The Community Resiliency Model® to promote nurse well-being

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The Community Resiliency ModelÒ to promote nurse well-being Linda Grabbe, PhD, FNP-BC, PMHNP-BCa,*, Melinda K. Higgins, PhDa, Marianne Baird, MN, RN, ACNS-BCb, Patricia Ann Craven, BSN, RNc, Sarah San Fratello, BSN, RN, CCRNb a

Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA b Emory Healthcare, Atlanta, GA c Children’s Healthcare of Atlanta, Atlanta, GA

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Article history: Received 19 June 2019 Received in revised form 28 October 2019 Accepted 10 November 2019

Keywords: Nurse Well-being Resilience Burnout Secondary Traumatic stress Randomized Controlled Trial

ABSTRACT Background: Rising rates of secondary traumatic stress and burnout among nurses signal a crisis in healthcare. There is a lack of evidence regarding effective interventions to improve nurse well-being and resiliency. Purpose: This study used a randomized controlled trial parallel design to test the effectiveness of a 3-hour Community Resiliency ModelÒ (CRM) training, a novel set of sensory awareness techniques to improve emotional balance. Methods: Registered nurses in two urban tertiary-care hospitals were invited to participate, which entailed attending a single 3-hour “Nurse Wellness and Wellbeing” class; 196 nurses consented and were randomized into the CRM intervention or nutrition education control group to determine if the CRM group would demonstrate improvement in well-being and resiliency, secondary traumatic stress, burnout, and physical symptoms. Findings: Pre/post data were analyzed for 40 CRM and 37 nutrition group members. Moderate-to-large effect sizes were demonstrated in the CRM group for improved well-being, resiliency, secondary traumatic stress, and physical symptoms. Participants reported using CRM techniques for self-stabilization during stressful work events. Conclusion: CRM shows promise as a brief resiliency training for hospital-based nurses. Cite this article: Grabbe, L., Higgins, M.K., Baird, M., Craven, P.A., & San Fratello, S. (2019, xxx). The Community Resiliency ModelÒ to promote nurse well-being. Nurs Outlook, 00(00), 1 13. https://doi.org/ 10.1016/j.outlook.2019.11.002.

Secondary stress, compassion fatigue, and burnout among nurses are threats to our health care system, the patients that it serves, and the nurses themselves. As primary providers of care, nurses hold a critical role in the quality of patient outcomes (Chau et al., 2015).

Because nurses experience high levels of burnout, sickness-related absenteeism, and leaving the profession, many healthcare organizations and nursing educational institutions are acutely aware of the well-being of the nursing workforce and interventions to support

Funding: Sigma Theta Tau and the Mundito Foundation. *Corresponding author: Linda Grabbe, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA 30322. E-mail address: [email protected] (L. Grabbe). 0029-6554/$ -see front matter Ó 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.outlook.2019.11.002

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wellness and professional satisfaction (Chesak, Cutshall, Bowe, Montanari, & Bhagra, 2019; Pipe et al., 2012; Virkstis, Herleth, & Langr, 2018). Professional nursing organizations, such as the American Nurses Association’s with its “Healthy Nurse, Healthy Nation” challenge, are calling on nurses to take control of their well-being in order to be educators, advocates, and role models of health, safety, and wellness for the general population (American Nurses Association, 2019). The American Nurses Association defines a healthy nurse as one who is able to maintain a balance and synergy of physical, intellectual, emotional, social, spiritual, personal, and professional well-being. Although “wellness” refers to physical health, “wellbeing” is a more global and holistic perspective on whole-of-life experience. Well-being has been described by the Centers for Disease Control and Prevention (CDC) as fulfillment, positive functioning, satisfaction with life, the presence of positive emotions, and the absence of negative emotions (CDC, 2018). Maintenance of mental health and well-being is of particular importance for nurses because of their intense work-related stress and the responsibility of caring for others. Under the challenging conditions of their work, nurses may experience secondary traumatic stress (STS). If their well-being is compromised, they may experience compassion fatigue, moral distress, burnout, illness, and absenteeism (ChristodoulouFella, Middleton, Papathanassoglou, & Karanikola, 2017). In addition to illness and absenteeism, nurses who work with impaired mental or physical wellbeing, exhaustion, or depression may also display “presenteeism” (reduced on-the-job productivity as a result of health problems), which has personal and professional costs, such as difficulty concentrating or making mistakes (Letvak, Ruhm, & Gupta, 2012). The need for attention to nurse mental wellness and wellbeing is more than underscored by recent suicides among nurses (Davidson, Zisook, Kirby, DeMichele, & Norcross, 2018, Davidson, Mendis, Stuck, DeMichele, & Zisook, 2018; Rizzo, 2018). Health care organizations are fully aware of the diminished job satisfaction, productivity, quality of care, safety, and job performance that come with compromised nurse well-being (Virkstis et al., 2018). Burnout among nurses has been shown to be significantly associated with patient harms, such as urinary tract and surgical site infections. When burnout is reduced, rates and costs of hospital infections drop, with substantial financial savings to institutions (Cimiotti, Aiken, Sloane, & Wu, 2012). Because of their exposure to pain, suffering, and secondary stress, many nurses simply decide to leave nursing, even within the first € , 2015), and two years of practice (Flinkman & Salantera healthcare institutions must grapple with turnover and short staffing. Attrition of nurses in healthcare organizations further aggravates nurse stress because of work overload and “voluntary” overtime demands. Ample literature addresses STS, burnout, and compassion fatigue among nurses, but there is a paucity of

