RESILIENCE TRAINING 1

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Implementation of Resilience Training for Nurses in Critical Care

Alex Clark, Kaitlynn Porterfield & Kayleigh Rickard

Centofanti School of Nursing, Youngstown State University

NURS 3749: Nursing Research

Danielle Class

April 6, 2022
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Implementation of Resilience Training for Nurses in Critical Care

Burnout, compassion fatigue, and turnover rates are surging amongst intensive care

nurses. Implementation of resilience programs has been proven to show positive results due to its

focus on resources to deal with stress. Working in the critical care unit has been described as a

high stress work environment. The impact of the stressful workplace can affect multiple elements

that “extend to the institutions, which incur the costs of absenteeism and high turnover of expert

personnel, and lower patient satisfaction” (Duchemin et.al., 2017, p. 11). It is important to

determine the validity of the presence or absence of resilience training in the critical care setting.

To evaluate this, we are going to discuss the characteristics of resiliency in nurses, burnout,

compassion fatigue, turnover, and the execution of resilience programs. These factors will help

dictate if there is any correlation between a presence or absence of resilience programs and the

effect it has on turnover rates and burnout with nurses in the critical care setting.

Search Strategy Narrative

The search strategy was based on answering the PICOT question, does resilience training

for critical care nurses impact burnout and turnover rates compared to no resilience training? The

databases used for the search consisted of Medline, ProQuest Nursing & Allied Health, and

Cumulative Index to Nursing and Allied Health Literature (CINAHL). All articles were posted in

the time frame of 2016 to 2022. The initial search granted 168 studies on all three databases

using the terms “nurses” and “resiliency training”. Key terms for the final search included:

critical care nurses, burnout, job turnover, resilience training, resiliency, burnout, compassion

fatigue, benefits, and negative impacts. After the search was tapered, the abstracts, methods, and

results were reviewed for each article to limit the literature review to 6 articles.
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Literature Review

The purpose is to determine if resilience training decreases burnout and turnover rates in

intensive care nurses. To identify if this correlation exists, the literature review includes the

characteristics of resiliency and creates a better understanding of how nurses deal with pressure

of the workplace. For optimal awareness, clarification of burnout and compassion fatigue is also

integrated in the review. Execution of resilience programs are examined to recognize whether

burnout, compassion fatigue, and turnover rates are exaggerated.

Characteristics of Resiliency in Critical Care Nurses

The study, “Resiliency in Emergency Nurses”, investigates whether resiliency affects

how certified emergency and critical care nurses overcome the stress in their workplaces. This

article defines resiliency as the ability to bounce back or overcome adversity and battle the

emotions resulting from the stress in the workplace. The first step to building resiliency is the

self-awareness of the emotions caused by stress. The research in this qualitative study was

gathered by interviewing registered nurses (RNs) in emergency departments of the central New

York ENA chapter. Results described seven resiliency concepts to formulate the interview by

specifying topics of inquiry.

There are two characteristics of resiliency related to decision-making in a quandary or

state of urgency. The French phrase, “presence d’esprit” is used to describe a nurse’s ability to

solve a problem with inventive thinking. “Presence d’esprit” is further characterized by finding

alternative ways to continue caring for a patient without becoming distracting or dwelling on

thoughts. An interviewed nurse explained the phrase in his/her own words, “…to be able to

manage it and prioritize and do what you need to do: try not to let it linger within you as you
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move on in your day” (Tubbert, 2016, p. 48). The other characteristic is decisive action, which is

decision-making without receiving all the background information of a situation. This resiliency

trait is built on past experiences where nurses have to quickly process information and make

hasty choices with self-confidence. Decisive action is having the ability to think through an issue

before proceeding and being able to adapt. A nurse must filter out the information that is not

essential to the matter and prioritize their actions.

In critical care settings, concentrating on tasks based on priority is an important role of

the nurse. Tubbert (2016) identified resilient nurses to have a trait called tenacity, the process of

moving forward until the desired result is accomplished. Desired outcomes are achieved by

attempting alternate solutions and interventions while working out challenges with creative

thinking. Tenacious nurses are goal-oriented and focus on priority despite fatigue or a

disadvantageous situation. The nurse’s ability to prioritize is also determined by how they react

to the stress they face in the critical care setting. Resilient nurses have self-discipline, the

capability to control their emotions and thought processes. Self-control includes remaining

optimistic in uncertain situations and maintaining organization among the chaos. The

interviewed nurses stated they control their emotions by recognizing the warning signs of stress

and using coping behaviors amid the chaos (Tubbert, 2016).

