Enhancing Nurse Manager Resilience in a Pandemic

Abstract

Nurse managers face many daily challenges that require strong resilience and skill. The COVID-19 pandemic placed nurse managers under exceptional pressure to deliver safe staffing resources, updated infection control practices, and communication with the multidisciplinary team. During the height of the pandemic in the summer of 2020, a group of nurse managers at a health system in the Midwest engaged in a resilience-building tool to strengthen their emotional well-being and work–life balance so that they could optimize their leadership support of their clinical teams and thrive in an unprecedented time.

Key Points.

• •Use of a resilience-building intervention (WISER tool) showed improvement in nurse manager emotional thriving and work–life balance during the COVID-19 pandemic.
• •Resilience-building interventions that can be individualized show the strongest success.
• •Higher resilience in nurse managers positively impacts their retention and job satisfaction.

Nurse managers (NMs) in the acute care setting consistently report moderate to high levels of stress, burnout, and intent to leave.¹ NMs directly impact patient safety and bedside nurse retention.² Competing priorities within the context of a high-stakes, fast-paced, complex work environment directly contribute to NM intent to leave. Specific factors include round-the-clock responsibility, large scope, difficult time management, perceived lack of support, and low job satisfaction^{3 , 4}; meeting the demands of administration, staff, and physicians⁵; and pressure to increase productivity with less staff and improve patient outcomes.⁶ These challenges and pressure require high levels of resilience in order for these leaders to be successful.^{7 , 8} Resilience is defined as a complex set of behaviors that are developed over time as a result of exposure to difficulties.⁹ Low NM resilience is an important area of focus due to the negative impact of NM turnover on clinical outcomes and the work environment for bedside nurses.

Purpose

In 2020, the COVID-19 pandemic amplified these stressors and pushed many nurse leaders to their limits in terms of resilience. A nurse leader at a health care system in the Midwest implemented a project focused on increasing resilience in the NM population during the pandemic due to the nature of the leaders’ impact on vital patient outcomes. The goal of the project was to increase self-reported resilience in this group of NMs from 3 regional hospitals over a 6-month period using an automated web-based tool.

The Wiser Tool

The resilience-enhancing intervention used for this project was the individualized Web-based Implementation of the Science of Enhancing Resilience (WISER) tool developed by the Duke Center for Healthcare Safety and Quality, which can be found at www.hsq.dukehealth.org/tools.¹⁰ Upon enrollment in the WISER tool, the NMs received an automated daily text message with a hyperlink to the website where different resilience enhancing tools were introduced. Days 1 through 5 were introductory videos to the tools themselves. Days 6 through 10 allowed the participants to choose which tool to use that day. This method aligned with the literature recommendation to individualize resilience coaching.11, 12, 13 The total time to participate was approximately 20 minutes per day, for 10 total days. This also ensured that the intervention did not place an undue workload on the NMs in order to fit with their busy schedules, and support work–life balance.

Each introductory video (days 1 through 5) included a message from Dr. Sexton where he discussed resilience strategies such as 3 Good Things, Gratitude, Awe, Cultivating Joy, and other examples. The participant is then directed to an exercise to practice each of the skills through the WISER platform and submit their response. Days 6 through 10 then allow the participants to select any of the resilience tools mentioned and submit their response in the same platform. This allows each participant to practice the new exercise of their choice.

Methods

Baseline demographics and various resilience-related scale scores were obtained during July and August of 2020. The participants completed the Emotional Thriving (ET) and Emotional Recovery (ER) Questionnaires as well as the Work Life Balance (WLB) scale. The ET and ER questionnaire are both 4-item validated scales intended to measure resilience in this target population.¹⁴ The 8-item WLB scale was established to measure employee well-being through the self-reported frequency of negative behaviors that are known to decrease resilience and increase emotional exhaustion.¹⁵ Participants completed all 10 days of the WISER tool and then responded to these same scale surveys 6 months later, in January of 2021.

Results

Seventeen NMs from 3 Baptist Health hospitals enrolled in the WISER tool after attending an educational WebEx session led by the project leader. Comments were also obtained asking the participants to identify their top stressors during this time. Themes from these comments included staffing, quarantine, safety of self/family, and feeling overwhelmed by uncertainty and communication.

Six months later, 7 of the original 17 participants responded to the follow-up survey, which included repeated ET/ER and WLB scales. The results showed improvement in overall mean scores for all 3. Additionally, the WLB scale demonstrated strong internal reliability as evidenced by Cronbach’s alpha of 0.83 at baseline and 6 months post-intervention. The respondents at the 6-month mark also responded to an additional set of questions regarding their perceptions of the WISER tool, which demonstrated overall favorable support for recommendation of this tool. Some comments included their perception of the tool including that it was challenging to make time for it, director support was influential in their completion, and that they would recommend this tool to their peers.

