Psychological interventions to foster resilience in healthcare professionals

Abstract

Background

Resilience can be defined as the maintenance or quick recovery of mental health during or after periods of stressor exposure, which may result from a potentially traumatising event, challenging life circumstances, a critical life transition phase, or physical illness. Healthcare professionals, such as nurses, physicians, psychologists and social workers, are exposed to various work‐related stressors (e.g. patient care, time pressure, administration) and are at increased risk of developing mental disorders. This population may benefit from resilience‐promoting training programmes.

Objectives

To assess the effects of interventions to foster resilience in healthcare professionals, that is, healthcare staff delivering direct medical care (e.g. nurses, physicians, hospital personnel) and allied healthcare staff (e.g. social workers, psychologists).

Search methods

We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.

Selection criteria

Randomised controlled trials (RCTs) in adults aged 18 years and older who are employed as healthcare professionals, comparing any form of psychological intervention to foster resilience, hardiness or post‐traumatic growth versus no intervention, wait‐list, usual care, active or attention control. Primary outcomes were resilience, anxiety, depression, stress or stress perception and well‐being or quality of life. Secondary outcomes were resilience factors.

Data collection and analysis

Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post‐test only).

Main results

We included 44 RCTs (high‐income countries: 36). Thirty‐nine studies solely focused on healthcare professionals (6892 participants), including both healthcare staff delivering direct medical care and allied healthcare staff. Four studies investigated mixed samples (1000 participants) with healthcare professionals and participants working outside of the healthcare sector, and one study evaluated training for emergency personnel in general population volunteers (82 participants). The included studies were mainly conducted in a hospital setting and included physicians, nurses and different hospital personnel (37/44 studies).

Participants mainly included women (68%) from young to middle adulthood (mean age range: 27 to 52.4 years). Most studies investigated group interventions (30 studies) of high training intensity (18 studies; > 12 hours/sessions), that were delivered face‐to‐face (29 studies). Of the included studies, 19 compared a resilience training based on combined theoretical foundation (e.g. mindfulness and cognitive‐behavioural therapy) versus unspecific comparators (e.g. wait‐list). The studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support.

Risk of bias was high or unclear for most studies in performance, detection, and attrition bias domains.

At post‐intervention, very‐low certainty evidence indicated that, compared to controls, healthcare professionals receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.45, 95% confidence interval (CI) 0.25 to 0.65; 12 studies, 690 participants), lower levels of depression (SMD −0.29, 95% CI −0.50 to −0.09; 14 studies, 788 participants), and lower levels of stress or stress perception (SMD −0.61, 95% CI −1.07 to −0.15; 17 studies, 997 participants). There was little or no evidence of any effect of resilience training on anxiety (SMD −0.06, 95% CI −0.35 to 0.23; 5 studies, 231 participants; very‐low certainty evidence) or well‐being or quality of life (SMD 0.14, 95% CI −0.01 to 0.30; 13 studies, 1494 participants; very‐low certainty evidence). Effect sizes were small except for resilience and stress reduction (moderate). Data on adverse effects were available for three studies, with none reporting any adverse effects occurring during the study (very‐low certainty evidence).

Authors’ conclusions

For healthcare professionals, there is very‐low certainty evidence that, compared to control, resilience training may result in higher levels of resilience, lower levels of depression, stress or stress perception, and higher levels of certain resilience factors at post‐intervention.

The paucity of medium‐ or long‐term data, heterogeneous interventions and restricted geographical distribution limit the generalisability of our results. Conclusions should therefore be drawn cautiously. The findings suggest positive effects of resilience training for healthcare professionals, but the evidence is very uncertain. There is a clear need for high‐quality replications and improved study designs.

Plain language summary

Psychological interventions to foster resilience in healthcare professionals

Background
The work of healthcare professionals (e.g. nurses, physicians, psychologists, social workers) can be very stressful. They often carry a lot of responsibility and are required to work under pressure. This can adversely affect their physical and mental health. Interventions to protect them against such stresses are known as resilience interventions. Previous systematic reviews suggest that resilience interventions can help workers cope with stress and protect them against adverse consequences for their physical and mental health.

Review question
Do psychological interventions designed to foster resilience improve resilience, mental health and other factors associated with resilience in healthcare professionals?

Search dates
The evidence is current to June 2019. The results of an updated search of four key databases in June 2020 have not yet been included in the review.

Study characteristics
We found 44 randomised controlled trials (studies in which participants are assigned to either an intervention or a control group by a procedure similar to tossing a coin). The studies tested a range of resilience interventions in participants aged on average between 27 and 52.4 years.

Healthcare professionals were the focus of 39 studies, with a total of 6892 participants. Four studies included mixed samples (1000 participants) of healthcare professionals and non‐healthcare participants. One study of resilience training for emergency workers examined 82 volunteers.

Of the included studies, 19 compared a combined resilience intervention (e.g. mindfulness and cognitive‐behavioural therapy) versus unspecific comparators (e.g. a wait‐list control receiving the training after a waiting period). Most interventions (30/44) were performed in groups, with high training intensity of more than 12 hours or sessions (18/44), and were delivered face‐to‐face (i.e. with direct contact and face‐to‐face meetings between the intervention provider and the participants; 29/44).

The included studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support.

Certainty of the evidence
A number of things reduce the certainty about whether or not resilience interventions are effective. These include limitations in the methods of the studies, different results across studies, the small number of participants in most studies, and the fact that the findings are limited to certain participants, interventions and comparators.

Key results
For healthcare professionals, resilience training may improve resilience, and may reduce symptoms of depression and stress immediately after the end of treatment. Resilience interventions do not appear to reduce anxiety symptoms or improve well‐being. However, the evidence found in this review is limited and very uncertain. This means that, at present, we have very little confidence that resilience interventions make a difference to these outcomes. Further research is very likely to change the findings.

