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The effectiveness of interventions to improve resilience among health professionals: A systematic review
Accepted Manuscript The effectiveness of interventions to improve resilience among health professionals: A systematic review
Michelle Cleary, Rachel Kornhaber, Deependra Kaji Thapa, Sancia West, Denis Visentin PII: DOI: Reference:
S0260-6917(18)30759-7 doi:10.1016/j.nedt.2018.10.002 YNEDT 3992
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
2 July 2018 19 September 2018 7 October 2018
Please cite this article as: Michelle Cleary, Rachel Kornhaber, Deependra Kaji Thapa, Sancia West, Denis Visentin , The effectiveness of interventions to improve resilience among health professionals: A systematic review. Ynedt (2018), doi:10.1016/ j.nedt.2018.10.002
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ACCEPTED MANUSCRIPT SUBMITTED 3rd July 2018 Nurse Education Today Systematic review Title: The effectiveness of interventions to improve resilience amongst health professionals: A systematic review Running title: Interventions for resilience
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Michelle Cleary, Rachel Kornhaber, Deependra Kaji Thapa, Sancia West, Denis Visentin *Michelle Cleary, RN; PhD, School of Health Sciences, College of Health and Medicine, University
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of Tasmania, Locked Bag 5052, Alexandria NSW 2015, [email protected]
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*Corresponding Author: Professor Michelle Cleary PhD, RN, School of Health Sciences, University of Tasmania, Lilyfield, Locked Bag 5052, Alexandria, NSW, Australia. 2015. Phone: +61 2 28572
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7954, email, [email protected]
Rachel Kornhaber, RN; PhD, School of Health Sciences, College of Health and Medicine,
Email: [email protected]
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University of Tasmania, University of Tasmania Locked Bag 5052, Alexandria NSW 2015, Australia.
Deependra Kaji Thapa, MPH; MSc, School of Health Sciences, College of Health and Medicine,
[email protected]
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University of Tasmania, University of Tasmania Locked Bag 5052, Alexandria NSW 2015, Australia.
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Sancia West, RN, PhD, School of Health Sciences, College of Health and Medicine, University of Tasmania, University of Tasmania Locked Bag 5052, Alexandria NSW 2015, Australia. [email protected]
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Denis Visentin, PhD, School of Health Sciences, College of Health and Medicine, University of Tasmania, University of Tasmania Locked Bag 5052, Alexandria NSW 2015, Australia.
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[email protected]
Conflicts of interest: None. Funding: This work was supported by Improving Mental and Critical Care Health (MaCCH)—UTas funding awarded under the UTAS Research Themes: Better Health Research Development Grant Scheme, supported by the Office of the Deputy ViceChancellor and FoH (C0025653). Author contributions: All authors have agreed on the final version and meet ICMJE criteria. Word count: 4800 includes Abstract, excludes References and Tables.
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ACCEPTED MANUSCRIPT Abstract Objective: To assess the effectiveness of resilience interventions in improving resilience outcome amongst health professionals. Background: The nature of health professionals’ work is physically and emotionally
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demanding, with trauma a common consequence with the act of providing health care
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Design: A systematic review
Data Source: A comprehensive search of the literature was conducted in February 2018 using
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PubMed, PsychInfo, Cumulative Index of Nursing and Allied Health Literature (CIHAHL) and
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Scopus.
Review Methods: Methodological quality was assessed and a standardized data coding form
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was used to extract data.
Results: Of the 33 included studies, 15 were single-arm pre-post design, 10 were RCTs, five
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used a non-randomised controlled design, and three were qualitative. Eleven studies (out of 16) showed a significant improvement in resilience scores while five (out of eight) studies reported a significant difference in resilience scores between treatment and control groups.
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Conclusion: Findings suggest that resilience training may be of benefit to health professionals.
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However, not all interventions enhanced resilience with training volume being more effective. Not all studies reporting resilience used standard resilience instruments. The results of the current review may inform resilience programs as well as future interventional studies on resilience building. Keywords: nursing, resilience, systematic review, training, health professionals
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ACCEPTED MANUSCRIPT Highlights
The definition of resilience and variation among assessment instruments are limitations of the resilience literature.
Resilience interventions with longer intervention length, session length and duration
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length are more effective. Larger RCTs among representative samples with follow-up and assessment of baseline
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Promoting resilience amongst health professionals is an approach to address workplace
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stress and reduce staff burnout.
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differences is required.
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ACCEPTED MANUSCRIPT Effectiveness of resilience interventions in improving resilience outcome among health professionals: A systematic review 1. Introduction Health professionals represent a workforce that is defined by high levels of work-
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related stress. The nature of the profession is physically and emotionally demanding, with trauma a common consequence of the act of providing health care (Wood et al., 2017) in a
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notoriously chaotic environment (Stephens, Smith, & Cherry, 2017). Some research has found
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that over 70% of nurses demonstrate high stress (Faraji, Valiee, Moridi, Ramazani, & Rezaei Farimani, 2012), and that over 40% of nurses plan to leave the profession, largely as a
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consequence of stress, within the next decade (Campbell et al., 2013). Even more alarmingly, newly graduated nurses are observed to leave their employment at a rate of 43% within the first
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three years of practice, also as a consequence of stress (Brewer, Kovner, Greene, Tukov-Shuser, & Djukic, 2012). The result of this burnout and stress can be higher levels of staff turnover and
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staff absenteeism (Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012), as well as impacting on the capacity to build therapeutic relationships with patients (Salyers, Flanagan, Firmin, & Rollins, 2015). In addition to burnout there are physical and psychological impacts
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resulting from the role of health professionals, including depression, anxiety, sleep disturbance
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and burnout (Zhou et al., 2017). Indeed, a recent study found that nurses had depression rates twice that of the general public (Robert Wood Johnson Foundation's Interdisciplinary Nursing Quality Research Initiative (INQRI), 2012) thus making stress and overwork some of the higher health concerns of the profession. Such concerns are particularly relevant to the sub-specialty of mental health and wellbeing. Burnout is particularly prevalent amongst mental health professionals with rates as high as 67% (Morse et al., 2012). Higher than normal exposure to violence and suicide, present a challenge to recruitment and retention in this area (Wang et al., 2015). Work environments that 4
ACCEPTED MANUSCRIPT result in high levels of stress and contain such levels of violence and demand can lead health professionals to feel that their work is undervalued if these issues are left unaddressed and risks are not properly assessed (Cherniack, 2015). 1.1 Background
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Coping mechanisms provide a mediator between effective performance as a health professional and their work-related stress. Collectively this includes physical, psychological
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and environmental resources that reflect cognitive and behavioural approaches (Zhou et al.,
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2017) allowing health professionals to continue to work in such environments. Coping mechanisms can be both positive and negative (Zhou et al., 2017). One such resource that
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provides and enhances coping mechanisms is the notion of resilience, which refers to one’s
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ability to respond and recover from adversity and setbacks (Werneburg et al., 2018). Indeed, the definition can be extended further to include the capacity to thrive, rather than just survive,
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in high stress environments (McAllister & Lowe, 2011). Resilience is referred to as a personal
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attribute, trait or even a process or cycle and can be developed or enhanced to improve a person’s positive coping mechanisms using specific strategies (Prosser, Metzger, &
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Gulbransen, 2017; Stephens et al., 2017). Promoting resilience amongst health professionals can therefore be considered an
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approach to address the higher than average levels of workplace stress and reduce staff burnout. While there exist approaches to lower workplace stress and there may be mitigatable organisational stressors (Chandler, 2014), there are limitations on stress reduction in healthcare settings and hence the development of resilience is important for staff working in this sector (Werneburg et al., 2018). Promoting and improving resilience may be achieved through mentorship, achieving balance in life, spirituality, exemplifying the positives, and practicing reflection (Jackson, Firtko, & Edenborough, 2007). Others have proposed more flexible
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ACCEPTED MANUSCRIPT working arrangements, including job sharing and shorter shifts, to reduce stress and promote resilience (Atkinson, Fullick, Grindey, & Maclaren, 2008; Gabel Speroni, 2014). Defined strategies to achieve increased resilience are well established. Training programs such as the Stress Management and Resiliency Training (SMART) program have produced improvements in stress, anxiety, resilience, happiness, mindfulness and burnout in
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health care staff after only 8 of 24 weeks (Magtibay, Chesak, Coughlin, & Sood, 2017). This
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finding is consistent with other applications of the SMART program where resilience levels of
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health care staff have managed to near levels consistent with the general population (Werneburg et al., 2018). Smartphone technology has also been engaged to improve resilience.
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The Provider Resilience app was designed to reduced compassion fatigue and burnout and uses self-awareness measures, cartoons, exercise suggestions and motivational quotes to enhance
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resilience in health care staff (Wood et al., 2017). However, health staff often believe that strategies to improve their health are often not being given adequate priority (Perry et al., 2016)
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and management remains unsupportive of health promotion interventions (Beaudet, Richard,
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Gendron, & Boisvert, 2011), further compounding the issue. Despite the range of training programs and strategies, there remains a paucity of
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research on the development of resilience among health professionals and how this resilience
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is developed (Prosser et al., 2017). The narrative surrounding stress in health environments remains largely negative, focusing on stress and burnout rather than focusing on the strengths and resilience that can come from adversity (Young & Rushton, 2017). Without structural and individual change, retention of health staff will remain a challenge (Koen, van Eeden, & Wissing, 2011). This systematic review therefore aims to examine the current evidence for the efficacy of interventions and programs for increasing resilience with the aim of establishing the best mechanisms for promoting resilience in the health care environment. 2. The Review 6
ACCEPTED MANUSCRIPT 2.1. Aim To assess the effectiveness of resilience interventions in improving resilience outcomes amongst health professionals.
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2.2 Design
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The study adopted the systematic review method to evaluate the effectiveness of resilience interventions. This review followed the Preferred Reporting Items for Systematic
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Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009).
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2.3 Search methods
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A comprehensive search of the literature was conducted in February 2018 using PubMed, PsychInfo, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Scopus. Boolean connectors AND, OR and NOT were utilised to combine the following MeSH
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and search terms: resilien*, hardiness, training, health personnel, health facility and staff development. The search was adapted for searches conducted across the databases to account for differences in syntax and indexed terms.
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The inclusion criteria encompassed peer reviewed primary research published in the
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English language evaluating resilience interventions either qualitatively or quantitatively among health professionals. Studies concerning all types of staff working in health settings or teaching hospitals were included. Any psychological interventions prospectively designed to develop or enhance the resilience among health professionals, irrespective of the content, method of delivery or duration, were included. Resilience interventions were considered only if the study title or aim(s) had explicitly identified resilience as the primary focus of the intervention. The primary outcome measure of interest was the effectiveness of resilience interventions in improving 7
ACCEPTED MANUSCRIPT resilience outcomes among the participants. Studies reporting any type of direct resilience outcomes were also included. Non-interventional studies; studies where the subjects were primarily non-health professionals or students; theoretical articles, commentaries, editorials and review articles; and
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articles published in non-English language were excluded. 2.4 Search outcomes
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The literature search yielded 1441 studies, which was supplemented by an additional
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10 studies from the reference lists of retrieved articles and manual searching of journals. After
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removing 61 duplicates, 1390 papers were subjected for title and abstract screening, which removed 1178 articles. The full text of remaining 212 articles screened and excluded 166
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articles that did not meet the inclusion criteria. The full text of the remaining 46 papers was examined in detail and assessed for eligibility on a consensus basis by all authors, yielding 33
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articles meeting the inclusion criteria for the final review (See Figure 1).
2.5 Quality appraisal
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Insert Figure 1 about here
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The quality of included studies were appraised using Joanna Briggs Critical appraisal
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tools (Tufanaru, Munn, Aromataris, Campbell, & Hopp, 2017). Two reviewers (DV and DKT) assessed the quality of the studies using the JBI Critical Appraisal Checklist for Randomized Experimental Studies and the JBI Critical Appraisal Checklist for Non-randomized Experimental Studies. The results of the critical appraisals are presented in Table 1 for RCTs and Table 2 for non-randomised experimental studies. Table 3 presents the appraisal of the qualitative data using the CASP tool (Critical Appraisal Skills Programme (CASP) checklists, 2013) (by MC, RK).
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2.6 Data extraction and synthesis A standardized data coding form (Joanna Briggs Institute, 2006) was used to extract data. One review author (DKT) extracted the following information: authors, year, country,
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study purpose, study participants and setting, study design, intervention modality and outcomes measured (resilience and other) (see Table 4). Studies directly measuring resilience as the
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outcome of interventions were reviewed in detail and extracted further information on
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resilience scale used, assessment and follow-up, baseline and post-intervention resilience scores and significant findings (Table 5). All authors then checked the extracted information
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and any discrepancies were resolved by discussion.
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Due to the heterogeneity of the study types in terms of design, intervention and outcome measures, a meta-analysis was not appropriate.
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3. Results
3.1 Characteristics of included studies
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The characteristics of included studies are summarised in Table 4. Of the 33 included studies, 15 used a single-arm pre-post design, 10 used a randomised controlled design, five
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used a non-randomised controlled (quasi-experimental) design and three used a qualitative
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design. Three single-arm pre-post studies and a quasi-experimental study reported mixed methods findings. Most of the studies used convenience sampling and the study participants
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were generally self-selected. The majority of the studies with a comparison group had a wait-
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list control where the controls were exposed with similar intervention after a waiting period. The majority of the included studies (n=22) were conducted in the USA. Other countries
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included Australia, Canada, Germany, the UK, Israel and Sierra Leone.
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Study participants were nurses in nine studies, physicians in four, with the majority of the studies (n=15) having mixed-group participants, which involved nurses, physicians,
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dieticians, clinic managers, health educators, health researchers, psychologists, maternal and child health workers, vaccinators, disease control assistants, social workers, clerical and
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support staff, and students. One study reported findings separately for oncology nurses and leadership groups. The participants in the remaining studies involved radiologists, faculty members including students, and support staff for people with an intellectual disability. Two studies did not specify the type of participants.
Some studies were conducted in palliative care, oncology and intensive care. Johnson, Emmons, Rivard, Griffin, and Dusek (2015) limited the study to clinically depressed health professionals and Mealer et al. (2014) included only those nurses who scored 82 or less on CD10
ACCEPTED MANUSCRIPT RISC (showing lower level of resilience). Sample sizes ranged from 5 to 1191 (5 to 14 in qualitative; 14 to 1191 in single-arm pre-post; 26 to 158 in RCTs and 25 to 286 in quasiexperiment). Among the studies, which reported the participants’ age, the average age ranged between 28 – 53 years.
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3.2 Interventions
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The interventions amongst the included studies differed widely in terms of content,
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duration, modes of delivery, evaluation methods and the number of assessments made.
Eleven studies used mindfulness based-interventions, with the majority using a
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modified version of the Mindfulness-Based Stress Reduction (MBSR) training program. Two
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used a standard 8-week MBSR, three evaluated a brief version of the MBSR, one compared online mind–body skills online herbs and dietary supplements training and five considered
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other mind-body skill interventions, incorporating elements such as interactive reflective
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writing, cognitive behavioural therapy, autogenic training on guided imagery and compassion fatigue. Five studies evaluated Stress Management and Resiliency Training (SMART), of
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which three used a 90-minute SMART session, one used 12 weekly sessions and one used an 8-week web-based module.
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Three studies used interventions related to cognitive behavioural therapy. Gray (2016) used ‘salutogenic coaching’ to workplace wellbeing, which was developed specifically for those experiencing organisational transition. Jakel et al. (2016) evaluated a mobile application named the Provider Resilience Mobile Application (PRMA) to alleviate compassion fatigue amongst health professionals. Two studies evaluated resilience workshops designed for health workers. Vesel, Waller, Dowden, and Fotso (2015) evaluated components of Helping Health Workers Cope (HHWC) project and Noone and Hastings (2009) evaluated a one-day
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ACCEPTED MANUSCRIPT Promotion of Acceptance in Carers and Teachers (PACT) workshop, based on the principles of acceptance and commitment therapy. West et al. (2017) assessed a participant-developed intervention to improve resilience. Other studies evaluated various training and workshops such as self-reflection, self-regulation, relaxation, self-care, work related stress reduction
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strategies, and problem-focused learning.
Face-to-face group based training was the main mode of delivery (n=25). One study
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used one-to-one training. Six studies used virtual interventions of which four used web-based
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online training, one employed computer assisted resilience training and another a mobile
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application.
