Reducing Staff Turnover and Clinician Burnout With a Structured Support Group During the COVID-19 Pandemic

Abstract

Retention and burnout have always been a challenge for nurse leaders, but the pandemic brought these concerns to a whole new level. And now the Great Resignation is affecting health care. So how can nurse leaders at hospitals and health care systems create a supportive environment for staff during a public health emergency? Structured support groups are a viable option for emphasizing self-care and wellness. We explain why we decided to form a structured support group for our intensive care unit nurses and illustrate the results from our clinical research team. In addition, we share feedback we received from participating nurses and offer advice on forming a structured support group in acute care settings. This strategy resulted in a change in the participant's behaviors after attending the structured emotional support group. This finding aligns with the literature, which supports strategies to protect nurses' mental well-being and to take preventive measures in critical situations. Using this as a foundation, a structured emotional support group can change nurse engagement and involvement in their process and practice, during times of crisis. Many other benefits could be realized from this strategy such as improved nursing practice and processes, improved nurse satisfaction, and improved recruitment and retention.

THE STRUCTURED support group was conducted within a 28-bed critical care unit (CCU) in a community hospital in a suburban area of southern California. The facility is a teaching hospital within a health care system that has a main hospital, a critical access hospital, and multiple ambulatory clinics. Prior to the COVID-19 pandemic, the unit reported minimal turnover, stable staffing, high morale, strong communication, and cohesiveness among frontline staff, department leadership, and organization administration.

During the COVID-19 pandemic, CCU nurses experienced unprecedented, sustained, intense stress related to increased patient acuity, increased patient volumes coupled with staffing shortages, and increased demands on nursing when patient families were not allowed to visit. Pandemic-related stressors included the need to learn new technology as the hospital introduced extracorporeal membrane oxygenation (ECMO) for the first time. The severity of illness related to COVID-19 drove an increase in patients on continuous renal replacement therapy, requirements to prone, and other less familiar therapies that required staff training and learning in a rapid manner. In addition, the higher patient census, the higher acuity, and the increase in unfamiliar therapies and medications led to substantially increased workloads. The unit saw high volumes of futile care, death, and prolonged dying processes that were not experienced or anticipated prepandemic. The nurses were responsible for delivering tragic news to patients' family members on a repeated basis.

THE ISSUE

Observations by leadership during the pandemic included the unit experiencing increased numbers of sick calls, escalations in leaves of absence, and increased registered nurse (RN) turnover, in particular, on night shift. In addition, staff self-reported feelings of frustration and impatience, which sometimes led to lateral violence, misunderstandings, and mistreatment of coworkers. Staff members reported sleep disturbances, feelings of wanting to avoid work, requesting assignments away from COVID-19 patients, wanting to decrease work commitments such as committee involvements, clinical advancement projects, precepting new employees, and unwillingness to work extra shifts or precept new employees. Leadership observed staff disinterest in learning new skills and avoidance of volunteering for educational opportunities. There were increased signs of emotional exhaustion including avoiding talking to patient family members when there were no positive patient changes to report, crying before, during, and after their shifts, and sadness that they could not help each other more. Nursing reported that they felt “abandoned” as ancillary services such as palliative care, social services, pharmacy, dietary, information services, and rehabilitation services tended to stay away from the “hot zones.” Hiring travelers proved to be challenging for existing staff. Leadership noticed resentment and a perception that travelers were making much more money than they were, yet they had to provide training for the temporary staff. There was a perception that the travelers were not as vested or engaged in the unit culture. Sometimes travelers were treated as members of the core staff “family” only to see them leave as contracts expired, resulting in additional feelings of loss.