The last three characteristics of a resilient nurse discussed in the article are interpersonal

connectedness, honesty, and optimism. A nurse must have interpersonal connectedness to create

a supportive environment for their coworkers. This social network created, promotes overcoming

adversity and is demonstrated by teamwork to strengthen psychological and physical support.

The research found that when two nurses coordinate patient care and consult each other, they
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build an interpersonal connection. The nurses can enhance their confidence and utilize each other

as a support system. When one nurse makes a mistake, coworkers can encourage and lift each

other up to create a supportive work atmosphere. Tubbert (2016) reports optimism as a feature of

a resilient nurse because encouragement develops a relaxed setting where destructive manners

and behaviors are alleviated. Alongside optimism and interpersonal connectedness, honesty

facilitates trust and integrity while interacting with one another. An interviewee stated, “Without

trust, you’re always double-checking, triple checking, micromanaging those around you and

questioning their integrity” (Tubbert, 2016, p. 49). Honesty and a setting where trust is

established allow nurses to provide exceptional care without interrupting the continuity of care.

These seven characteristics were all expressed in the interviews of the critical care nurses

throughout their careers. A resilient nurse has the ability to move forward through a stressful

situation. Without resiliency, nurses are unable to manage the workload, moral distress, and

effects of stress in the emergency department and as a result they burnout.

Burnout, Compassion Fatigue, and Turnover

Critical care nurses acquire significant stress from responding to life threatening injuries

whilst effectively empathizing with emotional suffering of the patient and their family. From

prolonged exposure to stressful working environments, critical care nurses experience higher

levels of burnout than other health care professionals. Burnout is defined by the field of

psychology as “The loss of charisma for work attributed to feelings of being worn out, or tired,

in performing work duties” (Wynn, 2020, p. 61). Therefore, burnout is exhaustion with the

ability to regenerate. Whereas compassion fatigue is defined as “A feeling of biological,

psychological, and social exhaustion caused by prolonged exposure to compassionate stress”

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(Wynn, 2020, p. 62). Thus, compassion fatigue is exhaustion without the ability to regenerate.

Burnout is employee-employer relationship conflicts where compassion fatigue is nurse-patient

conflicts. Understanding each distinct concept can help nurses achieve optimal occupational

health and well-being.

Burnout and compassion fatigue are often experienced by nurses caring for patients in

high-stakes environments. High stress environments are emotionally and physically demanding,

consequently increasing the risk of burnout and compassion fatigue. This can impact nurses

psychological and physical health. Due to the similarities and interchangeable use of these terms

in literature, often nurses do not recognize which they are experiencing. Burnout and compassion

fatigue have similar indications including stress, mood swings, exhaustion, poor job satisfaction,

and difficulty with managing personal conflicts. Exposure to stress decreases the body’s ability

to fight infection. Stress correlated with burnout progresses from the demands of the high-stake

work environments. While stress experienced with compassion fatigue results from secondary

traumatic stress. Secondary traumatic stress is a type of emotional stress that results from

memories of a traumatic event.

Exhaustion from burnout occurs when there has been an overexertion that leaves an

individual tired or worn out. This is often resolved by removing stressors and with periods of

rest. With compassion fatigue, exhaustion is the feeling that an individual is depleted even after

attempting to recharge. Compassion fatigue is a critical result of ineffective coping. Ineffective

coping occurs when an individual is unable to cope despite the coping mechanisms utilized. It is

vital that nurses have the ability to cope. When coping is ineffective, nurses cannot manage the
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stress from providing patient care, and lack of empathy occurs. Ultimately burnout that is not

resolved can provoke compassion fatigue.

Turnover rates in high-stakes environments are remarkable. Turnover occurs when nurses

seek work opportunities elsewhere to eliminate their current workplace related stress. Many

factors contribute to turnover including staff shortages, acuity of care, working conditions, long

shifts, burnout, poor employee relationships, unsupportive managers, and compassion fatigue.

With an increase in turnover rates additional staffing shortages occur, resulting in additional

burnout and low job satisfaction.