Very few studies reported on the longer‐term impact of resilience interventions. Studies used a variety of different outcome measures and intervention designs, making it difficult to draw general conclusions from the findings. Potential adverse events were only examined in three studies, showing no undesired effects. More research is needed of high methodological quality and with improved study designs.

Authors’ conclusions

Implications for practice

There is very uncertain evidence that resilience interventions are effective in improving resilience or certain resilience‐related factors such as optimism, self‐reported symptoms of depression, and stress or stress perception at post‐test (small and moderate effect sizes).The generalisability and applicability of the available evidence is limited by the scarcity of studies with long‐term follow‐up, the divergent efficacy measures used to assess resilience, the heterogeneous design and content of interventions (with a dominance of high‐intensity face‐to‐face interventions delivered in a group setting), and the limited geographical locations (i.e. high‐income countries). In addition, we rated the certainty of the evidence from this review as being very low across all primary outcomes at post‐test. We therefore cannot draw strong conclusions about the effects of resilience interventions, as the true effect may be markedly different from the estimated effect.

We know little about the longer‐term effects of resilience training on most outcomes, because few studies included follow‐up assessments. Booster sessions were not conducted in any of the included studies.

The limited evidence that resilience training improves well‐being or quality of life and several resilience factors might indicate the need to adapt the current intervention techniques used.

Overall, the results of our review provide very uncertain evidence about whether resilience‐training programmes may be helpful in stabilising and improving the mental health of healthcare professionals as an occupational group with high stressor exposure.

Implications for research

The findings of this review point to the need for further research of high methodological quality in order to determine the efficacy of resilience interventions in healthcare professionals.For future research, a consensus on the definition of resilience and adequate outcome measures to be used consistently across the field would be important. Following the growing consensus on resilience as a dynamic outcome (Bonanno 2015; Kalisch 2017), intervention studies might be guided by this definition and examine resilience as a primary outcome (Chmitorz 2018). Due to only five studies measuring healthcare professionals’ stressor exposure (Berger 2011; Cieslak 2016; Gelkopf 2008; Varker 2012; Wild 2016), it remains unclear whether healthcare professionals really benefit from resilience training by being better able to cope with stressors. Future studies should therefore measure resilience as a person’s mental health in relation to individual stressor load. Only if the risk or stressor exposure (which is different from the subjective perception of stress) is assessed, may researchers gain knowledge about the changes in resilience by an intervention. In addition to the number of stressors, certain covariates such as the type of stressors (e.g. micro‐ versus macro‐stressors, psychological versus physiological stressors, acute versus chronic stressors) or the perceived severity of stressors should be assessed.

Study designs; there is a need for improved comparators, at least treatment as usual (TAU) or ideally active and attention control (Chmitorz 2018), to allow fair comparisons between resilience intervention and control. As already suggested (Chmitorz 2018), resilience‐training programmes could be implemented during or after the presence of a stressor. However, future studies should also use designs in which resilience training is provided prior to circumscribed stress situations (e.g. rotation of a physician to an emergency ward), in order to draw conclusions on resilience effects of the intervention, and to see whether the training does indeed improve resilience to the specific stress situation (Chmitorz 2018; Kalisch 2015). In general, pre‐ and post‐assessments of the outcome indicators (e.g. for resilience) should be conducted, with future studies also filling the gap of longer follow‐up periods and measuring the stressor exposure before, throughout and after the intervention. Also, it could be interesting to investigate whether booster sessions might help maintaining the effects of training over time. To ensure sufficient statistical power, the use of adequate sample sizes based on a priori analyses seems to be an urgent need in this field. Intervention studies might also benefit from comprehensive baseline diagnostics of mental health (e.g. clinical interview) and better reporting of eligibility criteria for pre‐existing mental symptoms. This would allow for more precise conclusions about whether resilience training reduces (clinically relevant) mental symptoms. Furthermore, the conceptual implications of the resilience concept would require a baseline mental health assessment. In order to investigate the effects of interventions on resilience (i.e. mental health in relation to stressor load) and to determine a specific ‘resilience pattern or trajectory’ under consideration, the status of psychological functioning as an outcome of interest at baseline is important. For example, when researchers are interested in testing the effects of an intervention in stressor‐exposed individuals on the resilience trajectory of sustained mental health (see also Description of the condition), they would have to prove a positive mental health level at baseline and at post‐intervention. On the other hand, researchers considering a sample with elevated levels of mental symptoms at pre‐test would be able to investigate the resilience trajectory of recovery or even of post‐traumatic growth, i.e. an increased level of functioning compared to outset prior to stressors. Beyond RCTs, dismantling designs could be helpful in clarifying the efficacy of single components of resilience training.

In general, there is a need for better reporting of intervention studies using international guidelines such as the CONSORT statement (Schulz 2010). To guarantee higher transparency of study conduct and reporting, primary investigators could register trials or publish study protocols according to the SPIRIT guidelines (Standard Protocol Items: Recommendations for Interventional Trials; Chan 2013a; Chan 2013b).

Finally, future studies in this field should focus more on male participants and on employees above the age of 50. Research efforts should be intensified in low‐ and middle‐income countries in order to reach more robust conclusions about the effectiveness of training across various settings. For certain formats of intervention (e.g. online‐ and mobile‐based), more studies would be desirable.

In sum, there is still a need for additional evidence to answer the question about which resilience interventions are really effective in healthcare professionals and how they should ideally be implemented.

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Psychological interventions to foster resilience in healthcare professionals

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors’ conclusions

Plain language summary

Psychological interventions to foster resilience in healthcare professionals

Authors’ conclusions

Implications for practice

Implications for research

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