Organization leadership sought to support the CCU staff in several ways and provided regular hands-on assistance in proning. There was increased staff rounding on all shifts. The Quality Department and Social Services collaborated to provide critical incident debriefings 24 hours per day. Department leadership created streamlined documentation standards and treatment protocols without diminishing standards of patient care. Department leadership created a Relaxation/Wellness Room with a massage chair, essential oils, coloring pages, yoga mats, and other tools for self-care. There was restructured physician staffing to provide additional coverage and support on the night shift with an assigned resident in the department. There was increased focus on providing additional equipment and supplies when needed. The organization continued to have smaller-scale celebrations and gifts for Nurses' Day and Hospital Week. The nurses were supported in creating small “compassion gifts” (coffee mugs, candy, tea, snacks) to give when they saw a coworker struggling. Leadership maintained unit routines such as staff meetings using a Microsoft Teams format.

Despite these interventions, leadership continued to observe signs of fatigue, sadness, and moral distress. These observations led to an attempt to address the nurses' concerns and feelings, by developing a structured support group that was facilitated by a clinical psychologist. All staff members were invited to attend the Teams (WebEx) meeting. Feedback following the initial meeting led to the design of a weekly group meeting that is still in process as of the writing of this study. The group met weekly and was attended by many CCU staff members. Staff members were assured that no one from management would be at the support group sessions to encourage open, honest communication and a safe environment to vent. Nursing staff were encouraged to attend whenever they wanted, as many times as they wanted, and with whatever level of participation they felt comfortable with. During one session, the group's facilitator sought permission from the group participants to invite Administration representatives (COO, CNO, and VP of Quality) to the next group meeting to participate by listening only. Direct CCU Management did not attend the support group in any capacity.

There was anticipation that a support group such as this would provide immediate emotional support to staff and also enable the CCU staff to develop strategies to improve resiliency and emotional well-being. As the pandemic continued longer than most anticipated, the leadership wanted to determine the effectiveness of the structured support group in reducing the feelings of emotional distress and work-related stressors among nurses in the CCU.

Hospital leadership wanted to evaluate the structured support group and its role in reducing the feelings of moral distress among nurses in the CCU. Leaders wanted to assure that a support group such as this would enable the CCU staff to develop strategies to improve resiliency and emotional well-being.

To evaluate the structured peer support group on nurse resilience, emotional well-being, retention, job satisfaction, and suggestions for improvement, hospital leadership instituted a cross-sectional survey in April 2022 to collect data regarding the group's experience.

THE EVALUATION

Our clinical research team evaluated the effectiveness of the structured support group. With approval from the institutional review board, we invited our critical care nursing staff to participate in a survey in April 2022. Nurses were asked to evaluate the support group on resilience, emotional well-being, retention, and job satisfaction and suggest improvements.

The aim of this cross-sectional evaluation was to garner honest answers about the stress of working through the pandemic and whether or not the participant found value in emotional support services. The support group was implemented in hopes of providing the CCU staff a safe place to develop strategies to improve resiliency and emotional well-being.

The objectives were to:

1. Determine the prevalence of emotional well-being and job satisfaction among CCU nursing staff prior to the pandemic and at the time of the survey;

2. Determine the prevalence of emotional distress among CCU nursing staff who were exposed to structured emotional support during the COVID-19 pandemic;

3. Determine if offering structured emotional support for future unprecedented clinical experiences is a valuable tool for staff; and

4. Determine what improvements and/or changes should be made in emotional support offerings to better serve those seeking support.

METHODS

E-mails containing the consent and survey were sent to all critical care nursing staff members regardless of whether or not they participated in the structured support group. Participants were given 3 weeks to complete the anonymous survey. Reminder e-mails were sent 1 and 2 weeks after the initial invitation to participate. Data were analyzed after 1 week of study completion.

Eligibility criteria

To be included in the evaluation, the following criteria were required: critical care RN or nurse tech working at the organization in Ventura at the time of the study, at least 18 years old, and agreed to the information outlined in the electronic consent form. Since the structured emotional support group was only offered to CCU RNs or nurse techs, CCU physicians and other CCU staff were excluded from participating in the study.

Study population

The survey was offered to all 80 nurses in the CCU at an organization in Ventura in April 2022. A 50% (40 participants) response rate was anticipated; however, after 3 weeks only 24 individuals submitted the study survey, which yielded a 30% response rate.

