A Nurse-Led, Well-Being Promotion Using the Community Resiliency Model, Atlanta, 2020–2021

Abstract

The wrath of COVID-19 includes a co-occurring global mental health pandemic, raising the urgency for our health care sector to implement strategies supporting public mental health. In Georgia, a successful nurse-led response to this crisis capitalized on statewide organizations’ existing efforts to bolster well-being and reduce trauma. Partnerships were formed and joint aims identified to disseminate a self-care modality, the Community Resiliency Model, to organizations and communities throughout the state. (Am J Public Health. 2022;112(S3):S271–S274. https://doi.org/10.2105/AJPH.2022.306821)

COVID-19 exacerbated stress and trauma universally, creating a secondary pandemic that increased demand for mental health care in a system on the verge of crisis. An intense and immediate need for population well-being support resulted, and subsequent requests for resiliency training quickly followed. In response, three nurses in Georgia certified to teach the Community Resiliency Model (CRM) fast-tracked existing efforts to share this mental wellness training program across their state.

INTERVENTION AND IMPLEMENTATION

CRM, developed by the Trauma Resource Institute, has a rapidly growing body of evidence.^1–4 The model helps individuals (1) understand stress reactions in biological terms, (2) distinguish between sensations of distress and well-being, and 3) use sensory awareness skills to deal with difficult situations.⁵

The nurses created a Web site (www.crmgeorgia.org) to share their information and facilitate implementation of the model. In largely rural Georgia, variability in resources and access to care compound existing health disparities, so novel approaches were required.⁶ Cross-sector partnerships between health care and community organizations improve implementation outcomes.⁷ This prompted the nurses to strategically align with Resilient Georgia, a statewide coalition of more than 600 partners and stakeholders committed to addressing childhood trauma and building a stronger, more resilient Georgia, and the Georgia Nurses Association (GNA), the largest professional nursing association in the state.

The collaboration provided funding for participants, increasing the program’s capacity to provide classes at no charge, and created a larger network to support statewide reach. The objective was to reach all of Georgia’s 159 counties with free CRM classes. This would ensure geographically dispersed training and access to CRM throughout the state. The program aim was to support well-being for all Georgians by increasing resilience to stress and trauma. A logic model depicting this “pathway to resilience” is shown in Figure A (available as a supplement to the online version of this article at http://www.ajph.org).

Our cross-sector approach improved program planning, connecting nurses directly to community leaders to better understand local needs, provide follow-up consultations, and refer interested participants to the Trauma Resource Institute for CRM teacher certification.⁴ The Georgia Nurses Association hosted the virtual classes and conducted evaluations. Resilient Georgia added CRM to its “roadmap” for 16 regional grantees (a cluster of counties or organizations focused on increasing resilience). Grantees selected dates for a series of one-hour virtual CRM classes, remotely provided via Zoom’s Webinar platform. Word of mouth led other organizations to schedule classes. Class participants were introduced to CRM and the six easy-to-use wellness skills (Table 1).⁵ Three-hour workshops to reinforce model concepts and provide practice in CRM skills were offered as follow-up.

TABLE 1—

Community Resiliency Model (CRM) Skills

Skill	Description	Training Participant Exemplar:
Tracking	Conscious awareness of body sensations, differentiating between pleasant and unpleasant; basis for all CRM skills	Nurse walking into a patient room: “I sense my body and am aware of my tight shoulders and shallow breathing. As I notice these, I notice that I take a deep breath and feel more relaxed.”
Resourcing	Something that brings a sense of peace, safety, joy, or calm and awareness of associated body sensations	Teacher with students: “We start the day by naming a source of joy, like a favorite toy, and name the body sensations that go with it—‘jiggly face’ and ‘bubbly chest’ are common ones.”
Grounding	Awareness of sensations of support and security in the present moment	Police officer: “Before I step out of my patrol car, I place my hand on my [bullet-proof] vest, rest it there for a second, and feel stronger.”
Gesturing	Spontaneous, comforting gestures used intentionally to move into a resilient state	Student feeling anxious: “I purposefully stand up straighter, push my shoulders back and my chest out, and I feel more confident and in control.”
Help now!	Emergency strategies used when one is in a very distressed state: quick, focused activation of senses	Social worker/mother working from home and feeling agitated: “I could look around the room and name the colors or objects that I see, usually just in my head, not out loud, and I feel calmer.”
Shift and stay	Using a CRM skill and intentionally lingering with the experience until the unpleasant sensation or emotion abates	Medical student: “I was frustrated and in a bad mood, and I thought of my beach resource, remembering the sensory details of that experience. I stayed thinking about it and noticing sensations for about 15 seconds and noticed a shift into a better emotional state.”