rigorous studies to guide nurse leaders to the most effective and efficient means to enhance nurse resistance to stress (Cleary, Kornhaber, Thapa, West, & Visentin, 2018). This study aimed to test a novel, one-time resiliency intervention, the Community Resiliency ModelÒ or CRM, with hospital-based registered nurses in a Southeastern city in the United States. CRM is a simple, innovative, self-care program that provides a biological perspective on mental health and stress reactions. Mental well-being is enhanced through the use of sensory awareness skills (Miller-Karas, 2015). CRM is not therapy, but is based on the well-established psychotherapy approach of Somatic Experiencing, which uses body sensation perception to treat traumarelated symptoms (Levine, 1997; Payne, Levine, & Crane-Godreau, 2015). CRM was developed by Elaine Miller-Karas et al., Geneie Everett, and Laurie Leitch during their work in disaster zones using Somatic Experiencing techniques with disaster survivors (Miller-Karas, 2015). Under disaster conditions, trauma processing psychotherapy was not possible, but the stabilizing, sensory-awareness techniques of Somatic Experiencing could be taught quickly, even in a single encounter. Research on the techniques of CRM and its Somatic Experiencing antecedents demonstrated a lowered incidence of post-traumatic stress disorder (PTSD), reduced depression, improved well-being, and continued skill application among both disaster survivors and providers of care, as well as persons with chronic trauma exposures (Citron & Miller-Karas, 2013; Leitch, 2007; Leitch & Miller-Karas, 2009; Leitch, Vanslyke, & Allen, 2009; Parker, Doctor, & Selvam, 2008). However, CRM’s research base is limited because it is so new and, to date, there are no randomized trials of the model. CRM is part of a broader movement of mindfulness (the intentional awareness of present-moment thoughts, emotions, sensations, and other internal or external stimuli), which promotes a sense of calm and has demonstrated utility as treatment and prevention of depression, anxiety, PTSD, and addiction (Lang, 2017; Rodrigues et al (2017); Tang, Tang, & Posner, 2016; Williams, Teasdale, Segal, & Kabat-Zinn, 2007). CRM is a novel and noncognitive variant of mindfulness, which uses awareness of sensations in the body as a vehicle for emotional regulation. Body sensation awareness is called interoception or “felt-sense,” and may be the most fundamental form of mindfulness, because of its unique focus on the physical. Awareness of internal body sensation occurs in the insular cortex and adjacent brain structures, which appear to be the hub for emotional regulation, flexible behavior, empathy, social interaction, and sense of self (Gogolla, 2017). Sensory awareness with attention control may provide a direct means to counteract or reduce emotional distress € lzel, & Posner, 2015). CRM teaches six skills to (Tang, Ho enhance attention control while tracking body sensations before and after using the techniques. The techniques may preventatively attenuate the immediate

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impact of stress and trauma. If nurses integrate CRM skills in personal and work life, those with secondary stress and burnout may also experience a healing effect. By experiencing and intentionally lingering with pleasant or neutral sensations for as little as 12 seconds, a new, positive, neural pathway can be embedded in long-term memory, according to Hanson (2013).

Purpose The aim of this study was to investigate stress and wellbeing in a sample of hospital-based nurses and determine if a short resiliency intervention focusing on sensory awareness, would impact their capacity to tolerate stress.

Research Questions

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healthy, and adaptive (exercising, journaling, praying) coping techniques. Others may respond with unhealthy and maladaptive behaviors (self-harm, substance use, violence, dissociation, sleep problems), which may aggravate the dysregulation further. It is possible to get “stuck” outside of the Resilient Zone in a hyper- or hypoaroused state with symptoms akin to anxiety (stuck on high) or depression (stuck on low). Enhanced sensory awareness using CRM techniques provides learners with an internal sense of their “best self,” along with identifying individual triggers for loss of control of their emotional response to stress and trauma. CRM self-regulation skills may help to widen the Resilient Zone over time, or help to return to the Resilient Zone balance, when we notice that we are out of the Resilient Zone and use the skills to access a restorative parasympathetic state.

1. What are the characteristics of well-being, resil-

iency, secondary traumatic stress, burnout, and physical symptoms in a population of hospitalbased nurses? 2. What is the effect over time of a single 3-hour CRM class on the well-being, resiliency, secondary traumatic stress, burnout, and physical symptoms of nurses when compared to an active control group?

Theoretical Basis for the Intervention The key theoretical concept in CRM is the “Resilient Zone,” an internal state of balance where we are at our best, able to learn, solve problems, and work effectively with others. The undulating line in Figure 1 represents the autonomic nervous system with sympathetic dominance on the upswing (energy expenditure) and parasympathetic dominance (energy restoration) on the downswing. In the Resilient Zone or “OK” Zone, an individual is emotionally stable and capable of adapting to challenges or learn from them. Everyone has a Resilient Zone, but external or internal stressors or trauma may lead to being thrust out of the Zone (Figure 2) by excess sympathetic or parasympathetic discharge. The Resilient Zone becomes narrowed easily with fatigue, illness, hunger, or pain, but thanks to the body’s homeostatic mechanisms, energy and connection can usually be restored. Some people have a naturally wide or narrow Resilient Zone, which translates to different levels of stress tolerance. To cope, some may initiate self-soothing,

Figure 1 – The Resilient Zone. Reprinted with permission from the Trauma Resource Institute.