Data collection

Data were collected by means of an anonymous electronic survey administered by SurveyMonkey. Critical care nursing staff were invited to participate in the study via flyers, verbal invitation during daily rounding/huddles and staff meetings, and via a personal e-mail invitation sent to their hospital e-mail address. The e-mail invitation included a SurveyMonkey link, which contained an electronic acknowledgment (consent) to participate in the study. Participants agreed to be a part of the study once they reviewed the consent and continued to the survey questions. Participants were given 3 weeks to complete the survey. Reminder e-mails were sent 1 and 2 weeks after the initial invitation to participate.

All survey questions, with the exception of 2 open-response questions, were multiple-choice to ensure the anonymity of the study participants. In addition, certain demographic questions such as race, ethnicity, educational level, and income level were not included in the survey to avoid potential identification of study participants.

Analysis methods

Frequency methods were applied to provide summary statistics for covariates (Table 1). Bivariate models (Fisher's exact test) were also conducted to determine if there was a significant relation between any use of psychological or emotional support and select covariates (Table 2) and between the use of organization-offered CCU structured support and select covariates (Table 3). Stata 17 (College Station, Texas) was used for all statistical analyses.

Table 1. CCU RN or Nurse Tech Survey Participants (N = 24).

Demographics	n (%)
Age,a y
≤24	0 (0.0)
25-34	10 (41.7)
35-44	6 (25.0)
45-54	3 (12.5)
55-64	4 (16.7)
Gender identitya
Male	3 (12.5)
Female	20 (83.3)
Other	0 (0.0)
Prefer not to answer	0 (0.0)
Number of years as an RN or nurse techa
0-5	4 (16.7)
6-10	10 (41.7)
11-15	2 (8.3)
16-25	3 (12.5)
25+	4 (16.7)
Number of years as a CCU RN or nurse techa
0-5	10 (41.7)
6-10	6 (25.0)
11-15	1 (4.2)
16-25	4 (16.7)
25+	2 (8.3)
Number of years as at CMH Venturaa
0-5	8 (33.3)
6-10	8 (33.3)
11-15	2 (8.3)
16-25	4 (16.7)
25+	1 (4.2)
Emotional well-being prior to the pandemic
Excellent	4 (16.7)
Good	16 (66.7)
Fair	3 (12.5)
Poor	1 (4.2)
Very poor	0 (0.0)
Prefer not to answer	0 (0.0)
Emotional well-being at the time of survey vs prior to the pandemic
Better	2 (8.3)
Somewhat better	3 (12.5)
Undecided	5 (20.8)
Somewhat worse	8 (33.3)
Worse	6 (25.0)
Satisfaction with work prior to the pandemic
Completely satisfied	2 (8.3)
Very satisfied	11 (45.8)
Moderately satisfied	9 (37.5)
Slightly satisfied	0 (0.0)
Not at all satisfied	0 (0.0)
Prefer not to answer	2 (8.3)
Satisfaction with work at the time of survey
Completely satisfied	0 (0.0)
Very satisfied	4 (16.7)
Moderately satisfied	9 (37.5)
Slightly satisfied	7 (29.2)
Not at all satisfied	3 (12.5)
Prefer not to answer	1 (4.2)
There is value in group support or therapy
Strongly agree	9 (37.5)
Agree	9 (37.5)
Undecided	5 (20.8)
Disagree	1 (4.2)
Strongly disagree	0 (0.0)
Utilized psychological or emotional support during the pandemic
Yes	19 (79.2)
No	5 (20.8)
Utilized the following methods of emotional support during the pandemicb
Individual therapy (community-based)	11 (45.8)
Individual therapy (CMH-sponsored/EAP)	2 (8.3)
Group therapy	3 (12.5)
Group support (community-based)	3 (12.5)
Group support (CMH-based)	16 (66.7)
Spiritual support	7 (29.2)
Informal medical peer support	8 (33.3)
Informal family/friend support	11 (45.8)

Abbreviations: CCU, critical care unit; CMH, Community Memorial Hospital; EAP, Employee Assistance Program; RN, registered nurse.

