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Strengthening Resilience and Reducing Stress in Psychosocial Care for Nurses

Practicing in Oncology Settings

Article  in  The Journal of Continuing Education in Nursing · January 2016

DOI: 10.3928/00220124-20151230-03

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Strengthening Resilience and Reducing Distress through a Continuing Education Program

in Psychosocial Care for Nurses Practicing in Oncology Settings

Haikel A. Lim, HBSSc, MSc

Research Associate1 and MD Candidate5

Joyce Y. S. Tan, HBSSc

Research Assistant1

Jianlin Liu, HBSSc

Research Assistant1

Joanne Chua, BSc, MSc, MPsy (Clinical)

Senior Clinical Psychologist and Assistant Head for Psychology2

Emily N. K. Ang, BN, MN, DN, Cert Ed, ONCC, CNCC, RN

Deputy Director (Oncology Nursing),3 Professor,4 and Head4

Ee Heok Kua, MBBS, MD

Senior Consultant Psychiatrist1 and Tan Geok Yin Professor for Psychiatry and Neuroscience2

Rathi Mahendran

Senior Consultant Psychiatrist1 and Associate Professor2,5

Accepted for publication in The Journal of Continuing Education in Nursing on 7 October 2015. The final publication is available at Slack Inc.
Please cite this article as: Lim, H. A., Tan, J. Y. S., Liu, J., Chua, J., Ang, E. N. K., Kua, E. H., & Mahendran, R.. (2015). Strengthening
resilience and reducing distress through a continuing education program in psychosocial care for nurses practicing in oncology settings. The
Journal of Continuing Education in Nursing, in press.
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1
Department of Psychological Medicine, National University of Singapore, NUHS Tower

Block Level 9, 1E Kent Ridge Road, Singapore 119228

2
Department of Psychological Medicine, National University Hospital, NUHS Tower

Block Level 9, 1E Kent Ridge Road, Singapore 119228

3
National University Cancer Institute, Singapore, National University Health System,

NUHS Tower Block Level 7, 1E Kent Ridge Road, Singapore 119228

4
Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore,

Clinical Research Centre, Block MD11 Level 2, 10 Medical Drive, Singapore 117597

5
Duke-NUS Graduate Medical School Singapore, 8 College Road, Singapore 169857

Corresponding Author:

Dr. Rathi Mahendran

Associate Professor and Senior Consultant Psychiatrist

Department of Psychological Medicine, National University of Singapore

NUHS Tower Block, Level 9

1E Kent Ridge Road, Singapore 119228

Email: rathi_mahendran@nuhs.edu.sg

DID: +65 6772 3893 Fax: +65 6777 2191

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Abstract

Resilience has been identified as key to protecting nurses against the sequelae of their

work and compassion fatigue; however, a recent review highlighted a lack of training programs

targeted at improving resilience and studies providing evidence that resilience can even be

strengthened in nurses. The present exploratory study sought to examine if a continuing

education program for nurses practicing in oncology settings targeted at improving their

knowledge, attitudes, and practice behaviours in psychosocial care would also have a secondary

effect of improving resilience and reducing distress in these nurses. Non-parametric correlation

analyses revealed that improvements in knowledge and self-reported practices were related to

improvements in resilience, and that improvements in resilience were associated with reductions

in distress. While more targeted research is required, findings provide preliminary evidence that

continuing education programs targeted at psychosocial care may also be helpful in improving

resilience in nurses and consequently reducing distress.

Keywords: Resilience; Continuing education training; Oncology nursing; Psychosocial care;

Distress
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Strengthening Resilience and Reducing Distress through a Continuing Education Program

in Psychosocial Care for Nurses Practicing in Oncology Settings

Nurses face numerous stressors on a daily basis within their clinical workplace that often

result in clinically significant distress, well-being impairments, and eventually lead to burnout

(Lim, Bogossian, & Ahern, 2010). These debilitating effects may affect nurses’ ability to

effectively care for their patients (Barnett, Baker, Elman, & Schoener, 2007); as such, fostering

psychosocial resources like resilience has been highlighted as key to improving patient care and

surviving compassion fatigue and burnout in nurses (Jackson, Firtko, & Edenborough, 2007).