Twelve studies provided follow-up review sessions. Some studies had multiple follow-
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up with Magtibay et al. (2017) having one in person and another by telephone; Sood, Sharma, Schroeder, and Gorman (2014) had an optional session and two additional phone calls; Fortney,
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Luchterhand, Zakletskaia, Zgierska, and Rakel (2013) had 2 face-to-face group sessions, and,
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Rowe (2006) had four follow-up sessions. Follow-up particiption was generally low across the
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studies.
Thirteen studies involved home assignments in addition to the training sessions in
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which the participants practiced the skills and strategies learned during the workshops. The duration of resilience training ranged from a single one-hour session to one to two hours sessions over the course of 12 weeks. Eight studies had only one single session ranging from 1-hour to a whole day.
3.3 Outcome measures
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ACCEPTED MANUSCRIPT Most studies used multiple outcomes to assess the resilience intervention. Only 20 out of 33 studies measured resilience with the remainder using mental health symptoms as a proxy for resilience (Table 4).
Amongst the studies measuring resilience as an outcome, 15 studies used quantitative
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resilience measures, three used qualitative assessment and the remaining two used mixed methods. Fourteen studies used standard validated scales, with the 25-item version of the
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Connor-Davidson Resilience Scale (CD-RISC) being the most commonly used. Two studies
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used the 10-item version of CD-RISC and one used the 2-item version. Other standard resilience scales included the Brief Resilient Coping Scale (BRCS-4), Smith’s 6-item Brief
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Resilience Scale and the 14-item Resilience Scale. Three studies used non-validated resilience
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scales, with Everly, Lee McCabe, Semon, Thompson, and Links (2014) using a self-confidence questionnaire in a crisis context. Wald, Haramati, Bachner, and Urkin (2016) developed a
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questionnaire to evaluate professional resilience (post-intervention only), while Kemper and
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Rao (2017) rated self-reported resilience on a numeric rating scale.
Qualitative approaches (including mixed-methods) assessed the effectiveness of
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interventions in terms of whether participants were prepared to apply the intervention techniques learned (Wald et al., 2016), the impact of the program (Gray, 2016), understanding
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of resilience (Mealer et al., 2014), effectiveness of the intervention in relation to their personal resilience (G McDonald, Jackson, Wilkes, & Vickers, 2013), and workshop benefits and experiences (G. McDonald, Jackson, Wilkes, & Vickers, 2012).
Despite the availability of validated resilience scales, thirteen studies did not directly measure resilience. In addition, studies directly measuring resilience used additional nonresilience scales to assess mental health symptoms. As the focus was on the impact of interventions on resilience, we these findings are not reported in detail in the tables. In addition, 13
ACCEPTED MANUSCRIPT Rowe (2006) conducted correlation analyses and reported significant correlation of burnout with hardiness, stress, anxiety and coping style.
The frequency of outcome measurements ranged from one to seven. Three qualitative studies, one quantitative study and one mixed method study had a single post-intervention
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measurement. Fifteen studies had two outcome assessments, with 11 having both pre- and postintervention measurements. Four studies had assessments only at baseline and at follow-up.
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Twelve studies, in addition to pre- and post-intervention data, collected data at one or more
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follow-up points.
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While studies were not excluded based on the outcome of the quality appraisal in accordance with the exclusion criteria in this study, the appraisal identified some issues with Most of the studies did not evaluate baseline differences between the
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study quality.
intervention groups. Some RCTs did not fully report the randomization procedure, including
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blinding to treatment assignment. Loss to follow up was often not addressed in the statistical
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analysis. In addition, some studies often used self-selected convenience sampling with low
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sample size.
3.4 Effectiveness of the interventions
Baseline, post-intervention and follow-up resilience scores, and statistical differences are presented in Table 5. Amongst the studies measuring baseline and post-intervention resilience (n=16), 11 studies reported significant improvements in the resilience scores for the treatment group (Everly et al., 2014; Kemper & Khirallah, 2015; Kemper & Rao, 2017; Klatt, Steinberg, & Duchemin, 2015; Stefanie Mache, Bernburg, Baresi, & Groneberg, 2016; S. Mache, Vitzthum, Klapp, & Groneberg, 2015; Magtibay et al., 2017; Mealer et al., 2014; Sood, 14
ACCEPTED MANUSCRIPT Prasad, Schroeder, & Varkey, 2011; Werneburg et al., 2018; West et al., 2017). The remaining five studies (Chesak et al., 2015; Craigie et al., 2016; Fortney et al., 2013; Kemper, Lynn, & Mahan, 2015; Sood et al., 2014), although showing improvements in resilience scores, did not demonstrate statistically significant differences compared to baseline. Amongst the studies with a comparison group which reported resilience as an outcome measure, four RCTs reported
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a significant improvement in resilience compared to control (Klatt et al., 2015; Stefanie Mache
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et al., 2016; S. Mache et al., 2015; Sood et al., 2011), with the remaining RCTs (Chesak et al.,
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2015; Mealer et al., 2014; Sood et al., 2014) and a quasi-experimental study (Kemper et al., 2015) finding no significant difference compared to control.
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Six of the nine studies using CD-RISC reported a significant improvement in resilience
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(Klatt et al., 2015; Magtibay et al., 2017; Mealer et al., 2014; Sood et al., 2011; Werneburg et al., 2018; West et al., 2017); both studies using BRCS-4 reported significant improvements in
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resilience (Stefanie Mache et al., 2016; S. Mache et al., 2015); only one of two studies using
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Smith’s 6-item Brief Resilience Scale found significant difference in pre- and post-resilience scores (Kemper & Khirallah, 2015); while a study using Resilience Scale (RS-14) did not observe significant improvements in resilience (Fortney et al., 2013). Two studies using non-
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validated scales found significant improvements in resilience at post-intervention (Everly et al.,
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2014; Kemper & Rao, 2017).
In terms of type of resilience interventions, among the six mindfulness-based interventions reporting pre- and post- resilience scores, three reported significant improvements (Kemper & Khirallah, 2015; Klatt et al., 2015; Mealer et al., 2014). Similarly, three of five studies reported that SMART significantly improving resilience (Magtibay et al., 2017; Sood et al., 2011; Werneburg et al., 2018) and both of the cognitive behavioural therapy
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ACCEPTED MANUSCRIPT based interventions had a positive effect on resilience (Stefanie Mache et al., 2016; S. Mache et al., 2015).
In terms of mode of delivery, seven of eleven studies using face-to-face group-based training/workshops (Everly et al., 2014; Klatt et al., 2015; Stefanie Mache et al., 2016; S.
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Mache et al., 2015; Mealer et al., 2014; Werneburg et al., 2018; West et al., 2017) and three of four using online training (Kemper & Khirallah, 2015; Kemper & Rao, 2017; Magtibay et al.,
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2017) demonstrated improvements. One study (Sood et al., 2011) using one-to-one training
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also showed a significant improvement in resilience.
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Studies using qualitative approaches reported that workshops were beneficial to participants not only for understanding professional resilience but also to identify personal
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triggers for workplace stress and the importance of self-care. McDonald et al. (2012; 2013) reported personal gains, professional gains and personal resilience initiatives as outcomes of
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resilience training. The opportunity to work collaboratively with their peers outside of the
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pressure of the workplace had fostered more positive dynamics, removed the sense of hierarchy and promoted communication and different perspectives. This fostered a sense of a workplace
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that was more conducive to communication, which was integral to resilience. This study also noted the importance of self-care as a key mechanism to promote resilience, something that
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concurred with the findings of Wald et al. (2016). Being self-aware and adopting reflexive strategies were seen as tools in being pre-emptive against stress triggers and thereby becoming more resilient (Wald et al., 2016) and one’s own resilience was considered to affect the resilience of others, thus creating a flow-on effect (Gray, 2016). 4. Discussion This review aimed to analyse the effectiveness of resilience interventions in promoting resilience. The effectiveness of the interventions among the quantitative studies was assessed 16
ACCEPTED MANUSCRIPT based on improvements in resilience scores between pre- and post-intervention, and between intervention and control groups. Eleven (out of 16) studies showed a significant difference in resilience scores from pre- to post-intervention and five (out of eight) studies found a significant difference in resilience scores between the intervention and control groups. Findings suggest that training interventions may be of benefit to health professionals in improving
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resilience. Indeed, central to all the qualitative studies was the finding that it was participation
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in resilience workshops that had created self-awareness and greater understanding of the need
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for resilience, thereby promoting this as a particularly effective intervention. However, not all of the interventions enhanced resilience and the results are inconsistent. There were no specific
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patterns observed across the type of studies, characteristics of participants, nor mode of
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intervention delivery.
There were inconsistent findings in relation to duration of training, both in intervention
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duration and session duration. A trend was observed with interventions involving more training
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sessions being more likely to demonstrate significant improvements in resilience. For studies with less than eight intervention sessions (range one to six sessions), only three out of five studies showed significant improvement in resilience during post-intervention and one out of
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five studies demonstrated significant improvement in resilience during follow-up (follow up
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duration 1 to 9 months). For studies with eight or more sessions (range eight to 12), five out of seven studies had significant improvement in resilience during post-intervention and all the four (four out of four) studies had significant improvement in resilience during follow-up (follow up duration 3 to 6 months).
A similar trend was observed in terms of the duration of each training session, with interventions utilising longer duration being more likely to demonstrate significant improvements in resilience. Among the studies having an intervention length of 8 hours or less
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ACCEPTED MANUSCRIPT (range 90 minutes to 8 hours), only three out of five had significant improvement in resilience during post-intervention and two out of five studies had significant improvement in resilience during follow-up (follow up duration 1 to 6 months). Among the studies having a total intervention length of more than 8 hours (9 to 24 hours), four out of six had significant improvement in resilience during post-intervention and three out of four studies had significant
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improvement in resilience during follow-up (follow up duration 3 to 9 months). Similar results
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were found for total duration of the intervention. In summary, the volume of training enhanced
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the effectiveness of resilience intervention among health professionals, whether by increasing the number of sessions, the intervention length or the total intervention duration. This suggests
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that short interventions for resilience may be ineffective for health professionals.
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There were mixed results regarding the sustainability of the effect of the intervention, with only five out of nine studies showing significant improvements in resilience scores at
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follow-up. Resilience interventions were more likely to have a sustained effect where the
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interventions had more sessions, longer interventions and extended duration. This finding is consistent with Rowe (2006) who reported that long-term approaches yielded ongoing reductions in stress and burnout. However, sustainability of resilience improvements was not
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found in this review to be associated with having follow-up sessions, with only two out of six
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studies with follow-up sessions having significant long-term improvement in resilience. These findings may be due to the follow up-sessions in many studies being optional (e.g. Sood et al., 2011; Sood et al., 2014) resulting in low attendance, however it is likely that sustained improvements in resilience may be more difficult to achieve than other related measures.
This review also noted that there was a lack of uniformity in how the researchers constructed resilience or the way the way that outcomes were measured. Although the included studies in this review aimed to assess resilience interventions, only 20 of the 33 included studies
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ACCEPTED MANUSCRIPT directly measured resilience with the remaining studies assessing mental health. This is noted elsewhere (Gemma, Merryn, & Karen, 2016) and as there is no universally accepted definition of resilience, there is no widely agreed set of criteria for defining a particular type of intervention that constitutes a resilience-promoting effort. This lack of definition then leads to a lack of uniformity in how resilience is approached as part of research. One of the issues in
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assessing resilience outcomes is whether resilience is a trait that supports coping mechanism
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or a coping mechanism itself. This variation is extremely important in assessing interventions
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as teaching coping mechanisms may or may not have an effect on resilience, depending on how it is defined.
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If mental health is considered a marker of resilience then this too can be problematic as
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a number of studies showed that mental health measures such as depression (Sen, Kranzler, Krystal, & et al., 2010), stress (Almedom & Glandon, 2007; Garmezy, 1991; Luthar, 1991) and
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burnout (Fortney et al., 2013) are not correlated with resilience. Our review found that
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interventions that demonstrate improvements in mental health such as depression, negative emotions, burnout and stress, did not always improve resilience (see e.g. Craigie et al., 2016; Fortney et al., 2013; Sood et al., 2014). The possible innate nature of resilience may impede
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the capacity to improve resilience by interventions. The question would therefore be whether
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the reverse is true, with improvements in resilience also leading to improvements in mental health. While there was no comparisons to non-health care settings in the studies, the baseline scores for mental health measures of burnout and stress are indicative of the demanding environments in which the studies were conducted.
4.1 Implications for research, policy and practice
One of the main aims of resilience research should be identifying, defining and measuring the construct of resilience in a clear and consistent manner, and setting agreed 19
ACCEPTED MANUSCRIPT boundaries for what constitutes a resilience building interventions. Resilience building interventions must evaluate resilience outcomes and future studies should consider the effectiveness of alternative methods such as online training, and electronic interventions (e.g. apps). Larger RCTs among representative samples with longer and alternative follow-ups are required and assessment of baseline differences between the intervention groups is essential.
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Methodological improvements in the studies such as proper designing and reporting of RCTs,
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adequate description on attrition, and adequate statistical analysis among RCTs including
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treatment effect analysis are advised.
This review suggests that interventions to promote resilience for health professionals
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require a significant time investment. Adapting programs to the local context and schedule may
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be important when designing resilience interventions. Prolonged and sustained effort to support ongoing practice is necessary to improve resilience among health professionals. Special focus
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should be provided to retain participants throughout the sessions including follow-ups.
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4.2 Limitations
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The limitations of this review include both the limitations inherent in the included studies as well as the limitations of the review methodology. Many studies had low sample size,
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which will likely have precluded the detection of significant differences. Self-selected convenience sampling used in most studies might also have prejudiced highly motivated groups to participate in the research creating positive selection bias. Low sample size, the absence of random sampling particularly among the RCTs, high attrition among the studies and differential attrition across the interventions make the results less reliable and difficult to generalise. As most of the studies were pilot studies, the effectiveness of the resilience interventions reported should be considered preliminary. Studies with interventions having external assessment and practice components had limited mechanisms to monitor adherence. 20
ACCEPTED MANUSCRIPT The review also did not distinguish between sub-specialities of health, which would have indicated whether resilience, stress or interventions differed based on the nature of the health care being provided. The variation in the studies in terms of participants, methods, intervention types and outcome measures precluded a meta-analysis.
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5. Conclusion
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This review suggests that resilience interventions with longer intervention length,
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session length and duration length are more effective. Resilience building requires continuous follow up and regular coaching and hence managing the time availability of health
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professionals may be challenging due to their busy schedule. What constitutes resilience building interventions and what constitutes resilience outcomes should be clearly defined in
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international resilience building literature. A universal definition of resilience is important for research as well as a program perspective. Rigorous RCTs with larger sample size and longer
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follow-up to assess the effectiveness of different types of resilience interventions in terms of
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optimum dosage, training content, and follow-ups with comparison between traditional faceto-face with virtual web based online training are needed. The results of the current review may
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inform resilience programs as well as future interventional studies on resilience building.
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35
Hastings (2009)
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Craigie et al.
(2016) Jakel et al. (2016)
Gerhart et al.
Mehta et al. (2016)
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researcher and participants been considered? Have ethical issues taken into consideration? Was the data analysis
Is there clear statement of
How valuable is the
RI
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ACCEPTED MANUSCRIPT Table 4: Study characteristics Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To examine the impact of a worksite resilience training program on improving resiliency and health behaviors in healthcare employees
Quantitative , Singlearm, prepost test
Cognitive Behavioral Techniques SMART program 60-90-minute sessions per week, for 12 consecutive weeks
ConnorDavidson Resilience Scale
Perceived stress Anxiety Quality of life Health behaviors
Magtibay et al. (2017)
To assess efficacy of blended learning to decrease stress and burnout among nurses through use of the SMART program
Academic medical center staff N=159 assessed at baseline, 137 completed the program and 119 completed 3-month follow-up assessment Majority were female and > 40 years. Transplant nurses and nurse leaders N=50 (46F) Age: 24-63 years 45 participants completed the surveys at week 8, 40 at week 12, and 33 at week 24 Complete case analysis using last observation carried forward
Quantitative , Single arm, pre-post test
West et al. (2017) USA
To evaluate the effectiveness of a staff implemented activity plan as demonstrated by comparison of preand post-survey results
Cognitive Behavioral Techniques SMART program. Participants choose either web-based format, independent reading, or facilitated discussions or a combination. 12 modules over 8 weeks Additional two in-person (weeks 8 and 12) and two telephone (weeks 16, and 20) discussion sessions. Participants developed an activity plan to improve their levels of compassion and resilience. Once the activity plans were completed, they had two months to operationalize their respective activity plans.
