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• To refresh your knowledge of what is meant by resilience and how it is linked to physical and mental well-being
• To enhance your awareness of the adverse effects that the coronavirus disease 2019 (COVID-19) pandemic has had on nurses’ mental health, well-being and resilience
• To consider strategies that nurses, nurse leaders and managers, and healthcare organisations could use to promote resilience in nurses
Nurses are likely to encounter a wide range of distressing, challenging and sometimes traumatic situations. However, the coronavirus disease 2019 (COVID-19) pandemic has created unprecedented levels of stress, risk, uncertainty and anxiety for nurses. Nurses have been working in highly challenging conditions, particularly on the front line of patient care, which has had adverse effects on their mental health and well-being. The challenges generated by the COVID-19 pandemic have called into question the notion of nursing being an innately resilient profession. Consequently, the pandemic has reinforced the need for individuals, teams and healthcare organisations to foster resilience in nurses. This article discusses the theoretical underpinnings of resilience, explains what resilience in nurses means, and describes the adverse effects of the pandemic on nurses’ mental health and resilience. The article also explores how nurses’ resilience can be developed and enhanced from an individual and organisational perspective.
Nursing Standard. doi: 10.7748/ns.2021.e11678
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Cajanding RJ (2021) Individual and organisational strategies to develop resilience in the nursing workforce. Nursing Standard. doi: 10.7748/ns.2021.e11678
Published online: 06 September 2021
Nursing is known to be a stressful profession, and nurses at all levels are likely to encounter a wide range of distressing, challenging and sometimes traumatic situations (De Kock et al 2021). However, during the coronavirus disease 2019 (COVID-19) pandemic, nurses have been exposed to unprecedented levels of risk, uncertainty, stress and anxiety, particularly when working on the front line of patient care (Preti et al 2020, Vagni et al 2020). The pandemic has generated significant challenges for already overstretched healthcare systems, placing additional strain on organisations, exhausting medical supplies, facilities and beds, and putting staff under immense pressure. In these extraordinary circumstances, nurses have demonstrated remarkable levels of compassion, courage, altruism and resolve (Duncan 2020, Smith et al 2020).
Challenges for nurses during the pandemic have included increased workloads, decreased nurse-to-patient ratios, scarcity of essential resources such as personal protective equipment (PPE), and increased risk to their safety and that of others. Working in highly challenging conditions has had adverse effects on nurses’ mental and emotional health and well-being (Morley et al 2020, Preti et al 2020). Nurses have a duty to care for patients and families and maintain patient safety (Iserson 2020), but they must be able to exercise this duty of care without compromising their own safety, the safety of their families and their ability to continue to provide nursing care (Morley et al 2020).
The challenges resulting from the COVID-19 pandemic have called into question the traditional notion of nursing being an innately resilient profession (Morrison 2004). During the pandemic, many nurses have experienced moral and emotional distress, fears, anxiety and/or depression, all intensified by the uncertainty associated with the situation (Preti et al 2020). Consequently, the pandemic has reinforced the need to foster resilience in nurses in the short and long term (Heath et al 2020, Smith et al 2020). It has also provided an opportunity to reflect on nurses’ resilience individually and collectively (Jackson and Usher 2020).
This article explores resilience in nurses in the context of the COVID-19 pandemic. It discusses the theoretical underpinnings of resilience, describes the adverse effects of the pandemic on nurses, and identifies strategies that can used to develop and enhance resilience in nurses.
• During the coronavirus disease 2019 (COVID-19) pandemic, nurses have been exposed to unprecedented levels of risk, uncertainty, stress and anxiety, particularly when working on the front line of patient care
• Resilience can be a protective factor for nurses’ physical and mental well-being, and a high level of resilience can mitigate burnout, emotional exhaustion, anxiety, stress and depersonalisation
• Strategies that individual nurses can use to develop and enhance their resilience include: using self-awareness, and self-reflection; taking sufficient time for self-care; using stress management techniques; engaging in physical activity; cultivating their skills; and establishing supportive networks
• Healthcare organisations have a crucial role in fostering resilience in their staff, notably by fostering a work culture where staff feel they are listened to and taken seriously, and where they feel safe to express their views, experiences and needs
The term resilience originates from the Latin verb ‘resilire’, which has a range of meanings, including to ‘leap’, ‘rebound’ or ‘spring back’ (Frydenberg 2017). The American Psychological Association (2012) described resilience as ‘the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress’, further explaining that ‘resilience involves “bouncing back” from these difficult experiences’ and in some cases can entail significant personal growth. Resilience has been explored, conceptualised and interpreted in various ways, and research has shown that it can be developed and enhanced (Southwick et al 2014, Fisher et al 2019).