Depersonalization causes under par care for patients and is a consequence of burnout and

compassion fatigue. Depersonalization is often used as a bad coping mechanism to manage

exhaustion with burnout, but the nurse does not lack empathy for the patients. The nurse is often

focused on quickly moving from task to task and is “robotlike”. Depersonalization with

compassion fatigue is where the nurse lacks empathy and views patients as objects. The utmost

consequence of burn out and compassion fatigue is poor outcomes of patients from decreased

quality of care. Nursing errors occur from burnout and compassion fatigue resulting in adverse

events. As assessed through the Hospital Consumer Assessment of Healthcare Providers and

Systems (HCAHPS) burnout rates among nurses contributed to a decline in recommendations of

that establishment. Through care received patients can sense stress of the work conditions. If

patients continuously return negative HCAHPS scores due to displeasure of care, it can also

affect Medicare and Medicaid reimbursements that hospitals receive. Therefore, to prevent

potential losses it is advisable that hospitals address burnout and compassion fatigue in nurses.
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It is crucial for critical care nurses to have the ability to recognize both burnout and

compassion fatigue to help establish strategies that aid with coping and achieving optimal

occupational health. “Effectively coping with workplace stress has the potential to influence

workplace sustainability; positively impacting both burnout and compassion fatigue through a

reduction in turnover rates and improved job satisfaction” (Wynn, 2020, p. 68).

Resilience Programs

Lastly, a couple of resilience programs enacted in critical care units are going to be

analyzed to determine the effectiveness of resilience in nursing. Both studies were smaller, but

they had a control and intervention group. One study incorporated an in-person resilience

training program while the other utilized a web-based program. They both gave out surveys

following the intervention to establish what effect the programs have on nurses working in the

critical field. Ward (2017) states that “it is not known if and to what extent CCNs’ resiliency may

or may not be affected by self-care or associated with compassion satisfaction, interprofessional

relationships, professional quality of life (PPI) or intent to leave the critical care specialty area”

(p. 90). We can still look at the results of both these specific studies to find a correlation between

resilience training programs and resilience of nurses in the critical care setting.

To start out a small study was conducted where thirty-two surgical intensive unit

personnel participated. Participants of this study were randomly assigned to an intervention or

control group. 75% of this study were nurses with majority being women. According to

Duchemin et al. (2017), they hypothesized that “increasing resilience in ICU staff through a

mind-body intervention would decrease the effects of stress and risk for burnout” (p. 11). The

intervention program included weekly one-hour group sessions for a total of eight weeks that
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included yoga practices, music therapy, meditation, mindfulness, didactic introduction, and

discussions. Participants were also asked to perform daily twenty-minute reinforcement practices

which was listening to a CD recording provided by the group instructor, and they were to record

when they did this (Duchemin et al., 2017). The data of the study was collected using two

questionnaires, one that was taken one week prior to the start of the sessions and then one week

after they had ended.

The satisfaction with life questionnaire was the primary way to compute data which

provided high scores for all relating to the nurses being content with life and work. It was broken

down into four sections that were rated on a 1-5 scale from very dissatisfied to very satisfied.

These four sections observed satisfaction with health, capacity for work, ability to perform daily

activities, and quality of life. All the mean scores were rated over 3.9 which meant the

participants were satisfied with all four factors. In the study of Duchemin et al. (2017),

“participants described their work environment as highly stressful (mean [SD] score of 7.15

[1.89] on a scale of 1-10), with no significant difference between the two groups and no change

between the first and second sets of assessments” (p. 14). In addition to these scales used,

participants were also asked to rate the potential benefits of the intervention on importance. The

top rated with one hundred percent was recognizing their stress response. The next two following

that were learning mindfulness to deal with stress and then getting to know their coworkers in a

different way (Duchemin et al.,2017). These are significant results as it shows that the

implementation of the intervention program revealed the importance of factors related to stress

management.
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On the other hand, the web-based intervention program involved eighty-eight critical care

nurses. Surveys were given before and after the intervention. The intervention program was

named Nursilience, and it incorporated eight self-paced modules that were to be completed over

a duration of two-weeks. This study was done to determine if the promotion of self-care, stress

adaptation, and healthier coping produced a beneficial outcome. The surveys focused on five

dependent variables which were compassion satisfaction, professional quality of life, intent to

leave the critical care specialty area, PPIs, interprofessional relationships, and compassion

satisfaction (Ward, 2017). These five dependent variables were used to see what relationship

they posed with the independent variables of critical care nurses.

After completion of the pre-intervention survey, the participants were then granted access

to the modules for them to complete. The modules allowed participants to focus on self-care for

at least ten to thirty minutes per day. Resources provide by the program included mindfulness

exercises, calming music, areas of healing inspiration, a reading library, web-links, and videos.