Methods Description of Sample Participants were a convenience sample of nurses who responded to an email invitation to participate in a “Nurse Wellness” study. The invitation was sent to all 1,600 registered nurses employed at two large, urban tertiary care hospitals. One hundred ninety-six nurses responded to the invitation, signed the informed consent and completed a baseline survey on well-being and stress. These participants were then randomly placed in either the intervention or control group. The mean age of the nurses was 45.3 (median = 47) years, and their mean years of nursing experience was 17.7 (median = 17). Ninety-five percent of the 77 class attendees were female and came from a wide variety of hospital settings, including the emergency department, operating room, intensive care units, specialty units, out-patient clinics, and medical-surgical units. No other demographic information was collected.

Materials The pre-post survey included five previously validated measures: the WHO-5 Well-being Index (WHO-5), the Connor Davidson Resilience Scale-10 (CD-RISC), the Secondary Traumatic Stress Scale (STSS), the Copenhagen Burnout Inventory (CBI), and the Somatic Symptom Scale-8 (SSS-8). In addition to quantitative measures, we gathered evaluation comments from the participants immediately after their sessions regarding what they liked best or least about the class. Post-test surveys were collected at 1 week, 3 months, and 1 year after the class. A questionnaire was attached to each of the posttest surveys asking about frequency of skill use, sharing skills/knowledge with others, and examples of application at work.

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Figure 2 – Stressful and traumatic events and triggers. Graphic adapted by Elaine Miller-Karas from an original graphic by Levine/Heller. Reprinted with permission from the Trauma Resource Institute.

Measures The WHO-5 Well-being Index (WHO-5) includes five Likert-type items, where 0 = no time, and 5 = all of the time that assess well-being in the previous 2 weeks. This previously validated measure and reliable screen for depression and has been used as an outcome measure for clinical trials in multiple fields of study (Topp, Østergaard, Søndergaard, & Bech, 2015). Total scores range from 0 to 25, representing the worst possible well-being and best possible well-being, respectively. Scores are then multiplied by 4 to rescale the total from 0 to 100. Mean substitution within subject may be used if 20% or less of the items (1 of 5) is missing. A score of 50 or less is indicative of reduced well-being, and less than 29 may suggest clinical depression (Topp et al., 2015). Reliability in the current study was good (a = 0.90). The Connor Davidson Resilience Scale-10 (CD-RISC) is a 10-item clinical measure that examines stress tolerance and resilience in the previous month (CampbellSills & Stein, 2007). The CD-RISC is a validated measure of resilience, a predictor of treatment outcome, and a measure of biological (i.e., physical) changes in the brain. The scale may be used to screen people for high, intermediate, or low resilience (Davidson, 2018). Ten Likert-type items are based on how true each has been over the past month, where 0 = not true at all and 4 = nearly always. Total possible scores range from 0 to 40, where 0 indicates low resilience and 40 indicates highest possible resilience. Mean substitution within subject may be used if 7 of 10 items were completed (Davidson, 2018). Reliability in the current study was good (a = 0.89). The Secondary Traumatic Stress Scale (STSS) measures secondary trauma symptoms and has high levels of internal consistency and reliability, and convergent, discriminant, and factorial validity (Bride, 2007). This 17-item Likert-type scale asks how frequently each item

was true in the past seven days, where 1 = never and 5 = very often. Three subscales for symptoms related to intrusion, avoidance, and arousal are calculated; their sum is the total score; a higher total score indicates more secondary trauma. Range of total STSS is from 17 to 85. Mean substitution within subject may be used if < 20% of items is missing and no more than one item missing in each of the three subscales (B. Bride, personal communication. April 1, 2019). A cutoff score of 38 or higher was established among social workers to suggest that individuals are experiencing post-traumatic stress disorder (PTSD) (Bride, 2007). Additional scoring was provided to determine how many PTSD criteria were met for Intrusion (Criterion B), Avoidance (Criterion C), and/or Arousal (Criterion D) (Bride, 2007). Reliability in the current study was good(a = 0.92). Work-related burnout was measured with the Copenhagen Burnout Inventory (CBI), a scale that asks about symptoms of physical or psychological exhaustion and cognitive fatigue which individuals attribute to their workplace (Borritz et al., 2010; Kristensen, Borritz, Villadsen, & Christensen, 2005). The scores are a mean of the seven items (reversing item 7), and are scaled from 0 to 100. Average scores are considered valid if 4 of 7 items are completed (i.e., mean substitution within subject allowed if 3 items or fewer are missing) (T. Kristensen, personal communication. March 10, 2019). The CBI also has personal- and clientrelated subscales; only the work-related subscale was used in the current study. Scores designated by the scale’s originator allow for categorization into reference ranges, in which scores = 50 indicate “none to a low degree,” or a better psychosocial work environment and scores = 75 indicate “high to a very high degree,” signifying a poor work environment. Reliability in the current study was good (a = 0.91). The Somatic Symptom Scale-8 (SSS-8) is a valid and reliable 8-item scale measuring somatic symptoms

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burden (Gierk et al., 2014). Nurses were instructed to select responses based on how frequently the symptoms bothered them in the past 7 days, where 0 = not at all and 4 = very much. Scores were the sum of item responses, and could range from 0 to 32. In the case of missing items, prorated scoring was used (similar to the PHQ-15 from which the SSS-8 is derived) as long as no more than 25% (2 of 8) of items were missing (Gierk et al., 2015). Categorization of scores as suggested by the scale developer allows for cut points that indicate none to mimial (0 3), low (4 7), medium (8 11), high (12 15), or very high (16 32) somatic symptom burden (Gierk et al., 2014). Reliability in the current study was good( a = 0.82).

