1. Brown, Robin PhD, RN
  2. Abuatiq, Alham PhD, RN

Article Content

In healthcare, change is inevitable. Hospitals constantly engage in change to become more competitive and cost effective, which can have a tremendous impact on staff at every level of the organization. Nurses who work in hospital settings aren't immune to the effects of organizational change, and these effects may be underestimated by leadership.1 How nurses cope with change is often overlooked and underresearched.2

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Organizational change occurs when business strategies or major sections of an organization are altered. This is also known as reorganization, restructuring, or turnaround.3 Frequent changes in an organization can lead to change resistance or change fatigue. Change resistance involves intentional, disruptive behaviors utilized to sabotage change.4 In contrast, change fatigue is more passive; staff members become disengaged and apathetic about the changes, not openly expressing their dissent.5 Change fatigue can lead to an overwhelming feeling of stress, exhaustion, and workplace burnout, affecting nurses' overall health and well-being.5


Organizational change can lead to both positive and negative outcomes, but most research focuses on the negative effects of change, such as anger, anxiety, stress, and frustration. In addition, organizational change may negatively impact both the physical and psychological well-being of nurses if its rate is perceived as being too frequent.6 Employees negatively affected by change are more likely to report stress and emotional exhaustion, less likely to trust their employer, and more likely to leave the organization within the next year.1,5,7


According to a 2017 American Psychological Association study, 55% of employees experiencing organizational change reported feeling chronic stress, compared with 22% who didn't experience change. In addition, 35% reported adverse physical symptoms from their stress, including eating and smoking more during the workday, compared with only 8% who didn't encounter an organizational change.1 Researchers have also found that constant change within an organization leads to an increase in sick time, turnover rates, and change fatigue and a decrease in productivity, organizational commitment, and job satisfaction.5,6,8


The 2019 National Health Care Retention & RN Staffing Report indicated that the turnover rate for clinical nurses rose from 16.8% in 2017 to 17.2% in 2018.9 Nurses working in burn care, women's health, surgical services, and pediatrics recorded the lowest turnover rates, whereas those working in behavioral health, telemetry, and emergency care experienced the highest turnover rates. The cost of turnover for a clinical nurse ranges from $40,300 to $64,000, resulting in the average hospital losing $4.4 million to $6.9 million annually.9


One solution for lowering nursing turnover rates and decreasing anxiety, stress, and burnout is building resilience-the capacity to move forward in a positive way from traumatic or stressful experiences.10 In fact, the word resilience comes from the Latin resilire, meaning to leap back or spring back.11 Resilience is a dynamic process that allows individuals to access resources to cope with and recover from adversity.12 And it can be learned; the more experience and success in stress regulation that an individual has, the more he or she is equipped to deal with future stressors.10


This article explores the concept of resilience and how resilience training for nurses can help protect against the negative effects of stress caused by organizational change.


Literature review

A literature review was conducted using the Cumulative Index to Nursing and Allied Health Literature and EBSCO databases, with the keywords organizational change, resilience, and nurses. The following inclusion criteria were applied: published between 2008 and 2018, written in English, included research on resilience and organizational change, and focused on resilience in nursing practice. In total, 11 articles met the inclusion criteria (9 quantitative studies, 1 qualitative study, and 1 systemic literature review). After analysis, two main themes emerged: resilience and organizational change for nurses and other disciplines and resilience training for nurses in clinical practice.


Resilience and organizational change for nurses, other disciplines

Minimal research has been conducted on nurses' experiences with resilience and organizational change. According to Shirey, understanding personal resilience is crucial to drive effective change because people who possess high levels of resilience can more readily accept change without experiencing traumatic and debilitating consequences.13 Nurses often display high levels of emotional exhaustion, which is caused by stress in the hospital environment. Emotional exhaustion may be the result of changes in the work environment. Manzano, Garcia, and Ayala Calvo examined emotional annoyance (gradual state of psychological exhaustion) and resilience related to emotional exhaustion with 200 nurses in Spain.7 The study reported a significant association between emotional annoyance and emotional exhaustion. Nurses with higher resilience levels displayed a lower risk of emotional exhaustion.


Change fatigue in nurses is another negative effect of constant organizational change that's been minimally researched. To date, one study has been conducted with clinical nurses comparing change fatigue and resilience.8 Using a multiple regression model, the study reported that change fatigue and resilience had a negative association; however, it wasn't significant. The study found that hospital size was a predictor of change fatigue; as number of beds increased, change fatigue increased. Gender was a significant predictor of change fatigue, with male nurses having higher change fatigue scores than female nurses. In addition, education was a predictor of resilience; as education increased, resilience increased.


Although there's minimal research on nurses, organizational change, and resilience, other disciplines have been more well studied. Shin and colleagues found that resilience had a positive effect on nonnurse employees' commitment to organizational change and turnover.14 The findings of this study suggested that employees with higher resilience responded more favorably to organizational change by using resilience as a coping measure. Sherlock-Storey, Moss, and Timson offered a brief coaching intervention with nonnurse participants during an organizational change.15 Participants reported significant positive changes in resilience levels and confidence when dealing with organizational change after participating in the coaching program.