The concept of resilience was first discussed in the field of developmental psychopathology in Norman Garmezy’s pioneering work on children who had experienced traumatic or stressful life events (Garmezy 1987). In Garmezy’s work, resilience is defined as ‘the process of, capacity for, or outcome of successful adaptation despite challenging or threatening circumstances’ (Masten et al 1990). In one seminal study of 700 young people with significant risk factors including stress, poverty, parental discord and mental illness, Werner and Smith (1982) found that a significant proportion of them grew up into adulthood without manifesting destructive behaviours and were able to have successful and productive lives. Werner and Smith (1982) attributed these outcomes to ‘protective factors’ that supported these ‘resilient’ individuals to overcome adversity and thrive.
Resilience can be viewed as a trait or attribute, a process or an outcome:
• As a trait or attribute, a person’s resilience is influenced by a combination of genetic, biological, demographic, cultural, social, developmental, spiritual and economic factors (Southwick et al 2014).
• As a process, resilience can be developed, harnessed and cultivated (Rutter 1999).
• As an outcome, resilience is a positive adaptation in which a person maintains, regains or surpasses their previous level of functioning, health or well-being after having experienced adversity (Vella and Pai 2019).
Research has demonstrated the benefits of resilience in adapting to substantial challenges, distress, trauma and risk (Fisher et al 2019). By reacting to adversity with resilience, people can enhance their understanding, self-awareness, sense of direction and growth (Fleming and Ledogar 2008). Experiencing adversity leaves resilient individuals with higher levels of self-integration and functioning (Southwick et al 2014).
People have the potential to acquire and develop resilience even if they are not conscious of that potential, and the drive to develop resilience stems from internal and external motivations (VicHealth 2015). Furthermore, resilience can be developed and enhanced at several levels, for example the individual, family, group and/or community level (Southwick et al 2014).
Various studies of resilience in nursing before the COVID-19 pandemic have focused on high-intensity areas such as intensive care, emergency and acute care, burns, oncology, palliative care, psychiatry and the care of patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). In one US study of resilience in nurses working in the intensive care unit (ICU), less than one quarter (22%) of respondents considered themselves ‘highly resilient’ (Mealer et al 2012). In another US study, nurses working in high-intensity settings reported moderate-to-high levels of resilience (Rushton et al 2015). Their resilience was positively correlated with personal accomplishment, but was unaffected by their number of years of nursing experience (Rushton et al 2015). Guo et al’s (2018) study into burnout and resilience among hospital nurses in China reported that most of these nurses considered themselves to be ‘moderately’ resilient. Among nurses working in an oncology unit in Turkey, resilience was positively associated with years of experience, level of education and degree of social support (Kutluturkan et al 2016).
One study into the lived experiences of nurses working in residential older people’s care facilities in Australia demonstrated that clinical expertise, a sense of purpose in a holistic care environment, a positive attitude and a healthy work-life balance were important determinants of resilience (Cameron and Brownie 2010). Shin et al (2018) conducted a study to identify the types of resilience skills of clinical nurses working in the hospital setting. These resilience skills included the use of willpower and realistic coping strategies, managing and focusing on one’s mental health, seeking recognition and a sense of accomplishment, and taking pride in one’s job.
Resilience can be a protective factor for nurses’ physical and mental well-being (Yılmaz 2017) and a high level of resilience can mitigate burnout, emotional exhaustion, anxiety, stress and depersonalisation (Rushton et al 2015). It has also been shown to enhance nurses’ work performance, professional efficiency, care delivery and personal development (Manzano García and Ayala-Calvo 2012, Cooper et al 2020).
Research has identified that the COVID-19 pandemic has had various effects on nurses’ mental health and well-being, as well as on their resilience.