Mental or psychological resilience is the ability and capacity to cope successfully with

significant change, adversity, or risk (Rutter, 1987), and thrive in the face of adversity (Connor

& Davidson, 2003). Nurses’ resilience can be strengthened through mentorship programs that

develop and nurture professional relationships, and encourage positivity, emotional insight,

holistic balance, spirituality, and personal reflection (Jackson et al., 2007). Strengthening

resilience also requires a multi-level approach that builds on strengths and capabilities of the

individuals, while maintaining sensitivity to culture and context (Ungar, 2008). A recent

literature review, however, found no formal training programs and thus no evidence even

suggesting that resilience can be strengthened in nurses (McCann et al., 2013).

While under- and post-graduate nursing education programs may already have begun

incorporating resilience training, there remains a population of nurses presently practicing in

highly stressful settings who may potentially benefit from such programs. These nurses, however,

are also often time-strapped, with few opportunities to reflect on their practice, much less attend

training sessions specifically targeted at personal (and not professional) improvement

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(McAllister & McKinnon, 2009). It was thus of interest to explore if nurse continuing education

training programs may have a secondary effect of improving resilience and reducing distress.

As part of a healthcare quality improvement project to introduce routine distress

screening in a national cancer centre in Singapore, all nurses practicing in the medical- and

radiation-oncology units were invited to attend a voluntary continuing education (CE) training

program in psychosocial care and distress management. The two-hour standardised program

sought to improve (theoretical and applied) knowledge, attitudes, and practice behaviours (KAPb)

of these 180 nurses with various experience and training. The program was conducted in two

segments: a formal didactic session, which provided information on tools for measuring

emotional distress, clinical scenarios of patient presentations, and relaxation techniques such as

progressive muscle relaxation and controlled breathing; and a small group role-playing session

(of six to ten nurses) who were provided clinical scenarios for experiential learning facilitated by

psychologists and psychiatrists. The program outline and its efficacy have been described in

detail elsewhere (Mahendran et al., 2014); results revealed that the program improved applied

knowledge and self-reported practice behaviours and were sustained over 12-weeks.

The present study thus sought to investigate if changes in KAPb following such a CE

training program for nurses, would be associated with changes in their resilience and distress. It

was hypothesized that, after the CE program, improvements in KAPb (measured by the KAPb

Scale; Mahendran et al., 2014), would be positively correlated with improvements in resilience

(measured by the Resilience Scale; Wagnild, 2011) and reductions in distress (as measured by

the General Health Questionnaire; Goldberg & Williams, 1988).

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A subset of data from 162 female nurses (77% registered nurses) practicing in the

medical-oncology setting (65% inpatient settings; 53% had less than four years of experience)

that had attended the aforementioned CE training program and completed both baseline (one-

week pre-CE program) and follow-up measures (eight weeks post-CE program) were used for

the present analyses. Change scores were calculated by subtracting the baseline from the follow-

up scores of the measures of interest. All participants provided informed consent and the present

study had ethics approval from the Institutional Review Board at the National University of

Singapore.

As seen in Table 1, findings from these exploratory analyses revealed that improvements

in overall KAPb, specifically theoretical knowledge, applied knowledge, and practice behaviours

were positively correlated with improvements in resilience. Participants’ knowledge, attitudes,

and practice behaviours were unrelated to distress, but improvements in resilience were

correlated with reductions in distress. While no follow-up qualitative interviews were conducted

to examine processes underlying these findings, it is interesting to speculate on possible reasons.

Learning about the prevalence and effect of psychological distress on cancer patients’

treatment outcomes and prognoses, and the various ways in which nurses could play a part in

alleviating this sequelae may have resulted in a greater sense of participants’ self-efficacy and

community capability about managing such patients, which may have led to improvements in

resilience (Ungar, 2008). Participants may thus have been more likely to interact and engage

with patients on the causes of their distress, and offer skills (e.g., deep breathing or progressive

muscle relaxation) to alleviate distress symptoms, which may have also reinforced self-efficacy

and improved resilience. In their interactions with patients and identifying causes of distress,

participants may also have experienced patients’ adversity by proxy. This may have triggered
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personal reflection via social comparisons and a broadened perspective on their own lives and

dealing with their stressors, which has been shown to improve resilience (Jackson et al., 2007).

While much is still speculative, these findings provide preliminary evidence that nurse

resilience can be strengthened. Continuing education programs for nurses targeted at improving

psychosocial care for patients may thus also have a secondary effect of improving participants’

resilience, and consequently reducing their distress. More research, however, is required to

ascertain the veracity of these results in other settings and organisational and national cultures.
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References

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Acknowledgements

The authors would like to express their sincere gratitude to the participants of this study,

as well as the various study team members and oncology healthcare professionals who have

assisted with, and supported, the study.

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