^aMissing data for 1 participant.

^bResponses are not mutually exclusive.

Table 2. Prevalence of the Utilization of Psychological or Emotional Support During the Pandemic (N = 24)^a.

Demographics	No Use of Emotional Support (0) (N = 5), n (%)	Use of Emotional Support (1) (N = 19), n (%)	P
Age,b y			.74
≤24	0 (0.0)	0 (0.0)
25-34	3 (60.0)	7 (36.8)
35-44	1 (20.0)	5 (26.0)
45-54	1 (20.0)	2 (10.5)
55-64	0 (0.0)	4 (21.1)
Gender identityb			.54
Male	1 (20.0)	2 (10.5)
Female	4 (80.0)	16 (84.2)
Other	0 (0.0)	0 (0.0)
Prefer not to answer	0 (0.0)	0 (0.0)
Number of years as an RN or nurse techb			.00
0-5	4 (80.0)	0 (0.0)
6-10	0 (0.0)	10 (52.6)
11-15	0 (0.0)	2 (10.5)
16-25	1 (20.0)	2 (10.5)
25+	0 (0.0)	4 (21.1)
Number of years as a CCU RN or nurse techb			.39
0-5	4 (80.0)	6 (31.6)
6-10	0 (0.0)	6 (31.6)
11-15	0 (0.0)	1 (5.3)
16-25	1 (20.0)	3 (15.8)
25+	0 (0.0)	2 (10.5)
Number of years as at CMH Venturab			.14
0-5	4 (80.0)	4 (21.1)
6-10	0 (0.0)	8 (42.1)
11-15	0 (0.0)	2 (10.5)
16-25	1 (20.0)	3 (15.8)
25+	0 (0.0)	1 (5.3)
Emotional well-being prior to the pandemic			.21
Excellent	0 (0.0)	4 (21.1)
Good	3 (60.0)	13 (68.4)
Fair	2 (40.0)	1 (5.3)
Poor	0 (0.0)	1 (5.3)
Very poor	0 (0.0)	0 (0.0)
Prefer not to answer
Emotional well-being at the time of survey vs prior to the pandemic			.51
Better	0 (0.0)	2 (10.5)
Somewhat better	1 (20.0)	2 (10.5)
Undecided	2 (40.0)	3 (15.8)
Somewhat worse	2 (40.0)	6 (31.6)
Worse	0 (0.0)	6 (31.6)
Satisfaction with work prior to the pandemic			.11
Completely satisfied	0 (0.0)	2 (10.5)
Very satisfied	2 (40.0)	9 (47.4)
Moderately satisfied	1 (20.0)	8 (42.1)
Slightly satisfied	0 (0.0)	0 (0.0)
Not at all satisfied	0 (0.0)	0 (0.0)
Prefer not to answer	2 (40.0)	0 (0.0)
Satisfaction with work at the time of survey			.25
Completely satisfied	0 (0.0)	0 (0.0)
Very satisfied	0 (0.0)	4 (21.1)
Moderately satisfied	3 (60.0)	6 (31.6)
Slightly satisfied	1 (20.0)	6 (31.6)
Not at all satisfied	0 (0.0)	3 (15.8)
Prefer not to answer	1 (20.0)	0 (0.0)
There is value in group support or therapy			.22
Strongly agree	0 (0.0)	9 (47.4)
Agree	3 (60.0)	6 (31.6)
Undecided	2 (40.0)	3 (15.8)
Disagree	0 (0.0)	1 (5.3)
Strongly disagree	0 (0.0)	0 (0.0)

Abbreviations: CCU, critical care unit; CMH, Community Memorial Hospital; RN, registered nurse.

^a(0) and (1) indicate number of participants in that category.

^bMissing data for 1 participant.

Table 3. Prevalence of Use of Organization-Offered Structured CCU Support Group (N = 19)^a.