Longitudinal studies have demonstrated that epidemics and pandemics – such as the outbreaks of COVID-19, severe acute respiratory syndrome (SARS) or Ebola – tend to have detrimental psychological effects on healthcare professionals, who often experience post-traumatic stress disorder (PTSD), depression, anxiety, insomnia and general psychiatric symptoms, sometimes for several years (Preti et al 2020).
At the time of writing, studies were beginning to reveal the negative effects of the COVID-19 pandemic on nurses. Hu et al’s (2020) survey of more than 2,000 nurses caring for patients with COVID-19 in Wuhan, China, during the early stages of the pandemic identified that a significant number of nurses experienced moderate-to-high levels of anxiety and depression. It also found that witnessing colleagues becoming infected and dying intensified nurses’ fear and distress (Hu et al 2020). In March 2020, Kang et al (2020) reported that, since the beginning of the COVID-19 outbreak in December 2019, medical professionals in Wuhan were experiencing high levels of stress, anxiety, depressive symptoms, insomnia, denial, anger and fear.
One Italian study suggested that emergency situations such as the COVID-19 pandemic cause healthcare and emergency workers to develop severe stress reactions, putting them at high risk of secondary trauma (indirect exposure to trauma, through a first-hand account of a traumatic event, which may result in symptoms and reactions similar to PTSD) (Vagni et al 2020). Stressors included high levels of infectivity, scarcity of PPE, lack of definitive treatment, lockdown measures and witnessing high numbers of patient deaths (Vagni et al 2020). Graham et al (2020) suggested that nurses working during a pandemic are at a high risk of compassion fatigue and burnout, and that this can adversely affect their health-related quality of life and long-term health.
De Kock et al’s (2021) rapid review of the literature, which was published in January 2021, recognised that COVID-19 has had considerable negative effects on the psychological well-being of front-line hospital staff. It also identified that nurses may have been at higher risk of adverse mental health outcomes during the pandemic than other healthcare professionals. Pfefferbaum and North (2020) asserted that nurses were particularly vulnerable to emotional distress during the pandemic for several reasons, including: their risk of infection, and concerns about infecting their families; shortages of PPE; longer working hours; and their involvement in emotionally and ethically challenging situations. According to Odom-Forren (2020), many nurses experienced a ‘triple whammy’ during the pandemic, since they have had to manage the requirements of social distancing, their family and children, and the care of patients with COVID-19.
Shahrour and Dardas’ (2020) Jordanian study of acute stress disorder in nurses during the COVID-19 pandemic found that 64% of respondents were experiencing acute stress disorder and 41% were experiencing significant psychological distress, with younger nurses being more prone to psychological distress than older nurses. Similarly, in Shechter et al’s (2020) cross-sectional survey of physicians, advanced practitioners, residents, fellows and nurses conducted during a peak of inpatient admissions for COVID-19 in New York, US, respondents reported experiencing psychological symptoms such as acute stress (57%), depression (48%) and anxiety (33%). The risk of transmitting the infection to their family and friends, having to be socially distanced from their families, lack of control, lack of testing and lack of PPE were major sources of psychological distress (Shechter et al 2020).
In one UK study of the experiences of respiratory nurses working during the COVID-19 pandemic, almost half of the respondents reported moderate or low resilience scores, with lower scores being particularly prevalent among younger nurses with less experience (Roberts et al 2021). Bozdağğand Ergün’s (2020) Turkish study into determinants of resilience among healthcare professionals during the pandemic found that higher quality of sleep, positive mood, older age and higher life satisfaction were associated with higher resilience scores, while having a negative emotional state and being a doctor were associated with lower resilience scores.
In the Philippines, Labrague and De Los Santos (2020) examined the influence of individual resilience, social support and organisational support on nurses’ COVID-19-related anxiety. Levels of anxiety significant enough to affect well-being and work performance were present in around 38% of nurses. These dysfunctional levels of anxiety were significantly correlated with lower self-reported individual resilience scores, as well as lower levels of social and organisational support. Overall, nurses reported that they received moderate levels of social and organisational support, but 90% stated they were not fully prepared to manage patients with COVID-19 (Labrague and De Los Santos 2020).