Using a randomized controlled trial, Rogerson and colleagues investigated the effectiveness of a 5-hour, work-based resilience intervention program with nonnurses during a time of organizational change.16 Their study reported significantly higher resilience scores in the intervention group than the control group.


Resilience training for nurses in clinical practice

There's been a growing interest in building employee resilience. Numerous studies have reported the positive effects of resilience training, and findings indicate that resilience training can improve resilience, reduce stress, and promote employee well-being.16-20


Resilience training programs come in different forms but, unfortunately, no research has compared the effectiveness of the different programs.19 Studies that implemented resilience training with healthcare workers showed positive results. McDonald, Jackson, Wilkes, and Vickers offered six resilience workshops and a mentoring program over a 6-month period to 14 nurses and midwives.10 The intervention benefited the participants in both personal and professional areas by enhancing confidence, self-awareness, assertiveness, and self-care. Chan and colleagues sent questionnaires to healthcare workers in Singapore inquiring about previous mental health training.21 The study reported that those with resilience training were twice as likely to be resilient.


Pipe and colleagues examined how two workplace resilience sessions using HeartMath affected healthcare workers.18 The first session was a 5-hour course that focused on the impact of stress on the body-mind-spirit. The second session was a 2-hour session that built on basic techniques. Individuals were taught to recognize their stress symptoms and use learned skills to counteract the negative effects of stress, including the opportunity to use heart rate variability feedback. The study indicated that the intervention promoted positive strategies for coping and enhancing well-being both personally and organizationally.


A systematic review of studies that included resilience training in the workplace from 2003 to 2014 was conducted by Robertson, Cooper, Sarkar, and Curran.19 Findings showed that resilience training can improve resilience and is a useful way to develop mental health and subjective well-being among employees. Resilience training has several additional benefits, including enhanced psychosocial functioning and improved performance. The researchers recommended that future research use comparative designs to assess the utility of different training regimes; explore whether some people may benefit more or less from resilience training; and demonstrate consistency in how resilience is defined, conceptualized, developed, and assessed.


Ren and colleagues conducted an exploratory study on resilience and its influencing factors among hospital nurses in Guangzhou, China.22 The sample included 1,356 nurses from 11 general hospitals. Results revealed that the mean total score of nurses' resilience was significantly lower than the general population in China. Factors influencing nurses' resilience included self-efficacy, coping style, job stress, and education level. The researchers concluded that nurses had low resilience and couldn't effectively cope with job challenges and recover from adversity. This study recommended enhancing educational training, strengthening self-efficacy, choosing active coping, and decreasing job stress as strategies to effectively improve nurses' resilience.


Ramalisa and colleagues conducted a qualitative study describing how to strengthen nurses' resilience in a work environment with involuntary mental health patients.23 Nurses caring for involuntary mental health patients are faced with challenging situations while experiencing their own internal conflict. The researchers recommended the following factors to strengthen nurses' resilience: support, security measures and safety, teamwork, and staff-development programs and education.


Magtibay, Chesak, Coughlin, and Sood conducted a study to assess the efficacy of blended learning to decrease stress and burnout among nurses through use of the Stress Management and Resiliency Training (SMART) program.24 The end points of mindfulness, resilience, anxiety, stress, happiness, and burnout were measured at baseline, postintervention, and 3 months after to examine within-group differences. Findings showed statistically significant, clinically meaningful decreases in anxiety, stress, and burnout and increases in resilience, happiness, and mindfulness. Results supported blended learning using the SMART program as a strategy to increase access to resiliency training for nursing staff.


Mealer and colleagues conducted a randomized controlled trial of a resilience intervention with 27 ICU nurses.25 A 2-day educational workshop was offered, and both the intervention and control groups showed improved resilience scores and a significant decrease in posttraumatic stress disorder. Kemper and Rao offered a brief online resilience training program with 379 healthcare professionals and found a small but significant improvement in resilience, stress, positive and negative affect, and flourishing.26


Implications for nursing practice

Resilience is a learned quality that can be used to cope with stressful situations.27 This literature review demonstrates that resilience training is effective in improving resilience and reducing workplace stress and burnout. Other disciplines report a positive effect from resilience; however, there's minimal research involving nurses. To date, there's one correlational study of clinical nurses, change fatigue, and resilience. Additional research is needed to further understand the role of resilience for nurses dealing with organizational change. Also, future research using comparative designs to assess the effectiveness of the different types of resilience training is needed.


It's helpful for nurse managers to understand the negative effects of organizational change on clinical nurses. Offering resilience training programs may counteract these negative effects. There are different types of structured resilience training programs; for example, Magtibay and colleagues found a decrease in anxiety, stress, and burnout and an increase in resilience, happiness, and mindfulness among nurses who participated in the SMART program.24 In addition, Pipe and colleagues found that the HeartMath program promoted positive coping strategies. There's a cost associated with these educational programs, but the positive effects may outweigh the burden of the high cost associated with nurse turnover.18


Mitigate the negative

Building resilience is essential for nurses dealing with work-related stress. Resilience can be developed through training or self-development programs to mitigate the negative effects of organizational change.


INSTRUCTIONS Resilience as a strategy to survive organizational change



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