Demographics	No Use of Structured Group (0) (N = 1), n (%)	Use of Structured Group (1) (N = 18), n (%)	P
Age,b y			1.00
≤24	0 (0.0)	0 (0.0)
25-34	1 (100.0)	6 (33.3)
35-44	0 (0.0)	5 (27.8)
45-54	0 (0.0)	2 (11.1)
55-64	0 (0.0)	4 (22.2)
Gender identityb			1.00
Male	0 (0.0)	2 (11.1)
Female	1 (100.0)	15 (83.3)
Other	0 (0.0)	0 (0.0)
Prefer not to answer	0 (0.0)	0 (0.0)
Number of years as an RN or nurse techb			1.00
0-5	0 (0.0)	0 (0.0)
6-10	1 (100.0)	9 (50.0)
11-15	0 (0.0)	2 (11.1)
16-25	0 (0.0)	2 (11.1)
25+	0 (0.0)	4 (22.2)
Number of years as a CCU RN or nurse techb			1.00
0-5	1 (100.0)	5 (27.8)
6-10	0 (0.0)	6 (33.3)
11-15	0 (0.0)	1 (5.6)
16-25	0 (0.0)	3 (16.7)
25+	0 (0.0)	2 (11.1)
Number of years as at CMH Venturab			.56
0-5	1 (100.0)	3 (16.7)
6-10	0 (0.0)	8 (44.4)
11-15	0 (0.0)	2 (11.1)
16-25	0 (0.0)	3 (16.7)
25+	0 (0.0)	1 (5.6)
Emotional well-being prior to the pandemic			.11
Excellent	0 (0.0)	4 (22.2)
Good	0 (0.0)	13 (72.2)
Fair	1 (100.0)	0 (0.0)
Poor	0 (0.0)	1 (5.6)
Very poor	0 (0.0)	0 (0.0)
Prefer not to answer
Emotional well-being at the time of survey vs prior to the pandemic			1.00
Better	0 (0.0)	2 (11.1)
Somewhat better	0 (0.0)	2 (11.1)
Undecided	0 (0.0)	3 (16.7)
Somewhat worse	0 (0.0)	6 (33.3)
Worse	1 (100.0)	5 (27.8)
Satisfaction with work prior to the pandemic			1.00
Completely satisfied	0 (0.0)	2 (11.1)
Very satisfied	1 (100.0)	8 (44.4)
Moderately satisfied	0 (0.0)	8 (44.4)
Slightly satisfied	0 (0.0)	0 (0.0)
Not at all satisfied	0 (0.0)	0 (0.0)
Prefer not to answer	0 (0.0)	0 (0.0)
Satisfaction with work at the time of survey			1.00
Completely satisfied	0 (0.0)	0 (0.0)
Very satisfied	0 (0.0)	4 (22.2)
Moderately satisfied	1 (100.0)	5 (27.8)
Slightly satisfied	0 (0.0)	6 (33.3)
Not at all satisfied	0 (0.0)	3 (16.7)
Prefer not to answer	0 (0.0)	0 (0.0)
There is value in group support or therapy			1.00
Strongly agree	1 (100.0)	8 (44.4)
Agree	0 (0.0)	6 (33.3)
Undecided	0 (0.0)	3 (16.7)
Disagree	0 (0.0)	1 (5.6)
Strongly disagree	0 (0.0)	0 (0.0)

Abbreviations: CCU, critical care unit; CMH, Community Memorial Hospital; RN, registered nurse.

^a(0) and (1) indicate number of participants in that category.

^bMissing data for 1 participant.