Design The steps of the randomized controlled trial (RCT) are represented in the CONSORT (Consolidated Standards of Reporting Trials) flow diagram (Boutron et al., 2017) in Figure 3. This RCT was a collaboration between the two hospital nursing departments and the affiliated university School of Nursing. Permission to conduct the study was

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obtained from the hospital’s nursing research committees and the university’s institutional review board.

Procedure Participants in the intervention group attended a 3hour class CRM psychoeducation/sensory awareness skills training class, and the control group attended a 3-hour class on nutrition/healthy eating. The classes were similar in level of participation and interaction, and matched in style and use of resources. Both of the classes used lecture, active engagement, discussion, demonstration, and participation, for example, identification of “comfort foods,” “teach back” of the brain model by participants, skills stations, and various active experiences, such as mindful eating. The CRM intervention group could access the free CRM “ichill” app after the class, and the nutrition group learned to use the user-friendly, free “My Plate” app. The CRM class was provided by two of the authors (Grabbe and Baird) who are Certified CRM Teachers,

Figure 3 – CONSORT flow diagram for parallel randomized controlled trial of the Community Resiliency ModelÒ (CRM) non-pharmacological treatment.

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trained by California’s Trauma Resource Institute (TRI, 2019), and involved practice of the CRM skills: Tracking, Resourcing, Grounding, Gesturing, Shift and Stay, and Help Now! (see the CRM “ichill” app for explanations of the 6 skills). Tracking internal sensations, also called interoception or “felt-sense,” is fundamental to all of the CRM skills (Miller-Karas, 2015). The nutrition/ healthy eating control group class was taught by two of the authors (Grabbe and Craven, also a Certified Health Coach), with assistance and consultation with a registered dietician. Mindful eating constituted a slight blurring of treatments since it was also taught as part of CRM as a sensory exercise. The majority of classes took place at a shared hospitaluniversity space designated for continuing education and all participants earned 3 continuing education unit (CEU) certificates. Participants were given a variety of time options to take their class. Nurses were enrolled and attended classes between May, 2017, and May, 2018. No specific incentives were provided for completing post-tests at subsequent time points, aside from early notification of research results and the potential benefit of making a contribution to the profession. Power analysis was performed using PASS 2019 (Power Analysis and Sample Size Software, 2019). Given that 119 (61%) of the 196 nurses enrolled did not attend a class, the repeated measures model tests were powered at 80% at the 5% level of significance to only detect large group-by-time interaction effect sizes (Cohen’s f = 0.40 to 0.48) for a final sample size range of 50 to 70 subjects.

Data Analysis Participants entered pre- and postsurvey data directly into the REDcap system for data collection and management. REDCap (Research Electronic Data Capture) is a secure, internally-hosted, web-based application at Emory University that is designed to support data capture for designing clinical and translational research databases (Harris et al., 2019; 2009). Only the principal investigator and statistician had access to the data. Descriptive statistics were computed for all demographics and final instrument scores at each time point (baseline, 1 week, 3 months and 1 year). Internal conistency reliability was assessed for each instrument by computing Cronbach’s alpha for item responses at baseline. Pearson’s correlation coefficients were used to analyze the associations between the measured variables at baseline. Missing data due to attrition were assessed using t-tests to compare baseline scores for those who completed one or more follow-up surveys vs. those who only completed the baseline survey. Multilevel linear models were used to model the repeated measures, adjust for missing data due to attrition over time, and compare changes over time between the two groups, followed-up by post hoc tests performed using Sidak pairwise error rate adjustment (Hedeker & Gibbons, 2006). Given recent communications from the American Statistics Association (ASA), p-values for statistical

tests and models are reported, however, emphasis has been placed on reporting and interpreting effect sizes and clinically descriptive differences (Wasserstein, Schirm, & Lazar, 2019). So, in addition to performing statistical models and tests with reported p-values, effect sizes (Cohen’s d) were also computed based on the change scores from baseline to each follow-up time point (Cohen, 1988) to evaluate small (d = 0.2), moderate (d = 0.5), and large (d = 0.8) effect sizes to help determine clinically meaningful improvements. The percentages of subjects whose scores improved from baseline were also reported. All computations were performed using IBM SPSS Statistics for Windows, Version 24.0 (Armonk, NY: IBM Corp). Utility and application of skills and knowledge were obtained via questionnaires linked to each of the post-test surveys. The qualitative data from these questionnaires were analyzed and organized using manual “cut and paste” techniques (Webb, 1999).