SC
ConnorDavidson Resilience Scale
Happiness Stress Anxiety Mindfulness Burnout
ConnorDavidson Resilience Scale
Quality of Life (ProQOL-5) measuring Compassion Fatigue and Compassion Satisfaction
NU
MA
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PT E
CE
AC
N=168 RNs and support staff (Licensed Practical Nurses, Unit Desk Clerks, Nursing Assistants, and Patient Access Representative s) 157 completed the postsurveys.
RI
PT
Author, year, country Wernebur g et al. (2018) USA
Quantitative , Singlearm, prepost test
39
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To assess the effect of online training in mind-body skills on immediate changes in relaxation, resilience, stress, affect, and overall flourishing
N=379 (322F) nurses, physicians, and other staff at academic health centre in Ohio State University (364 completed module 1, 158 module 2 and 140 module 3)
Quantitative , Singlearm, prepost test
Three one-hour online training module on selfreflections (1) Introduction to Stress, Resilience, and the Relaxation Response, (2) Clinical Effects of the Relaxation Response, and (3) Physiologic Effects of the Relaxation Response
Participants rated their resilience on a scale ranging from 0 (not at all) to 10 (extremely)
Relaxation and stress, Positive and Negative Affect, Diener’s 8item Flourishing scale
Wald et al. (2016) Israel
To evaluate the outcomes of an interprofessional, experiential, skillsbased workshop (IESW) fostering self-awareness, selfdiscovery, reflection, and meaning-making, potentially prevention/attenuati on of burnout and promoting resiliency
Mixed methods, Single-arm, Post test
A two-hour interactive professional development workshop focusing on burnout, resiliency, physiology of stress, and experiential sessions of (1) mind-body medicine (MBM) exerciseautogenic training and (2) interactive reflective writing (IRW)enhanced reflection exercise
A questionnair e evaluating understandin g of professional resiliency
Burnout
Mehta et al. (2016) USA
To test the feasibility of the Relaxation Response Resiliency Program (3RP - a program targeted to decrease stress and increase resiliency) for Palliative Care Clinicians
N=16 (8F) faculty members of medicine, nursing and basic sciences (including clinicians) and students. The workshop was a component of a weeklong interprofession al health care professions education forum developed for university students and faculty Age: 45 ±13.3 (range 28–70) years N=15 (12F) palliative physicians, nurses and social workers in an academic medical centre. Age: 44 ± 8.1 years
Relaxation Response Resiliency Program (3RP) mind-body program based on cognitive behavioural therapy and positive psychology. An initial fourhour introductory session followed by four two-hour education sessions for two months.
No specific measures of resilience
Self-efficacy, Relaxation Response (Perceived Stress Scale), Stress Awareness, Adaptive Strategies, Optimism, Satisfaction with life
SC
NU
MA
D
PT E CE
AC
RI
PT
Author, year, country Kemper and Rao (2017) USA
Quantitative , Singlearm, prepost test
40
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To evaluate a selfcare skills training with solutionfocused counselling to support psychiatrists in handling their daily work challenges
N=72 (51F) physicians working in psychiatric department from twelve hospitals in the North of Germany (37 treatment, 35 control) Age: 33 ± 2.3 years
Quantitative , RCT, pre-post test Single blinded
Resilient coping behaviour: German version of the ‘Brief Resilient Coping Scale’ (BRCS)
Selfperceived job stress, Selfefficacy, Job satisfaction, Quality of Relationship
Gray (2016) UK
To evaluate the impact of a coaching programme, designed to support staff working for the National Health Service (NHS) in the UK, to develop lasting resilience and wellbeing
N=5 staff working for the National Health Service in the UK
Qualitative, postintervention
Psychosocial skills training combined with cognitive behavioural and solution-focused counselling Focused on principles of self-care techniques (i.e., mindfulness and acceptance based), cognitive behavioural training and solution-focused group work 12 weekly sessions of 1.5 hours The control group received no training. Salutogenic coaching approach to workplace wellbeing program involving the principles of positive psychology, neuroscience, and pedagogy. Three parts: propositional knowledge relating to workplace stress and salutogenesis; one to one coaching using the salutogenic model and using the salutogenic model as a team.
AC
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Author, year, country Mache et al. (2016) Germany
41
A qualitative questionnair e on impact of intervention on resilience
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To evaluate the outcomes of a pilot study of Aware Compassionate Communication: An Experiential Provider Training Series (ACCEPTS) for Palliative Care Providers.
N=21 (17F) nurses, physicians, social workers and other staff of local palliative care and hospice services Age: 53 (Range: 28 – 63) years
Quantitative , Singlearm, prepost test
No specific measures of resilience
Depression, Burnout, Posttraumatic stress, Experiential avoidance, Cognitive fusion
Jakel et al. (2016) USA
To evaluate the effect of the Provider Resilience mobile application (PRMA) will improve oncology nurses’ professional quality of life.
N=25F clinical nurses from an inpatient oncology unit at a medical centre in California Participants were nonrandomly allocated to the intervention (n=16) or control (n=9) group the control group. Age: 18–35 years
Quasiexperimenta l pre- and post-tests
MindfulnessBased Interventions and principles of Psychological Flexibility Theory ACCEPTS encompasses the principles of mindfulness and is tailored to the needs of providers who work with patients receiving palliative and hospice care to enhance psychological flexibility and communication. A group-based 8-week, 10session training series At baseline, the intervention and control groups received Compassion Fatigue education. The intervention group used the PRMA for six consecutive weeks. PRMA, which was developed by the Department of Defence to aid in alleviating CF. PRMA use was monitored for a six-week period via tracking software.
AC
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Author, year, country Gerhart et al. (2016) USA
42
No specific measures of resilience
Quality of Life (ProQOL-5) measuring Compassion Fatigue and Compassion Satisfaction
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To evaluate Mindful Self-care and Resiliency (MSCR) Intervention aimed at reducing compassion fatigue and improving emotional wellbeing in nurses.
N=21(20F) nurses recruited from a large Western Australia teaching hospital Age: 48.6±9.9 (range 24 to 62) years
Quantitative , Singlearm, prepost test
ConnorDavidson Resilience Scale (CDRISC10)
Patient Health Questionnari e-9, PTSD, CAGE questionnaire , Quality of Life (ProQOL-5), DASS-21, Anxiety, Passion for Work
Vesel et al. (2015) Sierra Leone
To describe the effect of counselling and psychosocial training on coping skills, stress levels, and providerprovider and provider-client relationships.
Data from the Helping Health Workers Cope (HHWC) project Health worker employed in primary health care facilities. Intervention: N=129 health workers who had been engaged in the intervention Control: 157 health workers employed in similar cadres
MSCR intervention was a total of 12 hours intervention, comprised a 1day educational workshop on compassion fatigue (CF) resilience and introduction to mindfulness, followed by weekly mindfulness skills seminars for 4 weeks. The 1-day workshop comprised education about CF and its causes, and skills to build CF resiliency. The follow-up seminars aimed to learn mindfulness to support CF resiliency skills. The HHWC project aimed to improve coping techniques among health workers by addressing workplace stressors and introducing support services, and to improve interpersonal relationships between health workers and with clients. 10 groupcounselling sessions on stress management, self-care and client-care. Refresher training was provided to all health workers after nine months
AC
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Author, year, country Craigie et al. (2016) Australia
Quasi experimenta l, mixed methods post-test
43
No specific measures of resilience
Quantitative survey on perceived stress, coping skills and relationships Qualitative data on job satisfaction, motivation, relationships and stress
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To investigate the feasibility of a psychosocial stress management and resilience training program for junior physicians. To assess the program for promotion of protective factors (such as resiliency) and job satisfaction and decreasing stress.
N=95 junior physicians specializing in different medical specialties (e.g., internal medicine, paediatrics, neurology, and gynaecology) 42 physicians (26F) treatment, and 43 (25F) controls. Age: 28 years
Quantitative , RCT, pre-post test
Brief Resilient Coping Scale (BRCS)
Perceived Stress, SelfEfficacy, Optimism and Pessimism, Job satisfaction, Copenhagen Psychosocial Questionnair e
Klatt et al. (2015) USA
To determine the feasibility/efficacy of Mindfulness in Motion (MIM) intervention in chronically high stress environment
Intensive Care Units (ICUs) N=34
Quantitative , RCT Wait-list control
The intervention group received 2 hours sessions per week for 12 weeks. Resilience training combined with cognitive behavioural and solution-focused counselling. The focus was on coping strategies, selfefficacy, communication, motivation, goal setting, improving emotional problems, etc. The control group received no training Mindfulness in Motion (MIM), a modified, short version of MindfulnessBased Stress Reduction (MBSR), delivered onsite. Focused on mindful awareness principles utilizing gentle yoga stretches and relaxing music. 8 weeks 1 hr/week, plus one 2 hr “retreat”.
AC
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Author, year, country Mache et al. (2015) Germany
44
ConnorDavidson Resiliency Scale (CDRISC 10)
Work engagement
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To assess the impact of an online elective in mind-body skills (MBS) on clinicians’ mindfulness, empathy, compassion, and confidence in providing calm, compassionate care.
Quasi experimenta l, pre-post test
12 one-hour online modules organized in 4 general topics: (1) focused attention meditation (2) mindfulness meditation; (3) positive affect meditation and (4) guided imagery/hypnosi s
Smith’s 6item Brief Resilience Scale
Mindfulness, Selfcompassion, Confidence in providing calm, compassionat e care, Empathy, Compassion
Kemper and Khirallah (2015) USA
To evaluated the acute changes associated with completing a 1-hour online module in enrolees’ stress, mindfulness, resilience, or empathy
N= 218 (159F) Midwestern university incoming graduate students, residents and fellows. Online course on herbs and dietary supplements (HDS) or mind–body skills (MBS) training for resilience, effectiveness, and mindfulness Age: 28 years 103 completed post-training survey (60 engaged in MBS). N=513 dietitians, nurses, physicians, social workers, clinical trainees, health researchers and trainees (students, residents, and fellows)
NU
SC
RI
PT
Author, year, country Kemper et al. (2015) USA
AC
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Quantitative , Prospective cohort study, preport test
45
Up to 12 onehour online modules, 3 for each of 4 types of mind–body skills: (a) focused attention meditation (b) mindfulness, (c) guided imagery and hypnosis, and (d) positive affect– generating meditation.
Smith’s 6item Brief Resilience Scale
Perceived Stress, Mindfulness, Empathy, Burnout
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To examine outcomes of a brief Stress Management and Resiliency Training (SMART) program within a nurse orientation program.
N=55 (52F) nurses who were new to the institution or transitioning to a new unit or new role undergoing new nurse orientation. 27 treatment and 28 control of which 40 (19 in intervention and 21 in control) completed the study. Average age of 28.2 years
Quantitative , RCT pre-post test
ConnorDavidson Resilience Scale (CDRISC 25)
Perceived Stress, Mindful Attention Awareness, Anxiety
Johnson et al. (2015) USA
To investigate the potential effect of resilience training on symptom relief for current or recurrent depression, and other psychological/ behavioural outcomes
N=40 actively working clinically depressed health professionals at health centre. Aged 18–65 years. 20 (18F) treatment 20 (16F) controls
Quasiexperimenta l, wait-list control, prepost test The first 20 consecutive individuals assigned to training group and remaining 20 individuals placed on wait-list control group
A 90-minute session focused on stress and resilience, integrating neuroscience and biology, and mind-body approaches to managing stress. A 1-hour followup session after 4 weeks. Participants also received biweekly handouts on each of the topics via email. The control group received a lecture associated with the nursing orientation program. 2.5-hour weekly mindfulness meditation sessions for eight weeks. Focus on discovering and developing selfcare skills and advance personal capacity for well-being. Focused on mindfulness meditation practice, nutrition, and exercise recommendation s. Individualized guidance from a psychiatrist, an exercise physiologist, and a clinical nutritionist were also provided.
RI
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AC
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Author, year, country Chesak et al. (2015) USA
46
No specific measures of resilience
Depression, Perceived Stress, Anxiety, Workplace productivity, Healthpromoting behaviour
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To test the efficacy of a SMART program for decreasing stress and anxiety and improving resilience and quality of life among physicians.
26 (11F) radiologists at radiology department Intervention N=13 (5F), Age: 47.4±8.8 years Control N=13 (6F), Age: 48.1±5.2 years
Quantitative , RCT, wait-list controlled
ConnorDavidson Resilience Scale
Perceived Stress, Anxiety, Quality of life, Mindfulness
Everly et al. (2014) USA
To describe an approach (RAPIDPFA) and summarize training evaluation data to determine if relevant knowledge, skills, and attitudes are imparted to trainees to support effective psychological first aid (PFA) delivery.
N = 1218 (1194 analysed) trainees (clerical and support staff, administrators, health educators, health planners, nurses, security personnel, social workers, and professional volunteers).
Quantitative , Singlearm, prepost test
A single 90-min group session with two followup phone calls. Learners were also taught to cultivate and guide their interpretations by five higherorder principles: gratitude, compassion, acceptance, meaning, and forgiveness. In addition, participants were trained in a structured relaxation intervention. A 1-day (6-hour) workshop. The core content of the training adheres to the acronym, RAPID, : Reflective listening, Assessment, Prioritization, Intervention, Disposition Although not part of the RAPID acronym, all training sessions end with a module on “Self Care,” covering signs and symptoms of stress, and several techniques to manage them.
AC
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Author, year, country Sood et al. (2014) USA
47
Selfconfidence in resilience in a crisis context
Required knowledge to apply PFA Perceived self-efficacy: belief in one’s own ability to apply PFA techniques
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To determine if a multimodal resilience training program for ICU nurses was feasible to perform and acceptable to the study participants.
29 (27 analysed) ICU nurses who were scored negative for being resilient (CD-RISC 25 score 82 or less) randomized into treatement (14) and control (15); Majority were female
Quantitative , RCT, pre-post test
ConnorDavidson Resilience Scale (CDRISC)-25
PTSD, Anxiety and Depression, Burnout, Client/Patient Satisfaction
Potter et al. (2013) USA
To evaluate a resiliency program designed to educate oncology nurses about compassion fatigue.
14 (13 analysed) oncology nurses employed in an outpatient infusion cancer centre. Age: 43.9 (28 – 61) years
Two-day workshop on resilience, psychological distress, selfcare, mindfulness exercise and written exposure therapy. Participants exercised writing therapy (twelve 30minute sessions), MBSR (15 minutes at least 3 times per week), 30 to 45 minutes of aerobic exercise (at least 3 days per week), and participated in a event-triggered cognitive behavioral therapy session. A five-week compassion fatigue resiliency program involving five 90-minute sessions. Focused on selfregulation, learning to relax, intentionality, self-validation, connection, and self-care. Between the third and fourth weeks, a fourhour retreat was conducted offsite to allow participants to debrief and practice selfcare, including a healing arts program.
Quantitative , Singlearm, prepost test
AC
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NU
SC
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Author, year, country Mealer et al. (2014) USA
48
No specific measures of resilience
Burnout, Quality of life, (ProQOLIV), Subjective distress, Job satisfaction
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To investigate whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians.
30 (18F) Primary care clinicians from departments of family medicine, internal medicine, and paediatrics. Age: 40.5±10.1 years 28 (93%) participants gave responses post-test and 23 (77%) gave responses for follow-ups (8 weeks and 9 months).
Quantitative , Singlearm, prepost test
Resilience Scale (RS14)
Job satisfaction, Quality of Life, DASS21, Perceived Stress, Compassion
Foureur et al. (2013) Australia
To pilot the effectiveness of an adapted mindfulness-based stress reduction intervention on the psychological wellbeing of nurses and midwives.
40 participants (20 midwives and 20 nurses) from two metropolitan teaching hospitals. Twenty-eight (70%) participants returned the post intervention surveys and 35% participated in qualitative interviews and focus groups.
Quantitative , Singlearm, prepost test
An abbreviated version of the mindfulnessbased stress reduction (MBSR) training program A total of 18 hours over 3 consecutive days on mindfulness practices and their application to practicing medicine and everyday life. Two follow-up sessions: 10 days after the end of the mindfulness training, and 2 to 3 weeks after the first follow-up. A one-day workshop on modified MBSR and 8 week daily meditation practice for 20 minutes The workshop focused on the impact of stress on being in the present moment, introduction to mindfulness, grounding and diffusion strategies, and forming habits.
