Resilience Training for Nurses: A Meta-Analysis

Xin Zhai, BSc; Li-na Ren, BSc; Yan Liu, BSc; Chao-jun Liu, MD; Xiao-guang Su, BSc; Bai-e Feng, BSc

Disclosures

Journal of Hospice and Palliative Nursing. 2021;23(6):544-550. 

In This Article

Discussion

In the present study, we have observed that the resilience scores of nurses improved after resilience training, which was also associated with reductions in stress, depression, anxiety, and burnout scores. Moreover, mindfulness, self-efficacy, and well-being scores were also improved in the participants. These resilience training programs utilized different techniques, including in-person workshops, web-based learnings, handout provisions, electronic discussions, and mind-body exercises. Some of the included studies used more than 1 of these training media. Most of these training programs had diffused schedules so that the participants were not taken out of their work, and therefore, the schedules of some training programs were up to 3 months long, which provided an opportunity for a blend of work and learning.

Resilience is found to be associated with better work and life prospects in nurses. A review of 38 studies that evaluated resilience in nurses found that resilience was positively associated with coping, self-efficacy, job satisfaction, and well-being.[14] A quantitative study of 327 nurses found that resilience was strongly correlated with positivity in nursing and the interpersonal skills of nurses, moderately correlated with adaptability in the workplace and hardiness, and had a low to moderate correlation with self-esteem and positive thinking. In this study, resilience correlated negatively with burnout and depression.[35] In another study in which resilience was positively correlated with job satisfaction, the authors noted that approximately 20% of job satisfaction with professional status as a nurse could be explained by resilience as a factor.[36] A study by Itzhaki and colleagues[37] found a positive but weak association between resilience and life satisfaction in mental health nurses.

Glass et al, who conducted an ethnographic study, suggested that cognitive reframing of personal characteristics like flexibility and adaptability and the use of emotional intelligence can make nurses more resilient and efficient. In this study, the participants reported that work challenges, psychological emptiness, and diminishing inner balance were affecting their efficiencies.[38] A study in which nurses were appraised for the identification of factors that contributed to their resilience found that positivity, spirituality, and work-life balance were the main features of their resilience.[39] The authors of a recent systematic review found that work-life balance, mindfulness, self-efficacy, self-reliance, passion, interest, positive thinking, and emotional intelligence were the characteristics that nurses identified as factors behind their resilience.[40]

Henshall et al,[11] who organized a resilience enhancing program for nurses, found that nurse work was characterized by the presence of high levels of stress and nurses had at least some level of resilience to tackle their duties. They found their mentorship-based intervention helpful in improving the resilience of nurses and suggested that dedicated resilience training programs with long-term impacts can significantly benefit the nursing profession and the healthcare system.[11] McDonald et al organized a work-based resilience training program for nurses, which was characterized by the incorporation of learning objectives, reflective insight, collaborative participation, experiential learning, and democratic group structure. The main objective of this program was to facilitate positive and practical attitudes in adapting coping strategies. They received positive response from the participants, who found the training beneficial for their work and life.[21]

Several meta-analyses have found correlations of resilience with mental health. These include positive association with good mental health in general[41] and inverse correlations with anxiety, depression, stress perception, and posttraumatic stress disorder.[42,43] Correlations are also observed between the resilience and personality traits in meta-analytical reviews, including positive associations with life satisfaction, optimism, positive affect, self-efficacy, self-esteem, openness, conscientiousness, and social support and inverse associations with negative affect and neuroticism.[42,44] Fletcher and Sarkar suggested that the focus of a resilience training program should be on personal qualities, environment, and mindset. They also suggested that an impactful resilience training program will need to focus on participant selection and experiential learning.[45]

Foster et al, who conducted a qualitative study on resilience training for nurses, found that the participants had positive attitudes toward resilience training and declared it helpful in improving their self-efficacy and stress appraising abilities. The authors stressed the need to improve structural and systemic processes affecting the nursing profession to strengthen nurse resilience.[19] It has been pointed out that without the considerations of causal factors, resilience training remains an incomplete intervention and better outcomes of resilience training can be achieved by addressing social, structural, and organizational factors.[46] A plenary panel of experts has recommended that resilience should be conceptualized at multiple levels (eg, at biological, social, and policy), and the focus of resilience should move away from an individual trait to a dynamic interactive process of adaptation.[47]

The outcomes of the present study have implications for further research and practice. At present, several concepts, such as mindfulness, self-efficacy, well-being, stress management, coping, adaptive flexibility, intrapersonal and interpersonal communication, social support, and others, are being used in training contents. However, the focused roles of these concepts are not as clear, although many authors have advocated for a positive role of mindfulness, spirituality, and social support. A meta-analysis has also found that the mindfulness training of nurses reduced burnout, emotional exhaustion, and depersonalization in nurses.[48] It is also suggested that resilience training programs with context for mental health and designs for stratification of different nursing roles and experience status should be conducted.[19] It is pointed out that the outcomes of resilience training may also depend on the proportion of the participants with already good resilience levels, which may necessitate recruiting at-risk populations for resilience training programs.[49] It is also important to use valid and reliable measures of resilience in future studies for more robust outcomes.[11] Many authors of studies included in this review stressed the need to conduct randomized controlled studies with larger sample sizes representative of diverse participation and longer follow-up.

There are some limitations of the present study. Varying designs, contents, and schedules of resilience training of the included studies and the use of different tools to measure resilience could have affected the outcomes to some extent. Although resilience and stress scores were reported by most of the included studies, other outcome measures such as depression, anxiety, and burnout were less available. Methodologically, the main limitation was the use of SMD as the meta-analysis method, which was able to judge the significance of the difference in scores after training but was unable to quantify the actual differences in scores. Subgroup analyses with regard to the use of different instruments were also not possible because of less availability of data.

Taken together, the present study found that resilience training improved resilience and reduced stress, anxiety, depression, and burnout of the participants. Moreover, improvements were also observed in mindfulness, self-efficacy, and well-being scores, although less data were available to evaluate these variables. However, training contents, schedules, and measuring tools varied greatly in these studies, and therefore, only a generalized assessment of the outcomes could be performed. More randomized controlled studies with larger sample sizes representative of diverse participation and longer follow-up can refine the outcomes observed in the present study.

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