Findings Research Question 1. What are the characteristics of well-being, resiliency, secondary traumatic stress, burnout, and physical symptoms in a population of hospital-based nurses? Of the 196 nurses who enrolled in the study, sizeable numbers reported mental and physical problems at baseline (Table 1). Thirty-six percent (n = 71) reported poor mental well-being; 28% (n = 54) met the criteria for PTSD; 55% (n = 107) had low resiliency scores; 47% (n = 90) reported work-related burnout symptoms; and 31% (n = 60) had physical symptoms. No significant differences were noted between the two randomized groups by age, years in nursing, or on any of the baseline measures. Older nurses and those with more years in nursing had higher resiliency and lower STS intrusion scores and, as expected, those with higher wellbeing and resiliency had lower STS, burnout, and somatic symptoms. Of the 196 nurses who completed baseline surveys and were randomized into treatment or control groups, only 77 (39.3%) came to a class and completed one or more of the follow-up surveys. The other 119 nurses (60.7%) completed a baseline survey, but did not attend a class. The majority of these did select a class to attend out of a menu of dates, but either cancelled or were “no-shows.” When compared to the 77 nurses who attended a class and completed one or more follow-up surveys, the proportion of the 119 nurses in the two randomization groups (CRM and nutrition) did not significantly differ. However, the 119 nonattendee nurses had slightly higher burnout scores (mean = 50.54, standard deviation [SD] = 20.53) compared to attendees (mean = 44.97, SD = 20.74, p = .068). They also had higher somatic symptom (SSS-8) scores (mean = 9.42, SD = 6.09) compared to attendees (mean = 7.08, SD = 5.52, p = .007), and they had higher proportions of

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medium, high and very high SSS-8 severity categories (medium: 20.3% vs. 15.6%; high: 20.3% vs. 13.0% and very high: 16.1% vs. 9.1% respectively). Nonattendees also had slightly higher proportions of nurses with low well-being, i.e., scores < 29: 17/118 (14.4%) compared to 5/77 (6.5%) of attendees (chi-square test p = .088). The 119 nonattendee nurses were not significantly different from the 77 class attendees in terms of age, years in nursing, resilience, or secondary traumatic stress scores. Research Question 2. What is the effect over time of a single 3-hour CRM class on the well-being, resiliency, secondary traumatic stress, burnout, and physical symptoms of nurses when compared to an active control group? To compare CRM and nutrition group changes in outcomes over time, multilevel linear models were performed for the data collected at the longitudinal time points. The results of these multilevel linear models for the changes over time by groups yielded nonsignificant results for the group-by-time interaction effects (p > .05, Table 2). However, four of the outcomes yielded significant time effects. The outcomes that significantly changed (and improved) over time were well-being (p = .006), resilience (p = .004), secondary traumatic stress (STSS) (p = .009), and somatic symptoms (SSS-8) (p = .004). However, time was not significant for burnout (p = .149). To further investigate these significant time effects, post hoc tests were performed for time within each group. All of the improvements over time for these four outcomes were for the CRM intervention group (well-being (F(3, 211.220) = 4.993, p =.002), resilience (F(3, 193.8) = 2.689, p =.048), secondary traumatic stress (F(3, 204.0) = 2.504, p =.060), and somatic symptoms (F(3, 191.2) = 3.185, p =.025)), with no significant time effects for the nutrition group (p >.10 for all post hoc time effect tests). Additionally, pairwise post hoc tests within time by group were also performed for these four outcomes for the CRM group. There were improvements in well-being for the CRM group from baseline to 1 year (p =.001) withthe CRM group having significantly higher scores at 1 year compared to the nutrition group (p =.025). Eighty percent of the nurses in the CRM group showed significantly improved well-being from baseline at 1 year. Additionally, the somatic symptoms (SSS-8) improvements for the CRM group were significant from baseline to 1 year (p =.023) where 60% of the nurses at 1 year showed significantly improved somatic symptoms from baseline. The CRM participants reported using the sensory awareness skills of tracking, grounding, and resourcing in difficult clinical situations of stress such as codes, crises, and with dying patients (Table 3). They reported sharing their CRM skills with family, friends, coworkers, and patients. Results of the study were shared with nursing leadership in the hospitals, as well as all study participants. Participants who had not attended a given class were invited to watch a recorded lecture of the CRM or the nutrition class, and receive CEUs.

