, anxiety, depression and burnout syndrome. The surveys were administered prior to the 12-week intervention and within one month after completing the intervention.
The resilience training intervention included a two-day educational workshop, written exposure therapy, mindfulness-based-stress-reduction (MBSR), exercise, and event-triggered cognitive behavioral therapy sessions.
Two-Day Educational Workshop: The two-day educational workshop included an introduction to self-care topics such as exercise and diet, drug and alcohol use, skills training for relaxation and building a supportive social network. An in-depth discussion and training session was also provided on the MBSR practices and written exposure therapy that would be instituted over the 12-week intervention period.
Written Exposure Therapy: ICU nurses were given weekly writing prompts and asked to write twelve 30 minute sessions with topics related to stress and challenges experienced in the work environment.
MBSR Practices: The mindfulness-based-stress-reduction (MBSR) techniques were demonstrated during the two-day educational workshop and ICU nurses were given an audio guide of the techniques to continue once they returned home. The participants were asked to practice the MBSR techniques for 15 minutes at least three times per week. These techniques included sitting meditation and the body scan. Sitting meditation is a simple practice that involves being silent and motionless but also paying close attention to the connection between your mind and body.
Exercise: The effects of exercise on physical and mental health are well known. This component of the resilience intervention involved engaging in aerobic exercise for 30-45 minutes at least three days per week. Each participant was provided with a free three month membership to the institution’s wellness center.
Event-Triggered Counseling Sessions: An event trigger to initiate therapy sessions was chosen because it applied an objective set of criteria that would help alleviate the stigma that is oftentimes associated with counseling sessions. ICU nurses were asked to participate in one-one-one cognitive behavioral therapy sessions that served to challenge negative thoughts and enhance resilience through cognitive flexibility and restructuring. The events that triggered these sessions were related to caring for a patient and included: patient death, traumatic injuries, end-of-life discussions, massive bleeding, performing CPR and delivering futile care to a terminal patient.
There were no interventions dictated by the protocol for the control arm. However, we did ask that the control group record any exercise performed over the 12-week period and complete the same surveys prior to and within one month after the 12-week intervention period.
Improved Resilience and Reduced Symptoms of PTSD and Depression
Twenty-nine eligible ICU nurses were enrolled in this study. Fourteen were randomized to the intervention arm and 15 were randomized to the control arm. One subject from each arm withdrew from the study prior to the initiation of the 12-week program leaving 27 nurses who participated in the 12-week training period. The nurses worked in medical, surgical, burn and cardiac ICU’s. The majority of nurses were female (92% intervention arm, 86% control arm), Caucasian (100% intervention arm, 100% control arm), had bachelor’s degrees (100% intervention arm, 100% control arm) and had been practicing in the ICU for 4-5 years.
The intervention was successfully implemented and there was a high percentage of participation in each of the components of the intervention (100% attendance at the two-day workshop, 100% completed all written exposure sessions, 88% completed the expected exercise regimen, 66% completed the required MBSR sessions and each participant attended a mean of two event-triggered counseling sessions). The feasibility of the multiple components of the intervention suggests that there is the potential to tailor the intervention based on satisfaction, strengths and weaknesses of the individual ICU nurse.
ICU nurses who were randomized to the intervention showed high levels of satisfaction based on a satisfaction measure.
ICU nurses who participated in the resilience training intervention showed improved resilience scores (CD-RISC scores pre-intervention 71, post-intervention 78, p=.05) and improved PTSD symptom scores (PDS symptom score pre-intervention 11.0, post-intervention 2, p=.01). In addition, participants in the resilience training intervention had a significant reduction in symptoms of depression (HADS-D pre-intervention 10.0, post-intervention 9.0, p=.03).
The results of this study suggest that a resilience training program in ICU nurses is both feasible and acceptable. This was a small pilot study that was not powered to reach statistical significance. Future research is needed to assess the effect of the intervention in a larger clinical trial.
Meredith Mealer is assistant professor, School of Medicine, Division of Pulmonary Sciences & Critical Care Medicine at the University of Colorado.