Developing individual resilience has been recognised as a potential strategy for nurses to manage the negative effects of working during a pandemic (Smith et al 2020). The COVID-19 pandemic has increased awareness of the need for nurses to develop resilience, which has subsequently led to a plethora of studies exploring how nurses can achieve this (Heath et al 2020). These studies have identified a range of strategies that nurses can implement and adapt as necessary in the context of their practice, such as:
• Self-awareness, self-reflection, critical debriefing, meditation and humour can be used to defuse highly charged and distressing situations, thoughts, feelings and emotions (Crane et al 2019).
• Taking sufficient time for self-care, using stress management techniques, engaging in physical activity and developing positive thinking can support nurses’ physical and mental well-being and enhance their self-esteem (Heath et al 2020).
• Focusing on one’s strengths, cultivating one’s skills and using positive affirmations can support nurses to focus on their qualities and overcome feelings of inferiority and shame (McDonald et al 2012).
• A supportive network of colleagues, family members and friends, virtual chat rooms and judicious use of social media can provide opportunities for self-expression and may prevent feelings of isolation and loneliness (Hartwig et al 2020).
When discussing resilience in nursing, the focus is often on individual nurses developing their own resilience. However, this puts the onus on nurses to find ways of managing workplace issues and can leave them feeling responsible for mitigating organisational shortcomings, systemic failures and political inadequacies. Focusing on individual resilience makes nurses responsible for how they cope with challenging situations, while healthcare organisations are not held to account for the circumstances that may have given rise to these challenging situations (Traynor 2018).
To address this issue, Traynor (2018) proposed the concept of critical resilience, which combines increased understanding of the broader organisational factors that are present in the workplace and the use of open, focused and mutually supportive discussions between nurses, nurse leaders and managers. Developing critical resilience could support nurses to adopt effective work practices and develop skills that enable them to manage their daily work, while becoming increasingly cognisant of the broader organisational factors affecting their work environment.
Healthcare organisations have a crucial role in fostering resilience in their staff, notably by fostering a work culture where staff feel they are listened to and taken seriously, and where they feel safe to express their views, experiences and needs.
It is important for nurse managers and leaders to work with staff to find solutions to challenges arising in the workplace, making time and providing opportunities for teams to come together to discuss these challenges. Collaboration and communication between employers and employees are crucial for developing resilient teams, as is a willingness from both parties to support each other and work towards a common goal (Hartwig et al 2020).
Healthcare organisations can implement strategies aimed at reducing risk and emotional distress for staff, including supporting work-life balance initiatives, listening to and acting on staff’s concerns, demonstrating visible leadership, and providing a sufficient volume of PPE (Roberts et al 2021). Since improvements in social and organisational support can lead to lower anxiety and higher resilience levels in nurses, employers should ensure their employees feel valued and put measures in place to enhance their well-being (Labrague and De Los Santos 2020).
Nurse managers, educators, leaders, academics and policymakers all have a role in developing resilience among staff. Supporting the development of resilience requires an individualised approach that takes into account each person’s experience, needs and emotional state (VicHealth 2015).
Masten and Reed (2002) identified three categories of strategies that nurses, nurse leaders and managers, and healthcare organisations can use to develop and enhance resilience:
• Risk-focused strategies, which focus on preventing, reducing and mitigating staff’s exposure to risk factors and stressors.
• Asset-focused strategies, which focus on increasing the quantity and quality of assets available to staff. These assets may include physical resources – such as high-quality teaching and mentoring, financial and community resources, and social support networks – and psychological resources such as hope, efficiency, altruism, self-efficacy, knowledge and optimism (VicHealth 2015).
• Process-focused strategies, which focus on mobilising and influencing systems, structures and processes that can be used to enable staff to learn essential skills and achieve ‘mastery of tasks’.
Table 1 provides examples of strategies that can be used to develop and enhance resilience in nurses, covering all three of these categories.
During the COVID-19 pandemic, nurses have had a crucial role in supporting patients’ safety, health and well-being. They have also been exposed to unprecedented levels of risk, uncertainty, stress and anxiety, with adverse effects on their mental health and well-being.
Promoting resilience in nurses is essential to support them to manage and overcome adversity, particularly in the context of the pandemic. Studies have shown that effective self-care, greater self-awareness, a supportive work environment and a range of other support strategies can assist nurses in developing and enhancing their resilience as individuals and within their teams. Healthcare organisations also have a crucial role in promoting resilience among nurses, supporting them to manage stress, uncertainty and adversity.
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