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Discussion and Recommendations This study described the stress and well-being of a convenience sample of hospital-based nurses and confirmed numerous other studies which identify alarming trends of poor mental well-being, STS, burnout, and physical health problems among nurses. The study measured the impact of a brief CRM training compared to a nutrition/healthy eating training among randomly assigned participants, and found improved well-being and stress resistance sustained over 1 year in the CRM group. Previous research with helping professionals has suggested that burnout precedes STS (Shoji et al., 2015), and the current study found that burnout to a “somewhat or to a high degree” (46.9%) exceeded STS (36.4%), possibly indicating a sequential progression of poor mental health. It may be that the exhaustion and frustration associated with burnout lead to increased vulnerability to the symptoms of STS (e.g., jumpiness, trouble concentrating, feeling numb, or loss of interest in being with others). Compromised mental well-being has been linked to “presenteeism,” or working in a less than resilient frame of mind, and this can have an impact on quality of care and costs to institutions. To a large extent, nurses are responsible for their own wellness and well-being. Vigilance regarding adequate sleep, good nutrition, regular exercise, and social interaction is required. Nurses must discover feasible, effective practices and habits to support their mental wellbeing and resiliency. Mindfulness training is part of yoga and meditation, and other avenues to well-being include self-reflection, gratitude, journaling, prayer, or support groups. Commitment to develop an effective daily self-care plan may help counteract the emotional exhaustion which comes with nursing, but institutional efforts to help reduce stressors and promote nurse personal and professional development are also crucial. Taylor contends that resiliency training by itself is inadequate in a work environment in need of significant improvements, so organizations must recognize and address variables that contribute to failure and emotional distress (Taylor, 2019). Workplace resilience may be seen as an ongoing interactive process between the nurse and the workplace to promote well-being and healthy responses to emotional distress or adversity (Delgado, Roche, Fethney, & Foster, 2019). The Advisory Board Nursing Executive Center Board recognizes that nurses cannot reach their potential under certain conditions. Nurse leaders have become aware of four “cracks” in the care environment: safety threats; compromises in care delivery; traumatic experiences without recovery; and technology, responsibilities, and protocols that isolate nurses from connecting with each other as part of daily work (Virkstis et al., 2018). Maslow’s hierarchy of needs provides a framework for what defines basic human needs, and among nurses, basic needs will go unmet if the

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Table 1 – Baseline Findings of 196 Nurse Participants in the Nurse Wellness and Well-Being Study Demographic Parameters and Measures

All

N

Age Years in nursing WHO-5 well-being score Wellbeing  50 Wellbeing < 50 (poor well-being) Wellbeing < 29 (possible clinical depression) CD resilience score Highest population quartile ( 36) Lowest population quartile ( 29) Secondary traumatic stress (STS) score Total No STS: Total  38 STS: Total > 38 No criteria Met for PTSD Criteria B Met (Intrusion) Criteria C Met (Avoidance) Criteria D Met (Arousal) All 3 criteria, B+C+D Met (PTSD) Copenhagen workrelated burnout score Total None to a very low or low degree (< 50) Somewhat to a high degree ( 50 to < 75) To a high, very high degree or always ( 75) Somatic symptom scale (SSS-8) Total None to minimal (< 4) Low (4 to < 8) Medium (8 to < 12) High (12 to < 16) Very high ( 16)

CRM

Nutrition

Mean (SD) [min, max] (%) 189 45.3 (13.2) [23, 73] 191 17.7 (13.3) [0, 50] 195 56.8 (19.5) [0, 100]

Mean (SD) [min, max] (%) 96 44.6 (13.4) [23, 70] 97 16.3 (13.7) [0, 50] 98 57.1 (18.6) [20, 100]

Mean (SD) [min, max] (%) 93 45.9 (13.0) [23, 73] 94 19.2 (12.9) [0, 50] 97 56.7 (20.3) [0, 92]

102 52.3% 71 36.4%

60 61.2% 38 38.8%

64 66.0% 33 34.0%

22

7

15 15.5%

11.3%

N

7.1%

N

196 29.2 (5.7) [13, 40] 33 16.8%

99 29.7 (5.4) [14, 40] 19 19.2%

97 28.8 (5.9) [13, 40] 14 14.4%

107 54.6%

53 53.5%

54 55.7%

195 35.2 (10.5) [17, 77]

98 35.4 (9.2) [17, 57.5]

97 35.0 (11.7) [17, 77]

124 63.6% 71 36.4% 52 26.7%

61 62.2% 37 37.8% 29 29.6%

63 64.9% 34 35.1% 23 23.7%

111 56.9%

57 58.2%

54 55.7%

81

41.5%

39 39.8%

42 43.3%

97

49.5%

47 47.5%

50 51.5%

54

27.7%

26 26.5%

28 28.9%

192 48.2 (20.7) [0, 100]

96 48.1 (20.1) [0, 100]

96 48.5 (21.4) [7.1, 96.4]

102 53.1%

53 55.2%

49 51.0%

66

34.4%

32 33.3%

34 35.4%

24

12.5%

11 11.5%

13 13.5%

196 8.5 (6.0) [0, 29]

99 8.3 (5.1) [0, 22]

97 8.7 (6.8) [0, 29]

44

22.4%

16 16.2%

28 28.9%

55 37 34 26

28.1% 18.9% 17.3% 13.3%

34 21 18 10

21 16 16 16

34.3% 21.2% 18.2% 10.1%

demands of the workflow exceed the capacity of the work environment to support their work. Safe staffing and the regular discussion of emotionally challenging situations with trained providers are among the basic needs that nurses have. However, stress management

Group Differences

t test p-value .511 .138 .909

.306

.796

.891

.633

21.6% 16.5% 16.5% 16.5%

interventions for nurses have focused on individual rather than organizational elements (Chesak et al., 2019). There is clearly a need both for modes of organizational empowerment of nurses and for methods of individual resiliency skill training for nurses.