AC
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Author, year, country Fortney et al. (2013) USA
49
No specific measures of resilience
General Health Questionnair e (GHQ-12), Sense of Coherence, DASS-14
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To assess the effects of a work-based, educational intervention to promote personal resilience in a group of nurses and midwives working in a busy clinical environment. To investigate the phenomenon of personal resilience in nurses and midwives.
14 female nurses and midwives at a women’s and children’s health service in a large, tertiary referral hospital aged range 26– 59 years
Qualitative, pre-post with followup
Effectivenes s of the workshops in relation to their personal resilience Qualitative
Effectiveness of the workshops in relation to their health and wellbeing.
Pipe et al. (2012) USA
To describe and report the outcomes of workplace stress management and resilience-building intervention that was implemented in a healthcare organization
N=44 oncology inpatient unit staff including nurses (n=29) and a selected group of hospital and clinic leaders, including clinical managers, supervisors and educators (n = 15) Age: 21 – 60 years
Quantitative , Singlearm, prepost test
Six resilience workshops and a mentoring programme conducted over a 6-month period. Focus on positive and nurturing relationships and networks; mentoring; positive outlook; hardiness; intellectual flexibility; emotional intelligence; life balance; spirituality; reflection; and critical thinking Two workshop sessions over 3weeks duration on coping and resilience. The first 5 hr session on ‘Transforming Stress’ focused on techniques for selfregulating stress The second 2 hr session was a reinforcement session. Theory of Human Caring Behavioural interventions that focus on improving selfregulation of physiological responses The programme also used heart rate variability feedback, to self-generate a healthier physiological state.
AC
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Author, year, country McDonal d et al. (2013) Australia
50
No specific measures of resilience
Personal and Organization al Quality (Personal and Organization al Quality Assessment‐ Revised)
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
To evaluate the effect of workplace self-care educational intervention to develop, strengthen and maintain personal resilience to counteract the negative experiences associated with workplace adversity.
N=14F nurses and midwives Age: 26 – 59 years
Qualitative, Single arm, Post test
Qualitative
Sood et al. (2011) USA
To assess a SMART program for increasing resiliency and quality of life, and decreasing stress and anxiety among Department of Medicine physicians at a tertiary care medical centre.
Quantitative , Randomized wait-list controlled trial, prepost test
Aiello et al. (2011) Canada
To describe the development, implementation, and results of resilience training prior to the emergence of the H1N1 pandemic and how this preparatory training would link to supportive psychosocial efforts during a pandemic.
N=40 (19F)academic medical centre staff Treatment: N=20 (9F), Age: 46.8± 8.3 years, (20 analysed ) Control: N=20 (10F), Age: 50.2±5.7 years (12 analysed) 1250 hospital staff from 22 departments 1020 (82%) analyzed
Resilience workshop Six 90-minute sessions one in each month for 6 months on work based self-care focusing mentoring relationships, building Hardiness, Maintaining a positive outlook, reflective and critical thinking Workshop. A single 90minute one-onone training in SMART on attention, relaxation (deep breathing); optional 30-60 minute followup session Cognitive Behavioral Techniques Resilience workshop A one-hour training session (5 to 50 staff in attendance) on influenza pandemics, stress, coping strategies and organizational resilience
Other measures
SC
Connor Davidson Resilience Scale (CDRS)
Perceived Stress, Anxiety, Quality of life, Fatigue
No specific measures of resilience
Post-session feedback surveys (8items)
NU
MA
Quantitative , Single arm, Post test
AC
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Author, year, country McDonal d et al. (2012)
51
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To test three versions of an interactive, computer-assisted training course (short, medium and long) designed to build resilience to the stresses of working during a pandemic.
158 hospital workers (136F, 85 nurses) randomly assigned to the short (7 sessions, 111 minutes), medium (12 sessions, 158 minutes) or long (17 sessions, 223 minutes) version. 127 (80%) completed
Quantitative , 3 arm RCT, pre-post test
No specific measures of resilience
Pandemic SelfEfficacy, Interpersonal problems, Coping Inventory: problemsolving and seeking support
Noone and Hastings (2009) UK
To pilot test a work stress acceptance intervention (Promotion of Acceptance in Carers and Teachers - PACT) for intellectual disability services support staff
N=28 (23F) support staff working for an independent community service domiciliary care and support for people with an intellectual disability Age: 37.43±10.0 years 14 attended follow-up sessions
Quantitative , Pre-post test
Participants were provided with a computer flash drive containing the course and instructions for administering the training The topics included: pandemic, resilience, psychological first aid, coping approaches, active listening, balancing family and work, danger signals and resources for getting help, relaxation skills. A one-day PACT workshops followed by a half-day followup booster session after 6 weeks PACT workshop was based on the principles of acceptance and commitment therapy
AC
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Author, year, country Maunder et al. (2010) Canada
52
No specific measures of resilience
General Health Questionnair e (GHQ–12), Stress
ACCEPTED MANUSCRIPT Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To examinine the relationships between stress and coping and explore both short- and long-term approaches to behavioural change. To examine the relationship between stress and coping.
N=126 Health care professionals (nurses, clinical staff, administrators, psychologists, social workers) were randomly assigned to 3 groups (shortterm, longterm, control). Age: 38.2± 7.6 years
Quantitative , 3 arm RCT, pre-post test
Group 1 were exposed to a stress management/ adaptive coping training, 1 time per week for 90 minutes for a duration of 6 weeks. Subjects in Group 2 were exposed to the same 6 week training condition as those subjects in Experimental 1 Group, but in addition were given a 1-hour "refresher" session at 5 months, 11 months, and 17 months. Subjects in the control group received no training.
Hardiness but not reported
Anxiety, Stress, Burnout, Coping Style
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Objectives
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Author, year, country Rowe (2006) USA
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ACCEPTED MANUSCRIPT Table 5: Effect of intervention for studies reporting resilience outcomes Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Wernebu rg et al. (2018) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Quantitative Pre, post and 3 months post intervention follow-up
12 sessions 12 weeks 60-90 minutes each
65.3 (11.5)
Magtiba y et al. (2017) USA
ConnorDavidson Resilience Scale (CDRISC 2), (2 items, range 0-8)
Quantitative At baseline (week 0), postintervention (week 8) and, weeks 12 and 24
6.2 (1.1)
West et al. (2017) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Quantitative Baseline and two months
8 weeks 12 sessions Follow up: in person and telephone at weeks 8, 12, 16, and 20 1 session for development of activity plan 2 months for implementat ion of the plan
Kemper and Rao (2017) USA
Resilience Numeric Rating Scales (010)
Postinterventi on Mean (SD) 76.1 (12.0)**
Relevant outcomes
78.5 (11.2) ** 3 month s
Statistically significant (p<0.01) improvements in resilience at the end of the intervention and extending to 3 months follow-up. Significant improvement in resilience score at 12 week and 24 week follow up, but not in post-test (8 week)
6.7 (1.2)* * 24 weeks
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6.3 (1.2)
Follo w-up Mean (SD)
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Study Country Title
74.2 (11.8)**
No follow up
6.9 (1.8)**
No follow up
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70.6 (12.8)
Online training 3 hours
6.3 (2.1)
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Quantitative Pre, post
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Staff who participated in the study by completing activity plans improved their level resilience. Self-developed activity plan can improve resilience. The change must come from within and nurses must identify the actions that work for them as individuals. Completing modules was associated with significant improvements in relaxation, resilience, stress, positive and negative affect, and flourishing (all p<0.01). Online focused attention meditation training is associated with improvements in relaxation, resilience, stress, affect, and flourishing.
ACCEPTED MANUSCRIPT Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Wald et al. (2016) Israel
Participants reporting that they better understand concepts of professiona l resiliency
Mixed methods Quantitative: post workshop questionnaire Qualitative: postintervention reflective workshop
1 session of 2 hour
-
Mache et al. (2016) Germany
‘Brief Resilient Coping Scale’ (BRCS), (4-item, range 4-20)
Quantitative: Before receiving the first training session (baseline), after 3 months (follow-up 1) and after 6 months (follow-up 2).
12 week, 12 sessions each of 1.5 hr
Postinterventi on Mean (SD) 3.93 (0.92)
Follo w-up Mean (SD)
Relevant outcomes
-
Participants reported better understanding of professional resiliency and felt better prepared to use meditation and reflective writing as coping tools. Reflective writing themes identified include experiencing/grapp ling with a spectrum of emotions (positive and negative) as well as challenge and triumph within clinical and teaching experiences as professionally meaningful. Significant improvement in perceived stress, resilience and selfefficacy in the intervention group, and persisted significant at both follow-ups when compared to control group. Mean change from baseline to first follow-up was +6.6 (treatment) versus +0.7 (control) and to second follow-up was +4.0 versus +1.9.
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53.2 (16.8)
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59.8 (18.1)*
57.2 (17.2) * 6 month s
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Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Postinterventi on Mean (SD) NA
Follo w-up Mean (SD)
Relevant outcomes
Gray (2016) UK
‘Wellbeing frames’ Impact of resilience and wellbeing programme on the participants , workplace and delivering project.
Qualitative: phenomenolog ical case study Data was collected during the three-part programme Post completion of the programme, a qualitative questionnaire (N=5) elicited impact of the programme.
No information of dose, duration and follow up
NA
NA
The programme achieved impact at micro (individual), meso (peer) and macro (team) levels, and in so doing served as a self-help tool for participants to manage a very stressful working environment, and remain engaged with delivering a high profile change in service delivery. Sustaining interdependence and interconnectedness is better achieved if the team have a tool to monitor team wellbeing and provide proactive support. No significant improvements for resilience from pre-test to post-test or at 1-month follow-up.
Craigie et al. (2016) Australia
ConnorDavidson Resilience Scale (CDRISC-10), (10-item, range 0-40) Resilience: Brief Resilient Coping Scale (BRCS)
Pre, post, and 1-month follow-up.
1 session 8 hours 4 weekly follow up sessions group based
28.2 (5.69)
29.6 (5.17)
28.7 (5.83) 1 month
12 week, 12 sessions each of 2 hr
54.3 (17.3)
61.8 (18.4)**
61.5 (17.9) ** 6 month s
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Quantitative Pre, post and 6 months followup
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Study Country Title
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Significant improvement in resilience, in the intervention group at post intervention and follow-up compared to the control group. Mean change from baseline to first follow-up was +7.5 (treatment) versus -0.3 (control) and to second follow-up was +7.2 versus 0.2.
ACCEPTED MANUSCRIPT Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Klatt et al. (2015) USA
ConnorDavidson Resiliency Scale (CDRISC 10)
Baseline: 1 week before the intervention and post-test 1 week after the last session
8 weeks 8 sessions 1 hour each One follow up of 2 hours
Not reporte d
Kemper et al. (2015) USA
Smith’s 6item Brief Resilience Scale Range 6-30
Quantitative Pre and post training survey
Online 12 weeks 12 hour sessions in total
3.0 (0.2)
Kemper and Khiralla h (2015) USA
Smith’s 6item Brief Resilience Scale Range 6-30
Quantitative Pre and post training survey
Chesak et al. (2015) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Postinterventi on Mean (SD) Not reported
Follo w-up Mean (SD)
Relevant outcomes
Not reporte d
Significantly imporvement between pre- and post-intervention (112.9% change from baseline, p = 0.02), but the scores were not reported. Participants value institutional support, relaxing music, and the instructor as pivotal to program success. No significant differences in resilience scores between the participants in MBS group and others. Changes in item mean scores from pretraining to posttraining: 0.06±0.3 (not significant) Resilience improved significantly among the participants in the Mindfulness in Daily Life module but not for the Introduction to Stress, Resilience, and the Relaxation Response module Resilience scores improved in the intervention group and declined in the control group, but the changes were not significant between the groups.
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Study Country Title
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Not reported
22.4 (4.3)
23.3 (4.4)**
-
1 session 90 minutes 1 follow up at four weeks
79.68 (9.59)
-
79.74 (11.82 ) 12 weeks
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Online 12 weeks 12 hour sessions in total
Baseline and 12 weeks following the intervention
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Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Postinterventi on Mean (SD) -
Sood et al. (2014) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Quantitative Baseline and 12-week post intervention
1 session 90 minutes 2 follow telephone calls
70.0 (12.8)
Everly et al. (2014) USA
Confidence in one’s own resilience in a crisis context (3 items)
Quantitative Pre-post assessments
1 day, 6 hour session
3.81 (0.74)
Mealer et al. (2014) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Mixed Quantitative: Pre-post test Qualitative: interpretive qualitative approach for analyzing writing examples
2 day workshop 12 week intervention
Follo w-up Mean (SD)
Relevant outcomes
73.0 (11.5) 12 weeks
Resilience improved in the follow-up, but the difference was not statistically significant; also, the changes were not significant when compared to the control arm. Statistically significant improvements in self-confidence about being a resilient Psychological First Aid provider. Both the intervention and control groups had a significant improvement in resilience scores, but the change did not differ significantly between the intervention and control groups. Major themes identified in the written exposure sessions were patient centric (death and dying, justice, interactions with patient and family), cognitive processing (rumination, guilt, and regret), work structure (understaffing, cumulative stress), and workplace relationships (conflict with peers, personal and professional boundaries).
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Study Country Title
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4.28 (0.64)***
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71 (media n)
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78* (median)
-
ACCEPTED MANUSCRIPT Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Fortney et al. (2013) USA
Resilience Scale (RS14) (Range: 14-98)
3 days of 18 hours 2 follow-up sessions 2 to 3 weeks
79.9 (95% CI, 75.284.6)
McDona ld et al. (2013) Australia
Qualitative: effectivene ss of the workshops in relation to their health, wellbeing and personal resilience.
Quantitative online survey At 4 points (baseline, and 1 day, 8 weeks, and 9 months post intervention) Qualitative: face-to-face, semistructured interviews Pre, post and 6 months’ postintervention follow up.
day full day workshop Mentoring for 6 months
NA
McDona ld et al. (2012) Australia
Post interventio n interviews at the end of each workshop on comments on workshop experiences and benefits. ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Postinterventi on Mean (SD) 82.0 (95% CI, 77.186.8)
Relevant outcomes
81.4 (95% CI, 76.286.6) 9 month s NA
No significant improvement in resilience scores at post-test and follow-ups
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NA
Follo w-up Mean (SD)
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Study Country Title
6 months, 90-minute session in each month
NA
NA
NA
Participants reported increased personal resilience by adopting the self-care and reflexive strategies learned from the workshop
one-on-one training 1 session 90minute Optional follow up
69.6 (13.3)
-
79.4 (11.3) * 8 weeks
Significant improvement in resilience at 8 weeks follow-up in study arm compared to the wait-list control
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Post-test qualitative semistructured interviews
Sood et al. (2011) USA
Baseline and week 8 post intervention
The intervention benefited personal and professional areas of the participants by enhancing confidence, selfawareness, assertiveness and self-care. Three major themes emerged in relation to the effects of the intervention: personal gains from resilience workshops; professional gains from resilience workshops; and personal resilience initiatives.
Higher scores indicating greater resilience
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* p ≤0.05, ** p ≤0.01, *** p ≤0.001
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Figure 1
Michelle Cleary, Rachel Kornhaber, Deependra Kaji Thapa, Sancia West, Denis Visentin PII: DOI: Reference:
S0260-6917(18)30759-7 doi:10.1016/j.nedt.2018.10.002 YNEDT 3992
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
2 July 2018 19 September 2018 7 October 2018
Please cite this article as: Michelle Cleary, Rachel Kornhaber, Deependra Kaji Thapa, Sancia West, Denis Visentin , The effectiveness of interventions to improve resilience among health professionals: A systematic review. Ynedt (2018), doi:10.1016/ j.nedt.2018.10.002
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ACCEPTED MANUSCRIPT SUBMITTED 3rd July 2018 Nurse Education Today Systematic review Title: The effectiveness of interventions to improve resilience amongst health professionals: A systematic review Running title: Interventions for resilience
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Michelle Cleary, Rachel Kornhaber, Deependra Kaji Thapa, Sancia West, Denis Visentin *Michelle Cleary, RN; PhD, School of Health Sciences, College of Health and Medicine, University
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of Tasmania, Locked Bag 5052, Alexandria NSW 2015, [email protected]
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*Corresponding Author: Professor Michelle Cleary PhD, RN, School of Health Sciences, University of Tasmania, Lilyfield, Locked Bag 5052, Alexandria, NSW, Australia. 2015. Phone: +61 2 28572
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7954, email, [email protected]
Rachel Kornhaber, RN; PhD, School of Health Sciences, College of Health and Medicine,
Email: [email protected]
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University of Tasmania, University of Tasmania Locked Bag 5052, Alexandria NSW 2015, Australia.
