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: 

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.

Read the full 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 strategy: 

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).

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