Each module had its own separate goals. Modules 1-4 dealt with stress including methods of

transition stress positively for growth, how to assess stress, what causes the stress, and self-care

strategies to combat it. Modules 5 and 6 focus on self-reflection and information on PPIs. PPIs

are psychological and psychosocial impairments such as burnout, compassion fatigue, and post-

traumatic stress disorder. These can result in lack of resilience especially seen in the nursing

field. Module 7 introduced simple exercises to build resilience. Module 8 provided exercises to

help with balancing work with life as far as self-care (Ward, 2017). At the conclusion of the

intervention program, another survey was to be taken by the participants.

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The Nursilience surveys were divided into sections to measure the results which were the

Professional Quality of Life Scale (ProQOL), Interpersonal Conflict at Work Scale (ICAWS),

and the Quantitative Workload Inventory (QWI). These were used in both the pre-intervention

survey 1 and post-intervention survey 2. The ProQOL scale measured various factors that

contribute to resilience: compassion satisfaction, burnout, and compassion fatigue. For all three

factors, their mean scores produced average numbers for both surveys. There were some changes

seen between both surveys that we are going to look at. For compassion satisfaction there was a

slight t increase from the first to second surveys. This is a positive as it can be assumed that the

intervention had an impact on increasing this factor. Another positive result is that the scores for

compassion fatigue decreased faintly from the pre-intervention survey to the post-intervention

survey. The mean scores for burnout increased a little between the two surveys which is not

ideal, but it was a small margin. Now for the ICAWS scale, the range of scores are from 4-20

where survey one resulted in a 7.78 and survey two with an 8.07. There was a small increase but

not a significant change between them, which meant that there was a low incidence of

interpersonal conflict in the workplace. The QWI scale had range totals from 5-25. There was an

increase of 0.15 in the ranges from the first to the second survey. Once again there was no

significant change between them. Both resulted in low scores related to work stress which is

positive. According to Ward (2017), “the question regarding the participant's intent to leave the

CCNs special care area was ‘have you actively looked for other employment?’ (p. 115). The

scores were recorded using 1 as being never to 5 being very often. In both surveys, the most

common answer was deemed as sometimes with 31% frequency in the first survey and 44% in

the second survey. Both resulted in about a 2.5 mean score on the scale which is halfway in
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between signifying indifference (Ward, 2017). Although there were small changes, the results

did show that the resilience intervention was beneficial.

To summarize, there has been a result of positive and negative effects implementing

resilience training in critical care units. With cooperation in taking advantage of the programs,

there may be more accurate results with seeing the effects. According to Ward (2017), “in

today’s high technology society, a web-based program was deemed to be more suitable and cost-

effective for the targeted population to actively participate at times more favorable for them”

(p.23). The in-person training allowed for them to see who was taking advantage of the program,

but web-based allows for more flexibility as it does not have specific meeting times and can be

done on one’s own free time. Both studies showed different approaches to resilience training

programs in the critical care setting and how it can be helpful for healthcare personnel but

specifically nurses.

Recommendations for Practice

Multiple approaches of self-care practices, renewal strategies, and colleague support are

often needed to help nurses overcome burnout and compassion fatigue states. Some of these

practices include yoga, meditation, mindfulness training, resilience training, music therapy,

relaxation techniques, building relationships and establishing trust with co-worker’s, didactic

introduction, and discussions. These practices can help overcome and also prevent burnout and

compassion fatigue. Although it is best to perform daily reinforcement practices; as little as

weekly one-hour group sessions can help decrease burnout, compassion fatigue, and turnover

rates. The strategies listed above are actions nurses can conquer for themselves. For optimal

occupational health of employees and overall stability of the company it is advisable that the
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institution takes action as well. Techniques the establishment can incorporate include building

the confidence of employees and recognition programs. Other implements that can reduce stress

in the work environment involve adequately training members of the workforce and sufficient

staffing. All-inclusive, it is absolutely pivotal nurses perform self-care.

Conclusion

The goal was to find out whether the presence or absence of resilience training in critical

care units would improve or impair resilience, burnout, and turnover rates in nurses. It was stated

by Tubbert (2016), that “through the rising awareness of resiliency in nursing, intervention can

be developed to counteract stress and potential nursing turnover in the nursing specialties and

nursing profession overall” (p. 51). There have been studies to prove a positive impact of the

resilience programs such as the ones stated above. The limitation was they were smaller studies,

but there still seemed to be improvement with the implementation of the programs. Not only did

we look at specific resilience programs executed, but also the features of a resilient nurse, and

consequences of the workforce such as burnout, turnover, and compassion fatigue. Although it is

shown that intervention programs are beneficial for critical care nurses, there is room for more

studies to be done to further prove that this helps with reducing turnover and preventing nurses

from becoming worn out in their work environment.

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