Deependra Kaji Thapa, MPH; MSc, School of Health Sciences, College of Health and Medicine,
[email protected]
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University of Tasmania, University of Tasmania Locked Bag 5052, Alexandria NSW 2015, Australia.
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Sancia West, RN, PhD, School of Health Sciences, College of Health and Medicine, University of Tasmania, University of Tasmania Locked Bag 5052, Alexandria NSW 2015, Australia. [email protected]
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Denis Visentin, PhD, School of Health Sciences, College of Health and Medicine, University of Tasmania, University of Tasmania Locked Bag 5052, Alexandria NSW 2015, Australia.
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[email protected]
Conflicts of interest: None. Funding: This work was supported by Improving Mental and Critical Care Health (MaCCH)—UTas funding awarded under the UTAS Research Themes: Better Health Research Development Grant Scheme, supported by the Office of the Deputy ViceChancellor and FoH (C0025653). Author contributions: All authors have agreed on the final version and meet ICMJE criteria. Word count: 4800 includes Abstract, excludes References and Tables.
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ACCEPTED MANUSCRIPT Abstract Objective: To assess the effectiveness of resilience interventions in improving resilience outcome amongst health professionals. Background: The nature of health professionals’ work is physically and emotionally
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demanding, with trauma a common consequence with the act of providing health care
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Design: A systematic review
Data Source: A comprehensive search of the literature was conducted in February 2018 using
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PubMed, PsychInfo, Cumulative Index of Nursing and Allied Health Literature (CIHAHL) and
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Scopus.
Review Methods: Methodological quality was assessed and a standardized data coding form
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was used to extract data.
Results: Of the 33 included studies, 15 were single-arm pre-post design, 10 were RCTs, five
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used a non-randomised controlled design, and three were qualitative. Eleven studies (out of 16) showed a significant improvement in resilience scores while five (out of eight) studies reported a significant difference in resilience scores between treatment and control groups.
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Conclusion: Findings suggest that resilience training may be of benefit to health professionals.
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However, not all interventions enhanced resilience with training volume being more effective. Not all studies reporting resilience used standard resilience instruments. The results of the current review may inform resilience programs as well as future interventional studies on resilience building. Keywords: nursing, resilience, systematic review, training, health professionals
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ACCEPTED MANUSCRIPT Highlights
The definition of resilience and variation among assessment instruments are limitations of the resilience literature.
Resilience interventions with longer intervention length, session length and duration
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length are more effective. Larger RCTs among representative samples with follow-up and assessment of baseline
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Promoting resilience amongst health professionals is an approach to address workplace
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stress and reduce staff burnout.
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differences is required.
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ACCEPTED MANUSCRIPT Effectiveness of resilience interventions in improving resilience outcome among health professionals: A systematic review 1. Introduction Health professionals represent a workforce that is defined by high levels of work-
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related stress. The nature of the profession is physically and emotionally demanding, with trauma a common consequence of the act of providing health care (Wood et al., 2017) in a
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notoriously chaotic environment (Stephens, Smith, & Cherry, 2017). Some research has found
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that over 70% of nurses demonstrate high stress (Faraji, Valiee, Moridi, Ramazani, & Rezaei Farimani, 2012), and that over 40% of nurses plan to leave the profession, largely as a
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consequence of stress, within the next decade (Campbell et al., 2013). Even more alarmingly, newly graduated nurses are observed to leave their employment at a rate of 43% within the first
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three years of practice, also as a consequence of stress (Brewer, Kovner, Greene, Tukov-Shuser, & Djukic, 2012). The result of this burnout and stress can be higher levels of staff turnover and
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staff absenteeism (Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012), as well as impacting on the capacity to build therapeutic relationships with patients (Salyers, Flanagan, Firmin, & Rollins, 2015). In addition to burnout there are physical and psychological impacts
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resulting from the role of health professionals, including depression, anxiety, sleep disturbance
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and burnout (Zhou et al., 2017). Indeed, a recent study found that nurses had depression rates twice that of the general public (Robert Wood Johnson Foundation's Interdisciplinary Nursing Quality Research Initiative (INQRI), 2012) thus making stress and overwork some of the higher health concerns of the profession. Such concerns are particularly relevant to the sub-specialty of mental health and wellbeing. Burnout is particularly prevalent amongst mental health professionals with rates as high as 67% (Morse et al., 2012). Higher than normal exposure to violence and suicide, present a challenge to recruitment and retention in this area (Wang et al., 2015). Work environments that 4
ACCEPTED MANUSCRIPT result in high levels of stress and contain such levels of violence and demand can lead health professionals to feel that their work is undervalued if these issues are left unaddressed and risks are not properly assessed (Cherniack, 2015). 1.1 Background
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Coping mechanisms provide a mediator between effective performance as a health professional and their work-related stress. Collectively this includes physical, psychological
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and environmental resources that reflect cognitive and behavioural approaches (Zhou et al.,
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2017) allowing health professionals to continue to work in such environments. Coping mechanisms can be both positive and negative (Zhou et al., 2017). One such resource that
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provides and enhances coping mechanisms is the notion of resilience, which refers to one’s
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ability to respond and recover from adversity and setbacks (Werneburg et al., 2018). Indeed, the definition can be extended further to include the capacity to thrive, rather than just survive,
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in high stress environments (McAllister & Lowe, 2011). Resilience is referred to as a personal
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attribute, trait or even a process or cycle and can be developed or enhanced to improve a person’s positive coping mechanisms using specific strategies (Prosser, Metzger, &
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Gulbransen, 2017; Stephens et al., 2017). Promoting resilience amongst health professionals can therefore be considered an
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approach to address the higher than average levels of workplace stress and reduce staff burnout. While there exist approaches to lower workplace stress and there may be mitigatable organisational stressors (Chandler, 2014), there are limitations on stress reduction in healthcare settings and hence the development of resilience is important for staff working in this sector (Werneburg et al., 2018). Promoting and improving resilience may be achieved through mentorship, achieving balance in life, spirituality, exemplifying the positives, and practicing reflection (Jackson, Firtko, & Edenborough, 2007). Others have proposed more flexible
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ACCEPTED MANUSCRIPT working arrangements, including job sharing and shorter shifts, to reduce stress and promote resilience (Atkinson, Fullick, Grindey, & Maclaren, 2008; Gabel Speroni, 2014). Defined strategies to achieve increased resilience are well established. Training programs such as the Stress Management and Resiliency Training (SMART) program have produced improvements in stress, anxiety, resilience, happiness, mindfulness and burnout in
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health care staff after only 8 of 24 weeks (Magtibay, Chesak, Coughlin, & Sood, 2017). This
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finding is consistent with other applications of the SMART program where resilience levels of
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health care staff have managed to near levels consistent with the general population (Werneburg et al., 2018). Smartphone technology has also been engaged to improve resilience.
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The Provider Resilience app was designed to reduced compassion fatigue and burnout and uses self-awareness measures, cartoons, exercise suggestions and motivational quotes to enhance
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resilience in health care staff (Wood et al., 2017). However, health staff often believe that strategies to improve their health are often not being given adequate priority (Perry et al., 2016)
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and management remains unsupportive of health promotion interventions (Beaudet, Richard,
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Gendron, & Boisvert, 2011), further compounding the issue. Despite the range of training programs and strategies, there remains a paucity of
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research on the development of resilience among health professionals and how this resilience
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is developed (Prosser et al., 2017). The narrative surrounding stress in health environments remains largely negative, focusing on stress and burnout rather than focusing on the strengths and resilience that can come from adversity (Young & Rushton, 2017). Without structural and individual change, retention of health staff will remain a challenge (Koen, van Eeden, & Wissing, 2011). This systematic review therefore aims to examine the current evidence for the efficacy of interventions and programs for increasing resilience with the aim of establishing the best mechanisms for promoting resilience in the health care environment. 2. The Review 6
ACCEPTED MANUSCRIPT 2.1. Aim To assess the effectiveness of resilience interventions in improving resilience outcomes amongst health professionals.
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2.2 Design
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The study adopted the systematic review method to evaluate the effectiveness of resilience interventions. This review followed the Preferred Reporting Items for Systematic
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Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009).
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2.3 Search methods
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A comprehensive search of the literature was conducted in February 2018 using PubMed, PsychInfo, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Scopus. Boolean connectors AND, OR and NOT were utilised to combine the following MeSH
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and search terms: resilien*, hardiness, training, health personnel, health facility and staff development. The search was adapted for searches conducted across the databases to account for differences in syntax and indexed terms.
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The inclusion criteria encompassed peer reviewed primary research published in the
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English language evaluating resilience interventions either qualitatively or quantitatively among health professionals. Studies concerning all types of staff working in health settings or teaching hospitals were included. Any psychological interventions prospectively designed to develop or enhance the resilience among health professionals, irrespective of the content, method of delivery or duration, were included. Resilience interventions were considered only if the study title or aim(s) had explicitly identified resilience as the primary focus of the intervention. The primary outcome measure of interest was the effectiveness of resilience interventions in improving 7
ACCEPTED MANUSCRIPT resilience outcomes among the participants. Studies reporting any type of direct resilience outcomes were also included. Non-interventional studies; studies where the subjects were primarily non-health professionals or students; theoretical articles, commentaries, editorials and review articles; and
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articles published in non-English language were excluded. 2.4 Search outcomes
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The literature search yielded 1441 studies, which was supplemented by an additional
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10 studies from the reference lists of retrieved articles and manual searching of journals. After
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removing 61 duplicates, 1390 papers were subjected for title and abstract screening, which removed 1178 articles. The full text of remaining 212 articles screened and excluded 166
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articles that did not meet the inclusion criteria. The full text of the remaining 46 papers was examined in detail and assessed for eligibility on a consensus basis by all authors, yielding 33
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articles meeting the inclusion criteria for the final review (See Figure 1).
2.5 Quality appraisal
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The quality of included studies were appraised using Joanna Briggs Critical appraisal
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tools (Tufanaru, Munn, Aromataris, Campbell, & Hopp, 2017). Two reviewers (DV and DKT) assessed the quality of the studies using the JBI Critical Appraisal Checklist for Randomized Experimental Studies and the JBI Critical Appraisal Checklist for Non-randomized Experimental Studies. The results of the critical appraisals are presented in Table 1 for RCTs and Table 2 for non-randomised experimental studies. Table 3 presents the appraisal of the qualitative data using the CASP tool (Critical Appraisal Skills Programme (CASP) checklists, 2013) (by MC, RK).
Insert Table 1, 2 and 3 about here 8
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2.6 Data extraction and synthesis A standardized data coding form (Joanna Briggs Institute, 2006) was used to extract data. One review author (DKT) extracted the following information: authors, year, country,
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study purpose, study participants and setting, study design, intervention modality and outcomes measured (resilience and other) (see Table 4). Studies directly measuring resilience as the
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outcome of interventions were reviewed in detail and extracted further information on
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resilience scale used, assessment and follow-up, baseline and post-intervention resilience scores and significant findings (Table 5). All authors then checked the extracted information
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and any discrepancies were resolved by discussion.
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Due to the heterogeneity of the study types in terms of design, intervention and outcome measures, a meta-analysis was not appropriate.
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3. Results
3.1 Characteristics of included studies
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The characteristics of included studies are summarised in Table 4. Of the 33 included studies, 15 used a single-arm pre-post design, 10 used a randomised controlled design, five
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used a non-randomised controlled (quasi-experimental) design and three used a qualitative
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design. Three single-arm pre-post studies and a quasi-experimental study reported mixed methods findings. Most of the studies used convenience sampling and the study participants
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were generally self-selected. The majority of the studies with a comparison group had a wait-
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list control where the controls were exposed with similar intervention after a waiting period. The majority of the included studies (n=22) were conducted in the USA. Other countries
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included Australia, Canada, Germany, the UK, Israel and Sierra Leone.
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Study participants were nurses in nine studies, physicians in four, with the majority of the studies (n=15) having mixed-group participants, which involved nurses, physicians,
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dieticians, clinic managers, health educators, health researchers, psychologists, maternal and child health workers, vaccinators, disease control assistants, social workers, clerical and
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support staff, and students. One study reported findings separately for oncology nurses and leadership groups. The participants in the remaining studies involved radiologists, faculty members including students, and support staff for people with an intellectual disability. Two studies did not specify the type of participants.
Some studies were conducted in palliative care, oncology and intensive care. Johnson, Emmons, Rivard, Griffin, and Dusek (2015) limited the study to clinically depressed health professionals and Mealer et al. (2014) included only those nurses who scored 82 or less on CD10
ACCEPTED MANUSCRIPT RISC (showing lower level of resilience). Sample sizes ranged from 5 to 1191 (5 to 14 in qualitative; 14 to 1191 in single-arm pre-post; 26 to 158 in RCTs and 25 to 286 in quasiexperiment). Among the studies, which reported the participants’ age, the average age ranged between 28 – 53 years.
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3.2 Interventions
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The interventions amongst the included studies differed widely in terms of content,
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duration, modes of delivery, evaluation methods and the number of assessments made.
Eleven studies used mindfulness based-interventions, with the majority using a
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modified version of the Mindfulness-Based Stress Reduction (MBSR) training program. Two
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used a standard 8-week MBSR, three evaluated a brief version of the MBSR, one compared online mind–body skills online herbs and dietary supplements training and five considered
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other mind-body skill interventions, incorporating elements such as interactive reflective
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writing, cognitive behavioural therapy, autogenic training on guided imagery and compassion fatigue. Five studies evaluated Stress Management and Resiliency Training (SMART), of
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which three used a 90-minute SMART session, one used 12 weekly sessions and one used an 8-week web-based module.
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Three studies used interventions related to cognitive behavioural therapy. Gray (2016) used ‘salutogenic coaching’ to workplace wellbeing, which was developed specifically for those experiencing organisational transition. Jakel et al. (2016) evaluated a mobile application named the Provider Resilience Mobile Application (PRMA) to alleviate compassion fatigue amongst health professionals. Two studies evaluated resilience workshops designed for health workers. Vesel, Waller, Dowden, and Fotso (2015) evaluated components of Helping Health Workers Cope (HHWC) project and Noone and Hastings (2009) evaluated a one-day
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ACCEPTED MANUSCRIPT Promotion of Acceptance in Carers and Teachers (PACT) workshop, based on the principles of acceptance and commitment therapy. West et al. (2017) assessed a participant-developed intervention to improve resilience. Other studies evaluated various training and workshops such as self-reflection, self-regulation, relaxation, self-care, work related stress reduction
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strategies, and problem-focused learning.
Face-to-face group based training was the main mode of delivery (n=25). One study
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used one-to-one training. Six studies used virtual interventions of which four used web-based
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online training, one employed computer assisted resilience training and another a mobile
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application.
Twelve studies provided follow-up review sessions. Some studies had multiple follow-
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up with Magtibay et al. (2017) having one in person and another by telephone; Sood, Sharma, Schroeder, and Gorman (2014) had an optional session and two additional phone calls; Fortney,
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Luchterhand, Zakletskaia, Zgierska, and Rakel (2013) had 2 face-to-face group sessions, and,
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Rowe (2006) had four follow-up sessions. Follow-up particiption was generally low across the
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studies.
Thirteen studies involved home assignments in addition to the training sessions in
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which the participants practiced the skills and strategies learned during the workshops. The duration of resilience training ranged from a single one-hour session to one to two hours sessions over the course of 12 weeks. Eight studies had only one single session ranging from 1-hour to a whole day.
3.3 Outcome measures
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ACCEPTED MANUSCRIPT Most studies used multiple outcomes to assess the resilience intervention. Only 20 out of 33 studies measured resilience with the remainder using mental health symptoms as a proxy for resilience (Table 4).