RESULTS

Table 1 provides descriptive statistics for age, gender identity, number of years as an RN or nurse tech, number of years as a CCU RN or nurse tech, number of years at the Community Memorial Hospital in Ventura, emotional well-being prior to the pandemic, emotional well-being at the time of survey versus prior to the pandemic, satisfaction with work prior to the pandemic, satisfaction with work at the time of survey, if there is value in group support or therapy, the utilization of psychological or emotional support during the pandemic, and the types of emotional support methods utilized during the pandemic. Of the 24 participants, approximately 41.7% (n = 10) were between the ages of 25 and 34 years and 83.3% (n = 20) were female. In terms of years of service, 41.7% (n = 10) of participants indicated having worked as an RN or nurse tech for 6 to 10 years, 41.7% (n = 10) of participants have worked as a CCU RN or nurse tech for 0 to 5 years, and approximately 66.6% (n = 16) of the participants indicated having worked at the organization in Ventura between 0 and 10 years. When reporting their emotional well-being prior to the pandemic, 83.3% (20) of participants indicated an emotional well-being of “good” or “excellent” in comparison with 16.7% (n = 4) of participants who indicated an emotional well-being of “fair” or “poor.” When asked about their emotional well-being at the time of the survey versus prior to the pandemic, 20.8% (n = 5) of participants indicated “somewhat better” or “better,” another 20.8% (n = 5) of participants were undecided, and 58.3% (n = 14) of participants indicated “somewhat worse” or “worse.”

Fisher's exact test was used to determine if there was a significant association between utilization of psychological or emotional support and select covariates from Table 1 (Table 2) and to determine if there was a significant association between the use of organization-offered CCU support group and select covariates from Table 1 (Table 3). The bivariate model outlined in Table 2 indicated that there is a statistical significance between the utilization of psychological or emotional support and the number of years as an RN or nurse tech (P < .001). However, the bivariate model outlined in Table 3 yielded no statistically significant results.

Participants who attended the organization-offered support group were able to provide additional feedback in the form or 2 free response questions that asked (1) what they found most helpful about the support group and (2) if they had any suggestions for improvements moving forward. Overwhelmingly, participants shared that they found it helpful to share their experience with their peers because it made them realize that they are not alone. They also shared that they found it helpful to have a clinical psychologist facilitate the group's discussion to help them process their difficult experience. In terms of improvements, participants shared that they would like for leadership to acknowledge their difficult experience, for the group meetings to continue meeting regularly, for weekly discussion topics, and to emphasize confidentiality among the group.

Nursing leader's observations after starting the support group included the following:

• Increased willingness to participate in precepting new employees;

• Increased engagement in learning activities—2 employees even traveled out of state for ECMO training;

• Return of focus to unit-based governance councils and projects to improve the department;

• Less lateral violence;

• Increased evidence of empathy;

• Greater ability of staff to identify and intervene when another staff member is distressed;

• Recognition that other clinicians (physicians, pharmacists, therapists, etc) also experienced moral distress and needed emotional support;

• Elimination of requests to “opt out” of being assigned COVID-19 patients;

• Increased vocalization of staff that they appreciated the support group;

• Staff were more emotionally prepared for the COVID-19 surge in January 2022;

• Emotions switched from sadness to anger when patients/family/visitors refused to get vaccinated;

• Staff perceived value in support group being available to them; and

• Leadership did presentation for staff to remember the joy in their work and provided tools to find joy.

DISCUSSION

The purpose of this evaluation was to determine if a structured emotional support group reduced distress in critical care nurses during the COVID-19 pandemic. The sample size for this study was very small; however, this evaluation proposes suggestions on how to improve this type of program in the future (eg, giving participants a pre- and postintervention group participation survey to evaluate them at baseline and postintervention, randomized study with an intervention and control arm, etc). The participants provided great feedback that we can implement in future events. This evaluation results suggest that the structured emotional support group had the desired impact of improved staff morale and job satisfaction.

CONCLUSIONS

This evaluation found a statistically significant difference in the participant's behaviors before and after attending the structured emotional support group. This finding aligns with the literature, which supports strategies to protect nurses' mental well-being1,2 and to take preventive measures in critical situations.3–6 Using this as a foundation, a structured emotional support group can change nurse engagement and involvement in their process and practice, during times of crisis. Many other benefits could be realized from this model, such as improved nursing practice and processes, reduced clinician burnout, improved nurse satisfaction, and improved recruitment and retention.