PLACE, TIME, AND PERSONS

This nurse-led approach for innovative population mental health was based in Atlanta but delivered across the state of Georgia. Program planning began in March 2020. The first virtual training was held in June 2020 and is ongoing. Free, virtual sessions were piloted with the Georgia Nurses Association and two health care organizations: Emory Healthcare, Georgia’s largest health care organization, and Grady Healthcare, the state’s largest public, not-for-profit provider. During this trial period of virtual deployment, training reached individuals in more than 50 of Georgia’s counties, with the goal of eventually providing training in all 159 of the state’s counties.

Collaborating with Resilient Georgia cast a broader net. Its funding included training for caregivers of the most vulnerable children and families in 16 multicounty Georgia regions. Community coalitions in the middle, northern, western, and eastern regions were also trained one by one via locally focused, remote delivery. Other training included staff from state-level organizations such as the Department of Education, Department of Juvenile Justice, and Division of Family and Children Services, as well as the Georgia Association of School Nurses and Association of Social Workers.

The program targeted all Georgians, beginning with front-line health care workers. During an 18-month response to the COVID-19 crisis, more than 1000 Georgians were trained. The largest number of participants trained at one time was 140, with an average of 20 individuals per training session.

PURPOSE

Resilience is protective against stress and trauma. The pandemic is a stressful and traumatic event at all levels. Risk of burnout, secondary stress, suicidality, and intent to leave the profession existed among health care workers before COVID-19 and is expected to worsen. In the populace, poor mental health, substance use, domestic violence, and self-injury are concerns.⁸ Previous CRM research demonstrated increased well-being in members of low-resource and low-recovery communities^1,9 and reduced secondary traumatic stress and an improved sense of well-being among front-line health care workers.^2,3 CRM incorporates trauma awareness along with resiliency skills, and thus it is a universally applicable model. Based in neuroscience, CRM is an evidence-informed approach to population mental health in times of both stability and crisis. Its concepts and skills are intended for laypersons and can be peer taught, and accordingly the model is an inexpensive, feasible approach that can be adapted and sustained in local contexts.

EVALUATION AND ADVERSE EFFECTS

Participant feedback was collected after each training on a four-question Likert scale and a qualitative question in Survey Monkey. Class organization, instructor effectiveness, content relevance, and incorporated skills were ranked on a scale of poor (1) to excellent (5); the overall mean ranking was 4.6 (range = 3–5). Remarkably, after just one hour of virtual CRM training, participants reported anecdotal use of CRM skills for their own well-being and to support others. Debriefings were held with collaborators every three months to identify improvement opportunities, primarily related to registration and scheduling. Evaluations also included the number of counties reached (50), the number of participants taught (almost 1000 in 18 months), and the number of referrals to CRM teacher certification through the Trauma Resource Institute (10).⁴ The implementation, including evaluations, has continued.

There have been no reported adverse effects of the implementation. CRM is highly trauma sensitive and invitational. For individuals with a trauma history, body awareness skills may be challenging or unpleasant, so CRM teachers are prepared to guide participants who become unsettled.

SUSTAINABILITY

A goal for sustainability is to certify more teachers to champion content in their local community. Any motivated person can become a CRM teacher. However, as influential community members, nurses are well positioned to integrate CRM teaching in both personal and work settings, contributing to a more widespread and scalable solution to the pandemic’s trauma. The model has a strong mind–body component, so it fits well with nursing’s whole-person health paradigm. Community health nurses are ideally situated to teach CRM and champion resilience.

CRM training sessions are live, brief, and free-standing. They offer a protective effect with the potential to contribute to large-scale improvement of public mental health.¹⁰ This program can be initiated for the price of a teacher certification (see the Trauma Resource Institute Web site).⁴ CRM is affordable and accessible, two critical aspects of a scalable and sustainable intervention. The large number of attendees and the distribution of locales trained contribute to a “critical mass” of resiliency. As community resiliency is enhanced, stress levels are more likely to stay low, even in the face of crises and emergencies, thus meeting the interests of community stakeholders for well-being across the state.

PUBLIC HEALTH SIGNIFICANCE

The public deserves attention to its collective mental health. Stress and trauma are ubiquitous, and the pandemic is an ongoing crisis that is exacerbating mental health problems and creating trauma at all levels of society. CRM is an efficient self-care model that complements other stress-reducing or clinical mental health modalities (e.g., psychotherapy, yoga, mindfulness practices). Leveraging nursing leadership and cross-sector partnerships to implement CRM is feasible and can be part of a multifaceted approach to improving population mental health.