Amongst the studies measuring resilience as an outcome, 15 studies used quantitative
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resilience measures, three used qualitative assessment and the remaining two used mixed methods. Fourteen studies used standard validated scales, with the 25-item version of the
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Connor-Davidson Resilience Scale (CD-RISC) being the most commonly used. Two studies
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used the 10-item version of CD-RISC and one used the 2-item version. Other standard resilience scales included the Brief Resilient Coping Scale (BRCS-4), Smith’s 6-item Brief
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Resilience Scale and the 14-item Resilience Scale. Three studies used non-validated resilience
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scales, with Everly, Lee McCabe, Semon, Thompson, and Links (2014) using a self-confidence questionnaire in a crisis context. Wald, Haramati, Bachner, and Urkin (2016) developed a
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questionnaire to evaluate professional resilience (post-intervention only), while Kemper and
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Rao (2017) rated self-reported resilience on a numeric rating scale.
Qualitative approaches (including mixed-methods) assessed the effectiveness of
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interventions in terms of whether participants were prepared to apply the intervention techniques learned (Wald et al., 2016), the impact of the program (Gray, 2016), understanding
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of resilience (Mealer et al., 2014), effectiveness of the intervention in relation to their personal resilience (G McDonald, Jackson, Wilkes, & Vickers, 2013), and workshop benefits and experiences (G. McDonald, Jackson, Wilkes, & Vickers, 2012).
Despite the availability of validated resilience scales, thirteen studies did not directly measure resilience. In addition, studies directly measuring resilience used additional nonresilience scales to assess mental health symptoms. As the focus was on the impact of interventions on resilience, we these findings are not reported in detail in the tables. In addition, 13
ACCEPTED MANUSCRIPT Rowe (2006) conducted correlation analyses and reported significant correlation of burnout with hardiness, stress, anxiety and coping style.
The frequency of outcome measurements ranged from one to seven. Three qualitative studies, one quantitative study and one mixed method study had a single post-intervention
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measurement. Fifteen studies had two outcome assessments, with 11 having both pre- and postintervention measurements. Four studies had assessments only at baseline and at follow-up.
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Twelve studies, in addition to pre- and post-intervention data, collected data at one or more
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follow-up points.
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While studies were not excluded based on the outcome of the quality appraisal in accordance with the exclusion criteria in this study, the appraisal identified some issues with Most of the studies did not evaluate baseline differences between the
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study quality.
intervention groups. Some RCTs did not fully report the randomization procedure, including
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blinding to treatment assignment. Loss to follow up was often not addressed in the statistical
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analysis. In addition, some studies often used self-selected convenience sampling with low
Table 5 about here
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sample size.
3.4 Effectiveness of the interventions
Baseline, post-intervention and follow-up resilience scores, and statistical differences are presented in Table 5. Amongst the studies measuring baseline and post-intervention resilience (n=16), 11 studies reported significant improvements in the resilience scores for the treatment group (Everly et al., 2014; Kemper & Khirallah, 2015; Kemper & Rao, 2017; Klatt, Steinberg, & Duchemin, 2015; Stefanie Mache, Bernburg, Baresi, & Groneberg, 2016; S. Mache, Vitzthum, Klapp, & Groneberg, 2015; Magtibay et al., 2017; Mealer et al., 2014; Sood, 14
ACCEPTED MANUSCRIPT Prasad, Schroeder, & Varkey, 2011; Werneburg et al., 2018; West et al., 2017). The remaining five studies (Chesak et al., 2015; Craigie et al., 2016; Fortney et al., 2013; Kemper, Lynn, & Mahan, 2015; Sood et al., 2014), although showing improvements in resilience scores, did not demonstrate statistically significant differences compared to baseline. Amongst the studies with a comparison group which reported resilience as an outcome measure, four RCTs reported
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a significant improvement in resilience compared to control (Klatt et al., 2015; Stefanie Mache
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et al., 2016; S. Mache et al., 2015; Sood et al., 2011), with the remaining RCTs (Chesak et al.,
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2015; Mealer et al., 2014; Sood et al., 2014) and a quasi-experimental study (Kemper et al., 2015) finding no significant difference compared to control.
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Six of the nine studies using CD-RISC reported a significant improvement in resilience
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(Klatt et al., 2015; Magtibay et al., 2017; Mealer et al., 2014; Sood et al., 2011; Werneburg et al., 2018; West et al., 2017); both studies using BRCS-4 reported significant improvements in
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resilience (Stefanie Mache et al., 2016; S. Mache et al., 2015); only one of two studies using
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Smith’s 6-item Brief Resilience Scale found significant difference in pre- and post-resilience scores (Kemper & Khirallah, 2015); while a study using Resilience Scale (RS-14) did not observe significant improvements in resilience (Fortney et al., 2013). Two studies using non-
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validated scales found significant improvements in resilience at post-intervention (Everly et al.,
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2014; Kemper & Rao, 2017).
In terms of type of resilience interventions, among the six mindfulness-based interventions reporting pre- and post- resilience scores, three reported significant improvements (Kemper & Khirallah, 2015; Klatt et al., 2015; Mealer et al., 2014). Similarly, three of five studies reported that SMART significantly improving resilience (Magtibay et al., 2017; Sood et al., 2011; Werneburg et al., 2018) and both of the cognitive behavioural therapy
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ACCEPTED MANUSCRIPT based interventions had a positive effect on resilience (Stefanie Mache et al., 2016; S. Mache et al., 2015).
In terms of mode of delivery, seven of eleven studies using face-to-face group-based training/workshops (Everly et al., 2014; Klatt et al., 2015; Stefanie Mache et al., 2016; S.
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Mache et al., 2015; Mealer et al., 2014; Werneburg et al., 2018; West et al., 2017) and three of four using online training (Kemper & Khirallah, 2015; Kemper & Rao, 2017; Magtibay et al.,
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2017) demonstrated improvements. One study (Sood et al., 2011) using one-to-one training
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also showed a significant improvement in resilience.
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Studies using qualitative approaches reported that workshops were beneficial to participants not only for understanding professional resilience but also to identify personal
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triggers for workplace stress and the importance of self-care. McDonald et al. (2012; 2013) reported personal gains, professional gains and personal resilience initiatives as outcomes of
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resilience training. The opportunity to work collaboratively with their peers outside of the
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pressure of the workplace had fostered more positive dynamics, removed the sense of hierarchy and promoted communication and different perspectives. This fostered a sense of a workplace
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that was more conducive to communication, which was integral to resilience. This study also noted the importance of self-care as a key mechanism to promote resilience, something that
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concurred with the findings of Wald et al. (2016). Being self-aware and adopting reflexive strategies were seen as tools in being pre-emptive against stress triggers and thereby becoming more resilient (Wald et al., 2016) and one’s own resilience was considered to affect the resilience of others, thus creating a flow-on effect (Gray, 2016). 4. Discussion This review aimed to analyse the effectiveness of resilience interventions in promoting resilience. The effectiveness of the interventions among the quantitative studies was assessed 16
ACCEPTED MANUSCRIPT based on improvements in resilience scores between pre- and post-intervention, and between intervention and control groups. Eleven (out of 16) studies showed a significant difference in resilience scores from pre- to post-intervention and five (out of eight) studies found a significant difference in resilience scores between the intervention and control groups. Findings suggest that training interventions may be of benefit to health professionals in improving
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resilience. Indeed, central to all the qualitative studies was the finding that it was participation
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in resilience workshops that had created self-awareness and greater understanding of the need
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for resilience, thereby promoting this as a particularly effective intervention. However, not all of the interventions enhanced resilience and the results are inconsistent. There were no specific
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patterns observed across the type of studies, characteristics of participants, nor mode of
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intervention delivery.
There were inconsistent findings in relation to duration of training, both in intervention
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duration and session duration. A trend was observed with interventions involving more training
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sessions being more likely to demonstrate significant improvements in resilience. For studies with less than eight intervention sessions (range one to six sessions), only three out of five studies showed significant improvement in resilience during post-intervention and one out of
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five studies demonstrated significant improvement in resilience during follow-up (follow up
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duration 1 to 9 months). For studies with eight or more sessions (range eight to 12), five out of seven studies had significant improvement in resilience during post-intervention and all the four (four out of four) studies had significant improvement in resilience during follow-up (follow up duration 3 to 6 months).
A similar trend was observed in terms of the duration of each training session, with interventions utilising longer duration being more likely to demonstrate significant improvements in resilience. Among the studies having an intervention length of 8 hours or less
17
ACCEPTED MANUSCRIPT (range 90 minutes to 8 hours), only three out of five had significant improvement in resilience during post-intervention and two out of five studies had significant improvement in resilience during follow-up (follow up duration 1 to 6 months). Among the studies having a total intervention length of more than 8 hours (9 to 24 hours), four out of six had significant improvement in resilience during post-intervention and three out of four studies had significant
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improvement in resilience during follow-up (follow up duration 3 to 9 months). Similar results
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were found for total duration of the intervention. In summary, the volume of training enhanced
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the effectiveness of resilience intervention among health professionals, whether by increasing the number of sessions, the intervention length or the total intervention duration. This suggests
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that short interventions for resilience may be ineffective for health professionals.
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There were mixed results regarding the sustainability of the effect of the intervention, with only five out of nine studies showing significant improvements in resilience scores at
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follow-up. Resilience interventions were more likely to have a sustained effect where the
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interventions had more sessions, longer interventions and extended duration. This finding is consistent with Rowe (2006) who reported that long-term approaches yielded ongoing reductions in stress and burnout. However, sustainability of resilience improvements was not
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found in this review to be associated with having follow-up sessions, with only two out of six
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studies with follow-up sessions having significant long-term improvement in resilience. These findings may be due to the follow up-sessions in many studies being optional (e.g. Sood et al., 2011; Sood et al., 2014) resulting in low attendance, however it is likely that sustained improvements in resilience may be more difficult to achieve than other related measures.
This review also noted that there was a lack of uniformity in how the researchers constructed resilience or the way the way that outcomes were measured. Although the included studies in this review aimed to assess resilience interventions, only 20 of the 33 included studies
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ACCEPTED MANUSCRIPT directly measured resilience with the remaining studies assessing mental health. This is noted elsewhere (Gemma, Merryn, & Karen, 2016) and as there is no universally accepted definition of resilience, there is no widely agreed set of criteria for defining a particular type of intervention that constitutes a resilience-promoting effort. This lack of definition then leads to a lack of uniformity in how resilience is approached as part of research. One of the issues in
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assessing resilience outcomes is whether resilience is a trait that supports coping mechanism
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or a coping mechanism itself. This variation is extremely important in assessing interventions
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as teaching coping mechanisms may or may not have an effect on resilience, depending on how it is defined.
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If mental health is considered a marker of resilience then this too can be problematic as
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a number of studies showed that mental health measures such as depression (Sen, Kranzler, Krystal, & et al., 2010), stress (Almedom & Glandon, 2007; Garmezy, 1991; Luthar, 1991) and
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burnout (Fortney et al., 2013) are not correlated with resilience. Our review found that
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interventions that demonstrate improvements in mental health such as depression, negative emotions, burnout and stress, did not always improve resilience (see e.g. Craigie et al., 2016; Fortney et al., 2013; Sood et al., 2014). The possible innate nature of resilience may impede
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the capacity to improve resilience by interventions. The question would therefore be whether
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the reverse is true, with improvements in resilience also leading to improvements in mental health. While there was no comparisons to non-health care settings in the studies, the baseline scores for mental health measures of burnout and stress are indicative of the demanding environments in which the studies were conducted.
4.1 Implications for research, policy and practice
One of the main aims of resilience research should be identifying, defining and measuring the construct of resilience in a clear and consistent manner, and setting agreed 19
ACCEPTED MANUSCRIPT boundaries for what constitutes a resilience building interventions. Resilience building interventions must evaluate resilience outcomes and future studies should consider the effectiveness of alternative methods such as online training, and electronic interventions (e.g. apps). Larger RCTs among representative samples with longer and alternative follow-ups are required and assessment of baseline differences between the intervention groups is essential.
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Methodological improvements in the studies such as proper designing and reporting of RCTs,
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adequate description on attrition, and adequate statistical analysis among RCTs including
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treatment effect analysis are advised.
This review suggests that interventions to promote resilience for health professionals
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require a significant time investment. Adapting programs to the local context and schedule may
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be important when designing resilience interventions. Prolonged and sustained effort to support ongoing practice is necessary to improve resilience among health professionals. Special focus
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should be provided to retain participants throughout the sessions including follow-ups.
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4.2 Limitations
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The limitations of this review include both the limitations inherent in the included studies as well as the limitations of the review methodology. Many studies had low sample size,
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which will likely have precluded the detection of significant differences. Self-selected convenience sampling used in most studies might also have prejudiced highly motivated groups to participate in the research creating positive selection bias. Low sample size, the absence of random sampling particularly among the RCTs, high attrition among the studies and differential attrition across the interventions make the results less reliable and difficult to generalise. As most of the studies were pilot studies, the effectiveness of the resilience interventions reported should be considered preliminary. Studies with interventions having external assessment and practice components had limited mechanisms to monitor adherence. 20
ACCEPTED MANUSCRIPT The review also did not distinguish between sub-specialities of health, which would have indicated whether resilience, stress or interventions differed based on the nature of the health care being provided. The variation in the studies in terms of participants, methods, intervention types and outcome measures precluded a meta-analysis.
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5. Conclusion
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This review suggests that resilience interventions with longer intervention length,
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session length and duration length are more effective. Resilience building requires continuous follow up and regular coaching and hence managing the time availability of health
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professionals may be challenging due to their busy schedule. What constitutes resilience building interventions and what constitutes resilience outcomes should be clearly defined in
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international resilience building literature. A universal definition of resilience is important for research as well as a program perspective. Rigorous RCTs with larger sample size and longer
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follow-up to assess the effectiveness of different types of resilience interventions in terms of
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optimum dosage, training content, and follow-ups with comparison between traditional faceto-face with virtual web based online training are needed. The results of the current review may
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inform resilience programs as well as future interventional studies on resilience building.
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stress levels, and interpersonal relationships. BMC Health Serv Res, 15 Suppl 1, S3.
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Wald, H. S., Haramati, A., Bachner, Y. G., & Urkin, J. (2016). Promoting resiliency for interprofessional faculty and senior medical students: Outcomes of a workshop using mind-body medicine and interactive reflective writing. Med Teach, 38, 525-528.
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Wang, S. M., Lai, C. Y., Chang, Y. Y., Huang, C. Y., Zauszniewski, J. A., & Yu, C. Y. (2015).
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K., . . . Sood, A. (2018). Improving Resiliency in Healthcare Employees. Am J Health Behav, 42, 39-50. doi:10.5993/AJHB.42.1.4
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West, M. M., Wantz, D., Shalongo, G., Campbell, P., Berger, K., Cole, H., . . . Cellitti, K. (2017). Evaluation of compassion and resilience in nurses: from evidence-based projects to research findings. Nursing and Palliative Care, 2, 1-7. Wood, A. E., Prins, A., Bush, N. E., Hsia, J. F., Bourn, L. E., Earley, M. D., . . . Ruzek, J. (2017). Reduction of Burnout in Mental Health Care Providers Using the Provider Resilience Mobile Application. Community Ment Health J, 53, 452-459. doi:10.1007/s10597-016-0076-5 Young, P. D., & Rushton, C. H. (2017). A concept analysis of moral resilience. Nurs Outlook, 65, 579-587. doi:10.1016/j.outlook.2017.03.009 27
ACCEPTED MANUSCRIPT Zhou, H., Peng, J., Wang, D., Kou, L., Chen, F., Ye, M., . . . Liao, S. (2017). Mediating effect of coping styles on the association between psychological capital and psychological distress among Chinese nurses: A cross-sectional study. J Psychiatr Ment Health Nurs,
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Figure 1: Flow diagram of studies identified, screened, assessed for eligibility, and included
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Was true randomization used for assignment of participants to treatment groups? Was allocation to treatment groups concealed? Were treatment group similar at the baseline? Were participants blind to treatment assignment? Were those delivering treatment blind to treatment assignment? Were outcomes assessors blind to treatment assignment? Were treatment groups treated identically other than the intervention of interest? Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed? Were participants analyzed in the groups to which they were randomized?
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JBI Question
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Table 1: JBI Critical Appraisal Checklist for randomized experimental studies
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Table 2: JBI Critical Appraisal Checklist for non-randomized experimental studies
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CASP Question
Is the qualitative
of the research
Are the aims stated clearly?