Table 2 – Outcomes Over Time by Group Outcome Well-being CRM

Nutrition

Resilience CRM

Nutrition

Burnout CRM

Nutrition

SSS-8 CRM

Mean (SD)

Baseline 1 week 3 months 1 year Baseline 1 week 3 months 1 year

98 33 32 25 97 36 35 26

57.06 (18.62) 63.76 (13.45) 63.72 (18.82) 70.24 (16.74) 56.74 (20.29) 61.11 (19.56) 63.31 (18.75) 62.46 (18.93)

Baseline 1 week 3 months 1 year Baseline 1 week 3 months 1 year

99 33 33 25 97 37 35 26 Group

29.65 (5.43) 30.42 (3.35) 30.94 (4.07) 31.72 (4.02) 28.82 (5.91) 30.22 (5.32) 31.00 (5.16) 30.54 (4.99) F(1, 234.3)=0.002

Baseline 1 week 3 months 1 year Baseline 1 week 3 months 1 year

98 32 33 25 97 37 35 26 Time

35.42 (9.21) 32.58 (8.80) 34.48 (10.66) 32.31 (9.53) 35.03 (11.74) 32.07 (10.52) 31.72 (9.05) 30.30 (9.56) F(3, 202.6)=1.799

Baseline 1 week 3 months 1 year Baseline 1 week 3 months 1 year

96 32 33 25 96 37 35 26 Group-by-Time

48.10 (20.14) 43.58 (20.31) 43.64 (25.60) 43.90 (18.32) 48.51 (21.44) 42.18 (21.31) 41.02 (20.10) 38.22 (20.26) F(3, 190.6)=0.684

Baseline 1 week 3 months 1 year

99 32 33 25

8.30 (5.06) 6.29 (3.95) 6.65 (5.06) 5.81 (4.55)

Change from Baseline1 Mean (SD)

Effect Size Cohen’s d

Improved Percent (%)

7.18 (10.88) 4.59 (15.48) 11.36 (13.00)

0.66 0.30 0.87

63.6% 65.6% 80.0%

1.78 (24.74) 3.43 (23.90) 4.31 (21.94)

0.07 0.14 0.20

47.2% 48.6% 38.5%

1.58 (3.83) 1.77 (4.57) 2.46 (5.91)

0.41 0.39 0.42

63.6% 57.6% 44.0%

0.86 (4.76) 1.42 (4.81) 1.79 (6.54)

0.18 0.30 0.27

48.6% 54.3% 50.0%

3.49 (9.74) 1.95 (8.66) 3.64 (10.60)

0.36 0.23 0.34

61.3% 62.5% 62.5%

0.74 (9/19) 1.02 (6.90) 2.97 (9.89)

0.08 0.15 0.30

51.4% 51.4% 50.0%

3.18 (13.54) 1.70 (18.53) 0.38 (15.33)

0.23 0.09 0.02

50.0% 51.5% 52.0%

0.73 (13.03) 2.00 (13.17) 5.37 (23.72)

0.06 0.15 0.23

54.1% 45.7% 50.0%

1.51 (4.39) 0.79 (4.03) 1.72 (4.50)

0.34 0.20 0.38

56.3% 51.5% 60.0%

Model Effect

F(df1, df2)

p-Value

Group Time Group-by-Time

F(1, 199.5)=1.907 F(3, 209.7)=4.214 F(3, 209.7)=1.700

.169 .006 .168

Group Time Group-by-Time

F(1, 210.0)=1.351 F(3, 192.9)=4.567 F(3, 192.9)=0.179

.246 .004 .910

Group Time Group-by-Time

F(1, 234.2)=0.002 F(3, 202.9)=3.926 F(3, 202.9)=0.271

.964 .009 .846

Group Time Group-by-Time

F(1, 234.4)=0.028 F(3, 202.6)=1.799 F(3, 202.6)=0.366

.866 .149 .777

Group Time Group-by-Time

F(1, 227.8)=0.709 F(3, 190.6)=4.581 F(3, 190.6)=0.684

.401 .004 .563

9

(continued on next page)

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STSS CRM

N

Nurs Outlook 00 (2019) 1 13

Nutrition

Time

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1 Note: Changes from baseline were computed for the participants who completed the post-test at that time point.

df1, numerator degrees of freedom; df2, denominator degrees of freedom; SD, standard deviation; SSS, Somatic Symptoms Scale; STSS, Secondary Traumatic Stress Scale.

0.07 (4.02) 1.01 (4.98) 0.71 (5.62) 97 37 35 26 Baseline 1 week 3 months 1 year

8.71 (6.79) 6.52 (4.79) 5.78 (4.33) 5.27 (4.26)

N Time

Nutrition

Outcome

Table 2 – (Continued)

Mean (SD)

Change from Baseline1 Mean (SD)

0.02 0.20 0.13

Effect Size Cohen’s d

45.9% 45.7% 50.0%

Improved Percent (%)

Model Effect

F(df1, df2)