Discussion/Implications

NM roles have historically been noted as challenging, even prior to the COVID-19 pandemic. Focused efforts on increasing their resilience have shown to improve their job satisfaction and retention, which in turn increases patient safety.^{3 , 7 , 8} The use of this individualized and automated resilience-building tool showed that it positively impacted a group of NMs during an especially challenging time. Hospitals and health care leaders can support their NMs through promotion of resilience-building strategies to retain top talent.

The NM participation rate was a challenge during the pandemic due to multiple demands placed on the leadership team. It was especially challenging to get response from the group on the day 10, 1-month, and 6-month follow-up surveys that occurred in the summer of 2020, fall of 2020 and winter of 2021. The pandemic surge was peaking during the fall and winter months, which was a direct contributing factor to participation. This brought to light how making time for even brief resilience building strategies is a lower priority on the nurse leaders’ list compared to operational needs that most likely included resiliency strategies and care for their frontline nursing staff. It is worth noting the respondent comments at the 6-month mark highlighted how influential their director’s support was in completing the program, reinforcing what we know as nurses and nurse leaders, we neglect our own needs to address the needs of others. Support from leadership at all levels to address resiliency throughout the nursing work force is necessary especially in a crisis.

Replication of this work in other acute care settings can glean key lessons from this group’s experience. Making sure that the NMs’ leaders are in support of the time to complete this is an important first step. It would also be helpful for the participants to debrief with the group to highlight which of these resilience exercises were most helpful to them. The debrief will also serve as a necessary support system and mechanism for accountability. This could help narrow the intervention focus and time investment for future nurse leaders. Organizations could also individualize some of the resilience tools to meet the cultural nuances of their nurse leader groups. For example, if the culture is one of high reliability, the nurse leaders would be able to set regular debrief and follow up’s on the effectiveness of 3 Good Things at the start of their operational meetings. Selection of only 1 or 2 resilience scales will also shorten the follow-up response time and increase the likelihood of NM response at day 10, 1 month, and 6 months.

This work added to a growing body of knowledge around enhancing resilience in the nursing workforce. It is worth noting that nurse leaders are in a particularly pivotal position to positively impact resilience through role modeling and self-care so that frontline nurses normalize and implement these practices. The nursing profession has historically been rated as the most trusted profession, and this is often linked to the self-sacrifice nurses are willing to make for patient care. However, as the nursing profession evolves to meet patient care needs, there is a clear need to alter this approach and change the culture of nursing to put self-care and resilience at the top of the priority list and skill adaptation. The COVID-19 pandemic has taught health care that this is a necessary next step for all nurses in order to be healthy enough to care for patients of the future. What the COVID-19 pandemic has demonstrated is we must do better in supporting the frontline staff. That support starts with concrete strategies, clear direction and communication, role modeling, and resiliency.

Conclusion

Nurse leaders have now turned their attention from the pandemic surge itself to the mental health and well-being of their teams. Strategies must be put in place to secure and support that work force in order to continue to provide care to our growing, challenging, diverse patient population. In addition to role modeling self-care practices, nurse leaders need opportunities to share the creative, successful strategies that have been implemented to support frontline staff, building resilience and promoting self-care. Nurse leaders should share these creative, successful strategies to build community and support for the nurses, especially during these very stressful times. The WISER tool shows promise as a means of enhancing resilience, not only for NMs, but also for nursing staff. It is accessible as an app and is easy, providing concrete evidence-based strategies to increase resilience.

Limitations

A small number of NMs participated in this project, making statistical analysis a challenge. However, the overall mean scores of the 3 validated scales demonstrated overall improvement. It is likely that a lower participation rate at 6 months was influenced by the level of work present for the NMs during the pandemic height. This disappointing decrease in participation during the chaos of a pandemic directly enforces the need for this type of intervention to build resiliency in the entire nursing work force. Nurse leaders are in a position to role model and implement positive strategies involving self-care. Nursing must be aggressive and strategic in the implementation of resiliency-building strategies at all levels. This is imperative to prepare for the future, meeting the needs of our very diverse patient population, in a variety of settings, able to manage the next crisis that presents.

Biography

Megan Carter, DNP, RN, NEA-BC, is Associate Chief Nursing Officer at Texas Health Harris Methodist Southwest in Fort Worth, Texas. She can be reached at Megan.carter.msn@gmail.com. Kathleen M. Turner, DNP, RN, is Associate Professor at Duke University School of Nursing in Durham, North Carolina.