Is the research design
Does the data collection
Recruitment strategy
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Ye Ye Y N Ye Y N Ye nc Y Ye
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Table 3: CASP
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publication
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Gray. (2015), UK
Authors and year of
PT E Yes
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How valuable is the
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ACCEPTED MANUSCRIPT Table 4: Study characteristics Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To examine the impact of a worksite resilience training program on improving resiliency and health behaviors in healthcare employees
Quantitative , Singlearm, prepost test
Cognitive Behavioral Techniques SMART program 60-90-minute sessions per week, for 12 consecutive weeks
ConnorDavidson Resilience Scale
Perceived stress Anxiety Quality of life Health behaviors
Magtibay et al. (2017)
To assess efficacy of blended learning to decrease stress and burnout among nurses through use of the SMART program
Academic medical center staff N=159 assessed at baseline, 137 completed the program and 119 completed 3-month follow-up assessment Majority were female and > 40 years. Transplant nurses and nurse leaders N=50 (46F) Age: 24-63 years 45 participants completed the surveys at week 8, 40 at week 12, and 33 at week 24 Complete case analysis using last observation carried forward
Quantitative , Single arm, pre-post test
West et al. (2017) USA
To evaluate the effectiveness of a staff implemented activity plan as demonstrated by comparison of preand post-survey results
Cognitive Behavioral Techniques SMART program. Participants choose either web-based format, independent reading, or facilitated discussions or a combination. 12 modules over 8 weeks Additional two in-person (weeks 8 and 12) and two telephone (weeks 16, and 20) discussion sessions. Participants developed an activity plan to improve their levels of compassion and resilience. Once the activity plans were completed, they had two months to operationalize their respective activity plans.
SC
ConnorDavidson Resilience Scale
Happiness Stress Anxiety Mindfulness Burnout
ConnorDavidson Resilience Scale
Quality of Life (ProQOL-5) measuring Compassion Fatigue and Compassion Satisfaction
NU
MA
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PT E
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N=168 RNs and support staff (Licensed Practical Nurses, Unit Desk Clerks, Nursing Assistants, and Patient Access Representative s) 157 completed the postsurveys.
RI
PT
Author, year, country Wernebur g et al. (2018) USA
Quantitative , Singlearm, prepost test
39
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To assess the effect of online training in mind-body skills on immediate changes in relaxation, resilience, stress, affect, and overall flourishing
N=379 (322F) nurses, physicians, and other staff at academic health centre in Ohio State University (364 completed module 1, 158 module 2 and 140 module 3)
Quantitative , Singlearm, prepost test
Three one-hour online training module on selfreflections (1) Introduction to Stress, Resilience, and the Relaxation Response, (2) Clinical Effects of the Relaxation Response, and (3) Physiologic Effects of the Relaxation Response
Participants rated their resilience on a scale ranging from 0 (not at all) to 10 (extremely)
Relaxation and stress, Positive and Negative Affect, Diener’s 8item Flourishing scale
Wald et al. (2016) Israel
To evaluate the outcomes of an interprofessional, experiential, skillsbased workshop (IESW) fostering self-awareness, selfdiscovery, reflection, and meaning-making, potentially prevention/attenuati on of burnout and promoting resiliency
Mixed methods, Single-arm, Post test
A two-hour interactive professional development workshop focusing on burnout, resiliency, physiology of stress, and experiential sessions of (1) mind-body medicine (MBM) exerciseautogenic training and (2) interactive reflective writing (IRW)enhanced reflection exercise
A questionnair e evaluating understandin g of professional resiliency
Burnout
Mehta et al. (2016) USA
To test the feasibility of the Relaxation Response Resiliency Program (3RP - a program targeted to decrease stress and increase resiliency) for Palliative Care Clinicians
N=16 (8F) faculty members of medicine, nursing and basic sciences (including clinicians) and students. The workshop was a component of a weeklong interprofession al health care professions education forum developed for university students and faculty Age: 45 ±13.3 (range 28–70) years N=15 (12F) palliative physicians, nurses and social workers in an academic medical centre. Age: 44 ± 8.1 years
Relaxation Response Resiliency Program (3RP) mind-body program based on cognitive behavioural therapy and positive psychology. An initial fourhour introductory session followed by four two-hour education sessions for two months.
No specific measures of resilience
Self-efficacy, Relaxation Response (Perceived Stress Scale), Stress Awareness, Adaptive Strategies, Optimism, Satisfaction with life
SC
NU
MA
D
PT E CE
AC
RI
PT
Author, year, country Kemper and Rao (2017) USA
Quantitative , Singlearm, prepost test
40
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To evaluate a selfcare skills training with solutionfocused counselling to support psychiatrists in handling their daily work challenges
N=72 (51F) physicians working in psychiatric department from twelve hospitals in the North of Germany (37 treatment, 35 control) Age: 33 ± 2.3 years
Quantitative , RCT, pre-post test Single blinded
Resilient coping behaviour: German version of the ‘Brief Resilient Coping Scale’ (BRCS)
Selfperceived job stress, Selfefficacy, Job satisfaction, Quality of Relationship
Gray (2016) UK
To evaluate the impact of a coaching programme, designed to support staff working for the National Health Service (NHS) in the UK, to develop lasting resilience and wellbeing
N=5 staff working for the National Health Service in the UK
Qualitative, postintervention
Psychosocial skills training combined with cognitive behavioural and solution-focused counselling Focused on principles of self-care techniques (i.e., mindfulness and acceptance based), cognitive behavioural training and solution-focused group work 12 weekly sessions of 1.5 hours The control group received no training. Salutogenic coaching approach to workplace wellbeing program involving the principles of positive psychology, neuroscience, and pedagogy. Three parts: propositional knowledge relating to workplace stress and salutogenesis; one to one coaching using the salutogenic model and using the salutogenic model as a team.
AC
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SC
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PT
Author, year, country Mache et al. (2016) Germany
41
A qualitative questionnair e on impact of intervention on resilience
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To evaluate the outcomes of a pilot study of Aware Compassionate Communication: An Experiential Provider Training Series (ACCEPTS) for Palliative Care Providers.
N=21 (17F) nurses, physicians, social workers and other staff of local palliative care and hospice services Age: 53 (Range: 28 – 63) years
Quantitative , Singlearm, prepost test
No specific measures of resilience
Depression, Burnout, Posttraumatic stress, Experiential avoidance, Cognitive fusion
Jakel et al. (2016) USA
To evaluate the effect of the Provider Resilience mobile application (PRMA) will improve oncology nurses’ professional quality of life.
N=25F clinical nurses from an inpatient oncology unit at a medical centre in California Participants were nonrandomly allocated to the intervention (n=16) or control (n=9) group the control group. Age: 18–35 years
Quasiexperimenta l pre- and post-tests
MindfulnessBased Interventions and principles of Psychological Flexibility Theory ACCEPTS encompasses the principles of mindfulness and is tailored to the needs of providers who work with patients receiving palliative and hospice care to enhance psychological flexibility and communication. A group-based 8-week, 10session training series At baseline, the intervention and control groups received Compassion Fatigue education. The intervention group used the PRMA for six consecutive weeks. PRMA, which was developed by the Department of Defence to aid in alleviating CF. PRMA use was monitored for a six-week period via tracking software.
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Author, year, country Gerhart et al. (2016) USA
42
No specific measures of resilience
Quality of Life (ProQOL-5) measuring Compassion Fatigue and Compassion Satisfaction
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To evaluate Mindful Self-care and Resiliency (MSCR) Intervention aimed at reducing compassion fatigue and improving emotional wellbeing in nurses.
N=21(20F) nurses recruited from a large Western Australia teaching hospital Age: 48.6±9.9 (range 24 to 62) years
Quantitative , Singlearm, prepost test
ConnorDavidson Resilience Scale (CDRISC10)
Patient Health Questionnari e-9, PTSD, CAGE questionnaire , Quality of Life (ProQOL-5), DASS-21, Anxiety, Passion for Work
Vesel et al. (2015) Sierra Leone
To describe the effect of counselling and psychosocial training on coping skills, stress levels, and providerprovider and provider-client relationships.
Data from the Helping Health Workers Cope (HHWC) project Health worker employed in primary health care facilities. Intervention: N=129 health workers who had been engaged in the intervention Control: 157 health workers employed in similar cadres
MSCR intervention was a total of 12 hours intervention, comprised a 1day educational workshop on compassion fatigue (CF) resilience and introduction to mindfulness, followed by weekly mindfulness skills seminars for 4 weeks. The 1-day workshop comprised education about CF and its causes, and skills to build CF resiliency. The follow-up seminars aimed to learn mindfulness to support CF resiliency skills. The HHWC project aimed to improve coping techniques among health workers by addressing workplace stressors and introducing support services, and to improve interpersonal relationships between health workers and with clients. 10 groupcounselling sessions on stress management, self-care and client-care. Refresher training was provided to all health workers after nine months
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Author, year, country Craigie et al. (2016) Australia
Quasi experimenta l, mixed methods post-test
43
No specific measures of resilience
Quantitative survey on perceived stress, coping skills and relationships Qualitative data on job satisfaction, motivation, relationships and stress
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To investigate the feasibility of a psychosocial stress management and resilience training program for junior physicians. To assess the program for promotion of protective factors (such as resiliency) and job satisfaction and decreasing stress.
N=95 junior physicians specializing in different medical specialties (e.g., internal medicine, paediatrics, neurology, and gynaecology) 42 physicians (26F) treatment, and 43 (25F) controls. Age: 28 years
Quantitative , RCT, pre-post test
Brief Resilient Coping Scale (BRCS)
Perceived Stress, SelfEfficacy, Optimism and Pessimism, Job satisfaction, Copenhagen Psychosocial Questionnair e
Klatt et al. (2015) USA
To determine the feasibility/efficacy of Mindfulness in Motion (MIM) intervention in chronically high stress environment
Intensive Care Units (ICUs) N=34
Quantitative , RCT Wait-list control
The intervention group received 2 hours sessions per week for 12 weeks. Resilience training combined with cognitive behavioural and solution-focused counselling. The focus was on coping strategies, selfefficacy, communication, motivation, goal setting, improving emotional problems, etc. The control group received no training Mindfulness in Motion (MIM), a modified, short version of MindfulnessBased Stress Reduction (MBSR), delivered onsite. Focused on mindful awareness principles utilizing gentle yoga stretches and relaxing music. 8 weeks 1 hr/week, plus one 2 hr “retreat”.
AC
CE
PT E
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NU
SC
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PT
Author, year, country Mache et al. (2015) Germany
44
ConnorDavidson Resiliency Scale (CDRISC 10)
Work engagement
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To assess the impact of an online elective in mind-body skills (MBS) on clinicians’ mindfulness, empathy, compassion, and confidence in providing calm, compassionate care.
Quasi experimenta l, pre-post test
12 one-hour online modules organized in 4 general topics: (1) focused attention meditation (2) mindfulness meditation; (3) positive affect meditation and (4) guided imagery/hypnosi s
Smith’s 6item Brief Resilience Scale
Mindfulness, Selfcompassion, Confidence in providing calm, compassionat e care, Empathy, Compassion
Kemper and Khirallah (2015) USA
To evaluated the acute changes associated with completing a 1-hour online module in enrolees’ stress, mindfulness, resilience, or empathy
N= 218 (159F) Midwestern university incoming graduate students, residents and fellows. Online course on herbs and dietary supplements (HDS) or mind–body skills (MBS) training for resilience, effectiveness, and mindfulness Age: 28 years 103 completed post-training survey (60 engaged in MBS). N=513 dietitians, nurses, physicians, social workers, clinical trainees, health researchers and trainees (students, residents, and fellows)
NU
SC
RI
PT
Author, year, country Kemper et al. (2015) USA
AC
CE
PT E
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MA
Quantitative , Prospective cohort study, preport test
45
Up to 12 onehour online modules, 3 for each of 4 types of mind–body skills: (a) focused attention meditation (b) mindfulness, (c) guided imagery and hypnosis, and (d) positive affect– generating meditation.
Smith’s 6item Brief Resilience Scale
Perceived Stress, Mindfulness, Empathy, Burnout
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To examine outcomes of a brief Stress Management and Resiliency Training (SMART) program within a nurse orientation program.
N=55 (52F) nurses who were new to the institution or transitioning to a new unit or new role undergoing new nurse orientation. 27 treatment and 28 control of which 40 (19 in intervention and 21 in control) completed the study. Average age of 28.2 years
Quantitative , RCT pre-post test
ConnorDavidson Resilience Scale (CDRISC 25)
Perceived Stress, Mindful Attention Awareness, Anxiety
Johnson et al. (2015) USA
To investigate the potential effect of resilience training on symptom relief for current or recurrent depression, and other psychological/ behavioural outcomes
N=40 actively working clinically depressed health professionals at health centre. Aged 18–65 years. 20 (18F) treatment 20 (16F) controls
Quasiexperimenta l, wait-list control, prepost test The first 20 consecutive individuals assigned to training group and remaining 20 individuals placed on wait-list control group
A 90-minute session focused on stress and resilience, integrating neuroscience and biology, and mind-body approaches to managing stress. A 1-hour followup session after 4 weeks. Participants also received biweekly handouts on each of the topics via email. The control group received a lecture associated with the nursing orientation program. 2.5-hour weekly mindfulness meditation sessions for eight weeks. Focus on discovering and developing selfcare skills and advance personal capacity for well-being. Focused on mindfulness meditation practice, nutrition, and exercise recommendation s. Individualized guidance from a psychiatrist, an exercise physiologist, and a clinical nutritionist were also provided.
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Author, year, country Chesak et al. (2015) USA
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No specific measures of resilience
Depression, Perceived Stress, Anxiety, Workplace productivity, Healthpromoting behaviour
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To test the efficacy of a SMART program for decreasing stress and anxiety and improving resilience and quality of life among physicians.
26 (11F) radiologists at radiology department Intervention N=13 (5F), Age: 47.4±8.8 years Control N=13 (6F), Age: 48.1±5.2 years
Quantitative , RCT, wait-list controlled
ConnorDavidson Resilience Scale
Perceived Stress, Anxiety, Quality of life, Mindfulness
Everly et al. (2014) USA
To describe an approach (RAPIDPFA) and summarize training evaluation data to determine if relevant knowledge, skills, and attitudes are imparted to trainees to support effective psychological first aid (PFA) delivery.
N = 1218 (1194 analysed) trainees (clerical and support staff, administrators, health educators, health planners, nurses, security personnel, social workers, and professional volunteers).
Quantitative , Singlearm, prepost test
A single 90-min group session with two followup phone calls. Learners were also taught to cultivate and guide their interpretations by five higherorder principles: gratitude, compassion, acceptance, meaning, and forgiveness. In addition, participants were trained in a structured relaxation intervention. A 1-day (6-hour) workshop. The core content of the training adheres to the acronym, RAPID, : Reflective listening, Assessment, Prioritization, Intervention, Disposition Although not part of the RAPID acronym, all training sessions end with a module on “Self Care,” covering signs and symptoms of stress, and several techniques to manage them.
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Author, year, country Sood et al. (2014) USA
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Selfconfidence in resilience in a crisis context
Required knowledge to apply PFA Perceived self-efficacy: belief in one’s own ability to apply PFA techniques
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To determine if a multimodal resilience training program for ICU nurses was feasible to perform and acceptable to the study participants.
29 (27 analysed) ICU nurses who were scored negative for being resilient (CD-RISC 25 score 82 or less) randomized into treatement (14) and control (15); Majority were female
Quantitative , RCT, pre-post test
ConnorDavidson Resilience Scale (CDRISC)-25
PTSD, Anxiety and Depression, Burnout, Client/Patient Satisfaction
Potter et al. (2013) USA
To evaluate a resiliency program designed to educate oncology nurses about compassion fatigue.
14 (13 analysed) oncology nurses employed in an outpatient infusion cancer centre. Age: 43.9 (28 – 61) years
Two-day workshop on resilience, psychological distress, selfcare, mindfulness exercise and written exposure therapy. Participants exercised writing therapy (twelve 30minute sessions), MBSR (15 minutes at least 3 times per week), 30 to 45 minutes of aerobic exercise (at least 3 days per week), and participated in a event-triggered cognitive behavioral therapy session. A five-week compassion fatigue resiliency program involving five 90-minute sessions. Focused on selfregulation, learning to relax, intentionality, self-validation, connection, and self-care. Between the third and fourth weeks, a fourhour retreat was conducted offsite to allow participants to debrief and practice selfcare, including a healing arts program.
Quantitative , Singlearm, prepost test
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Author, year, country Mealer et al. (2014) USA
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No specific measures of resilience
Burnout, Quality of life, (ProQOLIV), Subjective distress, Job satisfaction
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To investigate whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians.