p-Value

Nurs Outlook 00 (2019) 1 13

Workplace mediators are needed, i.e., rewards, recognition, policies, and programs to promote well-being and prevent understaffing, bullying, incivility, violence, or other environmental stressors. Among physicians, there are parallel and growing concerns regarding burnout, depression, early retirement, and suicide (Shanafelt, Dyrbye, & West, 2017). Physicians often perceive personal mental health as a taboo subject and may be reluctant to seek care because of shame, financial, or licensure issues (Reith, 2018). This tendency to deny mental health problems holds true for many nurses as well. Generally, a culture of stoicism exists in healthcare environments, and organizations may need to counteract this stoicism and the stigma around mental health care by normalizing mental health needs and encouraging staff to seek treatment in ways that minimize repercussions. Many authors have addressed the issue of nurse resiliency and related interventions (Chesak et al., 2019; Cleary et al., 2018; Mcdonald, Jackson, Vickers, & Wilkes, 2016; Stephens, Smith, & Cherry, 2017; Tubbert, 2016); Cleary and colleagues found a great range in modes of delivery, content, and duration of interventions, many of which enhanced resilience, with the lengthiest among them having the best response. Paradoxically, CRM compares favorably with other interventions, but is one of the briefest of resiliency interventions. CRM normalizes and depathologizes stress responses, rendering them more universal and understandable. This compassionate feature of CRM may be invaluable to hospitals that want to more actively engage in staff support. Persons who are trained in CRM learn to recognize when they are “stuck” outside their Resilient Zone and may seek help more readily. CRM is preventative self-care and does not pretend to be therapy; the skills do not take the place of psychotherapy or psychiatric medication when they are needed. In this study, a single 3-hour CRM class was sufficient to show a change in nurse well-being, but a series of shorter classes is also an option, and hospitals that have their own Certified CRM Teachers may conduct their own classes. Webinars are a possible means to convey CRM course content, but in-person practice is essential. Nearly all CRM class participants in this study wanted further practice of the skills, and some attendees wanted to train to become CRM teachers. Nurses who are CRM teachers are ideal agents for reaching nurses, physicians, pharmacists, paramedics, public safety officers, as well as patients and their families, among other groups. The natural consequence of a CRM-trained, resiliencyinformed staff is sharing of skills with patients and families, which would enhance nurse-patient interactions and promote patient resiliency and strength.

Limitations Only 196 of 1,600 nurses (12%) who were invited to participate in the Nurse Wellness and Well-Being class

ARTICLE IN PRESS Nurs Outlook 00 (2019) 1 13

11

Table 3 – Nurse Statement Samples Regarding Community Resiliency ModelÒ (CRM) Use in Follow-up Surveys Nurse Statements What CRM techniques did you use?

In what situations did you use the CRM skills?

“pushing up against a wall,” “touching different surfaces and noticing the associated physical sensations,” “paying attention to smells and sensations,” “body awareness,” “tracking sensations,” “the fabric of my scrubs,” “being still,” “coming back to the present,” “rubbing hands,” “visualizing CRM’s brain model” “clinical stressful/scary situations with patients,” “hectic times,” “difficult family dynamics,” “feeling anxious/unsettled/upset,” “in the midst of the chaos,” “to release stress,” “to leave work at work,” “at bedtime”

agreed to be in the study and completed the baseline survey on wellness and stress. It may be that these individuals self-selected for the study and attended the class because they were stressed by their work and were looking for ways to improve their well-being; alternatively, stressed nurses may not have had the energy to participate. Also, of the 196 nurses who consented and completed the pre-test, only 77 attended a class which lowered the statistical power to detect significant differences between the groups’ improvement over time for only large group-by-time effects. To obtain this number, the researchers had to teach a total of 24 classes over the course of a year. The maximum number of nurses at any class was eight, and often only two actually came (with several cancelling or not showing up). This study depended on self-reported measurements about nurse individual well-being, resilience, secondary traumatic stress, burnout, and somatic symptom characteristics. Biological measures of stress, such as salivary cortisol or galvanic skin response, were not included in the study, but would be reasonable to consider in future studies. Although one of the study’s strengths was its high participation rate in multiple follow-up surveys, the sample size was small, and may not have been representative of the general population of registered nurses, of multiple specialty areas, or of geographical location. Some participants did not complete specific post-tests, although 45 completed all 4 time-point surveys. Additionally, the sample size varied slightly between the five scales utilized, due to variations in missed or skipped items within each scale. The one slight area of overlap in content between the intervention and control groups was mindful eating which could be regarded as a confounding variable.

Conclusion The nursing workforce is exposed to stress and trauma by the very nature of its work. Like others in the helping professions, nurses may be the indirect victims of the trauma, illness, and loss which take place in healthcare settings. Secondary traumatic stress, poor mental wellbeing, and burnout are occupational hazards. Nurses are critical members of the patient care team, and if

they are distressed enough to leave nursing, then staffing, health care systems, and patient outcomes will also suffer. A brief and effective resiliency training such as CRM appears promising as a means to enhance nurses’ stress tolerance and capacity for self- and other-compassion under difficult working conditions. Replication of this study in other settings is recommended and our nutrition protocol for the control group is available on request. We suggest that healthcare institutions make resiliency training available as in-service education and that schools of nursing ensure that, as students learn how to take care of their patients, they also learn how to take care of themselves.

Acknowledgments Our deep gratitude goes to the registered nurses who participated in this study. The authors wish to thank Community Advanced Practice Nurses, the Mundito Foundation, Sigma Theta Tau International, Emory Healthcare, and Emory University’s Nell Hodgson Woodruff School of Nursing for support or facilitation of this research. We would like to thank Drs. Jeannie Cimiotti, Mary Gullatte, Laura Kimball, T. Stephen Jones, Elizabeth Corwin, Sharon Pappas, and Terence Chorba for their guidance. We appreciate the early assistance with this work from Kathy Steele, Alex Edwards, Xiqin Huang, Alexander King, Ariel McKenzie, and Dr. Cathy Vena. No conflict of interest is reported for any of the authors.

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