Caring for patients during the pandemic tested nurses' resilience. COVID-19 is not the first crisis to try their ability to push through hard times -- and it will not be the last. But building resilience over time can be more helpful than you can imagine.
All nurses can build resilience, according to Ronda Mintz-Binder, DNP, RN, CNE, Associate Professor, School of Nursing at Texas Tech University Health Science Center, Lubbock, Texas. "There is a huge connection -- a correlation -- between resiliency and stress," said Mintz-Binder. "If stress is extremely high, it's really hard to maintain that resiliency. If your resiliency is high and if you are able to build that, it helps to reduce job stress, burnout, compassion fatigue, etc."
Build Resilience by Reducing Stress
Building resilience involves reducing stress. Mintz-Binder, first author of the paper, "Exploring Strategies to Build Resiliency in Nurses During Work Hours," published in April 2021, studied how simple interventions that nurses can do on the job when they are experiencing stress could build resilience. Before COVID-19, Mintz-Binder and colleagues conducted a study at four Dallas-Fort Worth area hospitals surveying 90 medical-surgical nurses at those facilities. The nurse investigators created a toolkit of stress-relieving options based on nurse feedback and distributed it to those nurses. The toolkit included a short video about resiliency and stress and how to do the different activities in the kit.
Toolkits included techniques shown in the scientific literature to help with stress, including a lavender inhaler; coloring book and colored pencils; an activity book with puzzles; Sudoku and other brain teasers; free, downloadable, smartphone apps that reduce stress; and instructions for various breathing exercises.
Nurses in the study were asked to choose certain stress-reducing techniques and use them during 10 shifts in the following four to six weeks. Investigators gathered baseline data then asked nurses to complete short surveys right after using the interventions during work hours. They found that nurses were most likely to use the deep breathing techniques and lavender inhaler to relieve stress. Overall, the third most-used intervention was the coloring book, and fourth was Sudoku and brain teasers.
Lavender was the most used intervention with nurses under 30 years old.
Mintz-Binder admits this finding might be different during a COVID-19 crisis since nurses would have to think twice about using breathing techniques at the bedside. "Resiliency scores increased significantly over 10 shifts in six weeks," Mintz-Binder said. "Nurses felt more resilient and less stressed, according to self-reported stress levels. Most subjects, 97.1%, indicated the desire to continue using interventions beyond the study." Interestingly, nurses began by doing the interventions for only one to two minutes. But over the course of the study, they increased the time they devoted to the interventions to seven or eight minutes. Investigators also found, through nurse feedback before and during the study, that nurses routinely do not commit to taking breaks.
"Part of this is the culture created by leadership, including unit leaders," said Mintz-Binder. "Additionally, part of this is the personality of the nurses. It's stunning how they forgo breaks and work beyond their scheduled hours and barely make it to the bathroom, let alone eating and having breaks."
To encourage and support breaks often requires a culture change such as creating a soothing, enclosed replenishing space for nurses to go and eat or simply exist. Of course, that too might look differently during a pandemic like COVID-19. The area might be outdoors, for example. "More and more hospitals are creating these rooms," Mintz-Binder said. "I recently presented a second study at a Sigma Theta Tau Nurses Healthy Work Environment conference and found that there is a profound emphasis on really encouraging and supporting nurses to take the time off that they need." Mintz-Binder is a nurse researcher at one of the hospitals studied. She said her employer encourages nurses to take breaks, and the hospital has had relatively low nurse turnover despite a high COVID-19 caseload. Even though the pandemic may subside with vaccines, it will likely take time for bedside nurses to emotionally and psychologically recover from the trauma of the pandemic. "Any way that we can offer nurses immediate and quick interventions during work hours is essential, whether it is during a COVID-19 crisis or any other crisis or emergency," Mintz-Binder said. "I think nurses need to commit to one, two, or three strategies that feel good and work for them. The point is to actively and consistently take the time to practice them."
Protect, Listen, and Empower
Cynda Hylton Rushton, PhD, RN, FAAN, Anne and George L. Bunting Professor of Clinical Ethics and Professor of Nursing and Pediatrics at Johns Hopkins University, says it is important to recognize that the demands of the pandemic have exceeded the resources of many nurses -- not because they are deficient but because there are limits to every person or system's ability to adapt to stress and adversity. "A rubber band can only stretch so far before it breaks," Rushton said. "In our Frontline WIKI Wisdom report, nurses suggested that three things were needed to avoid the consequences of the pandemic: Protect us, listen to us, and empower us. This pandemic is not over, and we need to take the long view of how to fundamentally change the culture of health care." Regarding resilience, Rushton said there are a number of validated tools to measure different aspects. For example, general resilience can be measured by validated scales such as the Connor-Davidson Resilience Scale or Brief Resilience Scale. Rushton and colleagues recently validated the Rushton Moral Resilience Scale, which is free to use. Nurse.com covered Rushton's work in moral distress in the article, "Nurse author address moral distress in nursing in new book". According to Rushton, things shown in studies to help build resilience include, mindfulness, which is developing the neuropathways to support mental and emotional stability by focusing attention, calming the nervous system, and resetting when we are knocked out of our resilience zone. The most studied is the Mindfulness Based Stress Reduction Program.
Pause, Reflect, and Respond to Build Resilience
Rushton offers these tips for how nurses can build resilience: Pause. Do this first to calm your nervous system. You can do this with three slow, deep breaths as you draw up your meds or listen to your patient's heart or lungs with your stethoscope. As you do this, notice any tension in your body, how you are feeling right now, and what your mind is focused on. Finding space to pause throughout the day helps to reduce the buildup of stress and distress. Reflect. Once your nervous system has calmed, reflect on why you're a nurse and why you have chosen this path of service. This is both an anchor and a resource to motivate nurses to continue to show up and serve. This can happen in a breath in the midst of chaos, [when] nurses need the discipline to stay focused on what matters most and what is right in front of them. Nurse can also reflect on where their stress or distress is coming from -- where is there dissonance, confusion, or uncertainty? Realistically appraising the situation without being swept away by fear can help them maintain focus. Respond rather than react. Choose your responses. Being clear about what you are responsible for helps to reduce the burden of over responsibility. When you can respond with compassion rather than judgement, you are more likely to reduce the detrimental effect of the adversity and chaos. Know yourself and your limits. Learn to say no with integrity and let go of the unrealistic expectations that reinforce martyrdom and self-sacrifice. Extend compassion toward yourself. You are doing the best you can right now. Conserve energy. Fighting with reality will only add to exhaustion. Notice what depletes you and what nourishes you. Allow yourself to ask for what you need. Asking for help is a profound act of integrity. Create connections. Pause in a huddle to share something you are grateful for or just to check in. Remind yourself that you are not alone. Give and receive gratitude. You cannot be grateful and angry at the same time. Find small moments of gratitude during the day. Keep a gratitude journal and say "thank you" when someone offers you appreciation. Let go of what no longer serves. Create a daily ritual to let go of things left undone, are beyond your control, or require forgiveness. Editor's Note: This blog post was recognized as a Bronze winner in the Media/Publications category of the Spring 2022 Digital Health Awards. 