30 (18F) Primary care clinicians from departments of family medicine, internal medicine, and paediatrics. Age: 40.5±10.1 years 28 (93%) participants gave responses post-test and 23 (77%) gave responses for follow-ups (8 weeks and 9 months).
Quantitative , Singlearm, prepost test
Resilience Scale (RS14)
Job satisfaction, Quality of Life, DASS21, Perceived Stress, Compassion
Foureur et al. (2013) Australia
To pilot the effectiveness of an adapted mindfulness-based stress reduction intervention on the psychological wellbeing of nurses and midwives.
40 participants (20 midwives and 20 nurses) from two metropolitan teaching hospitals. Twenty-eight (70%) participants returned the post intervention surveys and 35% participated in qualitative interviews and focus groups.
Quantitative , Singlearm, prepost test
An abbreviated version of the mindfulnessbased stress reduction (MBSR) training program A total of 18 hours over 3 consecutive days on mindfulness practices and their application to practicing medicine and everyday life. Two follow-up sessions: 10 days after the end of the mindfulness training, and 2 to 3 weeks after the first follow-up. A one-day workshop on modified MBSR and 8 week daily meditation practice for 20 minutes The workshop focused on the impact of stress on being in the present moment, introduction to mindfulness, grounding and diffusion strategies, and forming habits.
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Author, year, country Fortney et al. (2013) USA
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No specific measures of resilience
General Health Questionnair e (GHQ-12), Sense of Coherence, DASS-14
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To assess the effects of a work-based, educational intervention to promote personal resilience in a group of nurses and midwives working in a busy clinical environment. To investigate the phenomenon of personal resilience in nurses and midwives.
14 female nurses and midwives at a women’s and children’s health service in a large, tertiary referral hospital aged range 26– 59 years
Qualitative, pre-post with followup
Effectivenes s of the workshops in relation to their personal resilience Qualitative
Effectiveness of the workshops in relation to their health and wellbeing.
Pipe et al. (2012) USA
To describe and report the outcomes of workplace stress management and resilience-building intervention that was implemented in a healthcare organization
N=44 oncology inpatient unit staff including nurses (n=29) and a selected group of hospital and clinic leaders, including clinical managers, supervisors and educators (n = 15) Age: 21 – 60 years
Quantitative , Singlearm, prepost test
Six resilience workshops and a mentoring programme conducted over a 6-month period. Focus on positive and nurturing relationships and networks; mentoring; positive outlook; hardiness; intellectual flexibility; emotional intelligence; life balance; spirituality; reflection; and critical thinking Two workshop sessions over 3weeks duration on coping and resilience. The first 5 hr session on ‘Transforming Stress’ focused on techniques for selfregulating stress The second 2 hr session was a reinforcement session. Theory of Human Caring Behavioural interventions that focus on improving selfregulation of physiological responses The programme also used heart rate variability feedback, to self-generate a healthier physiological state.
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Author, year, country McDonal d et al. (2013) Australia
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No specific measures of resilience
Personal and Organization al Quality (Personal and Organization al Quality Assessment‐ Revised)
ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
To evaluate the effect of workplace self-care educational intervention to develop, strengthen and maintain personal resilience to counteract the negative experiences associated with workplace adversity.
N=14F nurses and midwives Age: 26 – 59 years
Qualitative, Single arm, Post test
Qualitative
Sood et al. (2011) USA
To assess a SMART program for increasing resiliency and quality of life, and decreasing stress and anxiety among Department of Medicine physicians at a tertiary care medical centre.
Quantitative , Randomized wait-list controlled trial, prepost test
Aiello et al. (2011) Canada
To describe the development, implementation, and results of resilience training prior to the emergence of the H1N1 pandemic and how this preparatory training would link to supportive psychosocial efforts during a pandemic.
N=40 (19F)academic medical centre staff Treatment: N=20 (9F), Age: 46.8± 8.3 years, (20 analysed ) Control: N=20 (10F), Age: 50.2±5.7 years (12 analysed) 1250 hospital staff from 22 departments 1020 (82%) analyzed
Resilience workshop Six 90-minute sessions one in each month for 6 months on work based self-care focusing mentoring relationships, building Hardiness, Maintaining a positive outlook, reflective and critical thinking Workshop. A single 90minute one-onone training in SMART on attention, relaxation (deep breathing); optional 30-60 minute followup session Cognitive Behavioral Techniques Resilience workshop A one-hour training session (5 to 50 staff in attendance) on influenza pandemics, stress, coping strategies and organizational resilience
Other measures
SC
Connor Davidson Resilience Scale (CDRS)
Perceived Stress, Anxiety, Quality of life, Fatigue
No specific measures of resilience
Post-session feedback surveys (8items)
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Quantitative , Single arm, Post test
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Author, year, country McDonal d et al. (2012)
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ACCEPTED MANUSCRIPT Objectives
Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To test three versions of an interactive, computer-assisted training course (short, medium and long) designed to build resilience to the stresses of working during a pandemic.
158 hospital workers (136F, 85 nurses) randomly assigned to the short (7 sessions, 111 minutes), medium (12 sessions, 158 minutes) or long (17 sessions, 223 minutes) version. 127 (80%) completed
Quantitative , 3 arm RCT, pre-post test
No specific measures of resilience
Pandemic SelfEfficacy, Interpersonal problems, Coping Inventory: problemsolving and seeking support
Noone and Hastings (2009) UK
To pilot test a work stress acceptance intervention (Promotion of Acceptance in Carers and Teachers - PACT) for intellectual disability services support staff
N=28 (23F) support staff working for an independent community service domiciliary care and support for people with an intellectual disability Age: 37.43±10.0 years 14 attended follow-up sessions
Quantitative , Pre-post test
Participants were provided with a computer flash drive containing the course and instructions for administering the training The topics included: pandemic, resilience, psychological first aid, coping approaches, active listening, balancing family and work, danger signals and resources for getting help, relaxation skills. A one-day PACT workshops followed by a half-day followup booster session after 6 weeks PACT workshop was based on the principles of acceptance and commitment therapy
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Author, year, country Maunder et al. (2010) Canada
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No specific measures of resilience
General Health Questionnair e (GHQ–12), Stress
ACCEPTED MANUSCRIPT Settings and participants
Study design
Intervention modality
Resilience measures
Other measures
To examinine the relationships between stress and coping and explore both short- and long-term approaches to behavioural change. To examine the relationship between stress and coping.
N=126 Health care professionals (nurses, clinical staff, administrators, psychologists, social workers) were randomly assigned to 3 groups (shortterm, longterm, control). Age: 38.2± 7.6 years
Quantitative , 3 arm RCT, pre-post test
Group 1 were exposed to a stress management/ adaptive coping training, 1 time per week for 90 minutes for a duration of 6 weeks. Subjects in Group 2 were exposed to the same 6 week training condition as those subjects in Experimental 1 Group, but in addition were given a 1-hour "refresher" session at 5 months, 11 months, and 17 months. Subjects in the control group received no training.
Hardiness but not reported
Anxiety, Stress, Burnout, Coping Style
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Objectives
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Author, year, country Rowe (2006) USA
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ACCEPTED MANUSCRIPT Table 5: Effect of intervention for studies reporting resilience outcomes Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Wernebu rg et al. (2018) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Quantitative Pre, post and 3 months post intervention follow-up
12 sessions 12 weeks 60-90 minutes each
65.3 (11.5)
Magtiba y et al. (2017) USA
ConnorDavidson Resilience Scale (CDRISC 2), (2 items, range 0-8)
Quantitative At baseline (week 0), postintervention (week 8) and, weeks 12 and 24
6.2 (1.1)
West et al. (2017) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Quantitative Baseline and two months
8 weeks 12 sessions Follow up: in person and telephone at weeks 8, 12, 16, and 20 1 session for development of activity plan 2 months for implementat ion of the plan
Kemper and Rao (2017) USA
Resilience Numeric Rating Scales (010)
Postinterventi on Mean (SD) 76.1 (12.0)**
Relevant outcomes
78.5 (11.2) ** 3 month s
Statistically significant (p<0.01) improvements in resilience at the end of the intervention and extending to 3 months follow-up. Significant improvement in resilience score at 12 week and 24 week follow up, but not in post-test (8 week)
6.7 (1.2)* * 24 weeks
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6.3 (1.2)
Follo w-up Mean (SD)
PT
Study Country Title
74.2 (11.8)**
No follow up
6.9 (1.8)**
No follow up
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70.6 (12.8)
Online training 3 hours
6.3 (2.1)
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Quantitative Pre, post
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Staff who participated in the study by completing activity plans improved their level resilience. Self-developed activity plan can improve resilience. The change must come from within and nurses must identify the actions that work for them as individuals. Completing modules was associated with significant improvements in relaxation, resilience, stress, positive and negative affect, and flourishing (all p<0.01). Online focused attention meditation training is associated with improvements in relaxation, resilience, stress, affect, and flourishing.
ACCEPTED MANUSCRIPT Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Wald et al. (2016) Israel
Participants reporting that they better understand concepts of professiona l resiliency
Mixed methods Quantitative: post workshop questionnaire Qualitative: postintervention reflective workshop
1 session of 2 hour
-
Mache et al. (2016) Germany
‘Brief Resilient Coping Scale’ (BRCS), (4-item, range 4-20)
Quantitative: Before receiving the first training session (baseline), after 3 months (follow-up 1) and after 6 months (follow-up 2).
12 week, 12 sessions each of 1.5 hr
Postinterventi on Mean (SD) 3.93 (0.92)
Follo w-up Mean (SD)
Relevant outcomes
-
Participants reported better understanding of professional resiliency and felt better prepared to use meditation and reflective writing as coping tools. Reflective writing themes identified include experiencing/grapp ling with a spectrum of emotions (positive and negative) as well as challenge and triumph within clinical and teaching experiences as professionally meaningful. Significant improvement in perceived stress, resilience and selfefficacy in the intervention group, and persisted significant at both follow-ups when compared to control group. Mean change from baseline to first follow-up was +6.6 (treatment) versus +0.7 (control) and to second follow-up was +4.0 versus +1.9.
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59.8 (18.1)*
57.2 (17.2) * 6 month s
ACCEPTED MANUSCRIPT Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Postinterventi on Mean (SD) NA
Follo w-up Mean (SD)
Relevant outcomes
Gray (2016) UK
‘Wellbeing frames’ Impact of resilience and wellbeing programme on the participants , workplace and delivering project.
Qualitative: phenomenolog ical case study Data was collected during the three-part programme Post completion of the programme, a qualitative questionnaire (N=5) elicited impact of the programme.
No information of dose, duration and follow up
NA
NA
The programme achieved impact at micro (individual), meso (peer) and macro (team) levels, and in so doing served as a self-help tool for participants to manage a very stressful working environment, and remain engaged with delivering a high profile change in service delivery. Sustaining interdependence and interconnectedness is better achieved if the team have a tool to monitor team wellbeing and provide proactive support. No significant improvements for resilience from pre-test to post-test or at 1-month follow-up.
Craigie et al. (2016) Australia
ConnorDavidson Resilience Scale (CDRISC-10), (10-item, range 0-40) Resilience: Brief Resilient Coping Scale (BRCS)
Pre, post, and 1-month follow-up.
1 session 8 hours 4 weekly follow up sessions group based
28.2 (5.69)
29.6 (5.17)
28.7 (5.83) 1 month
12 week, 12 sessions each of 2 hr
54.3 (17.3)
61.8 (18.4)**
61.5 (17.9) ** 6 month s
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Significant improvement in resilience, in the intervention group at post intervention and follow-up compared to the control group. Mean change from baseline to first follow-up was +7.5 (treatment) versus -0.3 (control) and to second follow-up was +7.2 versus 0.2.
ACCEPTED MANUSCRIPT Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Klatt et al. (2015) USA
ConnorDavidson Resiliency Scale (CDRISC 10)
Baseline: 1 week before the intervention and post-test 1 week after the last session
8 weeks 8 sessions 1 hour each One follow up of 2 hours
Not reporte d
Kemper et al. (2015) USA
Smith’s 6item Brief Resilience Scale Range 6-30
Quantitative Pre and post training survey
Online 12 weeks 12 hour sessions in total
3.0 (0.2)
Kemper and Khiralla h (2015) USA
Smith’s 6item Brief Resilience Scale Range 6-30
Quantitative Pre and post training survey
Chesak et al. (2015) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Postinterventi on Mean (SD) Not reported
Follo w-up Mean (SD)
Relevant outcomes
Not reporte d
Significantly imporvement between pre- and post-intervention (112.9% change from baseline, p = 0.02), but the scores were not reported. Participants value institutional support, relaxing music, and the instructor as pivotal to program success. No significant differences in resilience scores between the participants in MBS group and others. Changes in item mean scores from pretraining to posttraining: 0.06±0.3 (not significant) Resilience improved significantly among the participants in the Mindfulness in Daily Life module but not for the Introduction to Stress, Resilience, and the Relaxation Response module Resilience scores improved in the intervention group and declined in the control group, but the changes were not significant between the groups.
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22.4 (4.3)
23.3 (4.4)**
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1 session 90 minutes 1 follow up at four weeks
79.68 (9.59)
-
79.74 (11.82 ) 12 weeks
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Baseline and 12 weeks following the intervention
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Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Postinterventi on Mean (SD) -
Sood et al. (2014) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Quantitative Baseline and 12-week post intervention
1 session 90 minutes 2 follow telephone calls
70.0 (12.8)
Everly et al. (2014) USA
Confidence in one’s own resilience in a crisis context (3 items)
Quantitative Pre-post assessments
1 day, 6 hour session
3.81 (0.74)
Mealer et al. (2014) USA
ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Mixed Quantitative: Pre-post test Qualitative: interpretive qualitative approach for analyzing writing examples
2 day workshop 12 week intervention
Follo w-up Mean (SD)
Relevant outcomes
73.0 (11.5) 12 weeks
Resilience improved in the follow-up, but the difference was not statistically significant; also, the changes were not significant when compared to the control arm. Statistically significant improvements in self-confidence about being a resilient Psychological First Aid provider. Both the intervention and control groups had a significant improvement in resilience scores, but the change did not differ significantly between the intervention and control groups. Major themes identified in the written exposure sessions were patient centric (death and dying, justice, interactions with patient and family), cognitive processing (rumination, guilt, and regret), work structure (understaffing, cumulative stress), and workplace relationships (conflict with peers, personal and professional boundaries).
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4.28 (0.64)***
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78* (median)
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ACCEPTED MANUSCRIPT Outcome measurem ent
Assessment and follow-up
Training duration
Baseli ne Mean (SD)
Fortney et al. (2013) USA
Resilience Scale (RS14) (Range: 14-98)
3 days of 18 hours 2 follow-up sessions 2 to 3 weeks
79.9 (95% CI, 75.284.6)
McDona ld et al. (2013) Australia
Qualitative: effectivene ss of the workshops in relation to their health, wellbeing and personal resilience.
Quantitative online survey At 4 points (baseline, and 1 day, 8 weeks, and 9 months post intervention) Qualitative: face-to-face, semistructured interviews Pre, post and 6 months’ postintervention follow up.
day full day workshop Mentoring for 6 months
NA
McDona ld et al. (2012) Australia
Post interventio n interviews at the end of each workshop on comments on workshop experiences and benefits. ConnorDavidson Resilience Scale (CDRISC), (25item, range 0-100)
Postinterventi on Mean (SD) 82.0 (95% CI, 77.186.8)
Relevant outcomes
81.4 (95% CI, 76.286.6) 9 month s NA
No significant improvement in resilience scores at post-test and follow-ups
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Follo w-up Mean (SD)
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6 months, 90-minute session in each month
NA
NA
NA
Participants reported increased personal resilience by adopting the self-care and reflexive strategies learned from the workshop
one-on-one training 1 session 90minute Optional follow up
69.6 (13.3)
-
79.4 (11.3) * 8 weeks
Significant improvement in resilience at 8 weeks follow-up in study arm compared to the wait-list control
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Sood et al. (2011) USA
Baseline and week 8 post intervention
The intervention benefited personal and professional areas of the participants by enhancing confidence, selfawareness, assertiveness and self-care. Three major themes emerged in relation to the effects of the intervention: personal gains from resilience workshops; professional gains from resilience workshops; and personal resilience initiatives.
Higher scores indicating greater resilience
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Figure 1