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NIHR Signal Training for clinical competence and resilience reduced job strain among intensive care nurses in France

Published on 5 February 2019

doi: 10.3310/signal-000726

A five-day educational course showed potential to reduce work-based stress and burnout among nurses working in intensive care units in France. The study conducted in multiple adult intensive care units aimed to identify the effects of an intensive, continuing medical education program on occupational stress. 

The course focussed on nursing theory, role-play and debriefing sessions. Six months after attending the programme, intensive care unit nurses showed reduced levels of job strain compared to their counterparts who had not received the course.

This study showed that a relatively short programme of training helped to reduce stress, sick leave and improve staff retention among intensive care unit nurses in the short- to medium-term. It is not known whether these effects have a lasting impact. This was a small-scale study of 198 nurses with different education and training systems. The results may need adapting and validating within a UK setting, but this study provides a useful addition to a growing evidence base on workplace learning and wellbeing.

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Why was this study needed?

Intensive care unit (ICU) nurses work in increasingly pressured environments and are often exposed to heightened levels of occupational stress. Psychological distress, posttraumatic stress disorder and burnout can be the result, and higher levels have been reported in this professional group. A recent UK survey of ICU nurses and physicians found raised levels of moral distress amongst the staff. Reasons included better patient survival rates but at a substantial cost to quality of life.

Workforce stress is of key concern for health service employers. It can lead to sickness, absence and high staff turnover resulting in poorer quality of service provision and reduced cost-effectiveness. There have been calls to address this problem. This study aimed to identify if a multimodal education program was effective in reducing job stress in ICU nurses.

What did this study do?

This randomised controlled trial involved 198 nurses from eight adult ICUs in France. An intensive five-day course including simulation, role play and debriefing was given to 101 randomly-selected nurses.

Outcomes were compared to a control group of the remaining 97 nurses who did not receive the course. A valid and reliable measure known as the Job Content Questionnaire was used to assess stress levels in both groups before, and six months after the course. 

Any lasting effects of the education programme beyond six months are not captured by this study. It is also unclear which components of the training course had a direct impact on the overall outcomes of the study, and further investigation of this is suggested.

What did it find?

  • After six months, job strain was 13% in the group receiving the education programme and 67% in the group not receiving training (mean difference [MD] -54%, 95% confidence interval [CI] -40 to -64). This was based on levels of perceived psychological demand and decision latitude – the use of personal skills, autonomy and varied tasks.
  • During the six month follow-up period, absenteeism was 1% in the group who received the education programme compared to 8% in the control group (MD - 7%, 95% confidence interval [CI] -1 to -15).
  • Four nurses in the education group left the ICU compared to 12 in the control group over the six month follow-up period (MD - 8, 95% confidence interval [CI] 0 to 17).
  • The five-day intervention cost the employer 2000 Euros per nurse.

What does current guidance say on this issue?

The NICE 2105 guideline on workplace health provides generic advice focussing on the fostering of supportive work environments to promote positive health and wellbeing.  The UK Health and Safety Executive management 2018 standards for work-related stress provide risk management strategies for employers to use in mitigating for poor health and wellbeing in the workplace. 

Whilst there is a considerable amount of published literature identifying high stress in ICU staff, there are currently no specialist guidelines on how to ease stress within this specific group.

What are the implications?

This study worked on the assumption that training focused on clinical competence and resilience would improve the ability to cope with work-related stress. The results show potential for favourable outcomes in achieving reduced job strain, absenteeism and retention of ICU nurses. An understanding of what components of the program contribute to the outcomes is still needed.

It is noteworthy that the costs to NHS employers of this type of staff training are likely to considerably outweigh the costs of absenteeism and possibly poor staff retention. Training for nurses before and after registration is different in France compared to the UK, and use of simulation is widespread in this country. However, it is useful to see experimental studies of workplace interventions that address common problems of staff wellbeing and retention in this way. 

Citation and Funding

El Khamali R, Mouaci A, Valera S et al; SISTRESSREA Study Group. Effects of a multimodal program including simulation on job strain among nurses working in intensive care units: A randomized clinical trial. JAMA. 2018;320(19):1988-97.

This research was funded by grant PHRIP 14-0061 from the French Ministry of Health (Programme Hospitalier de Recherche Infirmière et Paramédicale [PHRIP]) and by funding from the Assistance Publique–Hôpitaux de Marseille.  No conflicts of interest were declared.

Bibliography

Azoulay E, Herridge M. Understanding ICU staff burnout: the show must go on. Am J Respir Crit Care Med. 2011:184(10):1099-1100.

Colville GA, Dawson D, Rabinthiran S et al. A survey of moral distress in staff working in intensive care in the UK. J Intensive Care Soc. 2018:0(0):1-8.

HSE. What are the management standards? London: Health and Safety Executive; 2018.

Kumar A, Sore P, Gupta S, Wani A. Level of stress and its determinants among intensive care unit staff. Indian J Occup Environ Med. 2016:20(3):129-32.

Moss M, Good VS, Gozal D et al. An official critical care societies collaborative statement: burnout syndrome in critical care health care professionals: a call for action. Am J Crit Care. 2016:25(4):368-76.

NICE. Workplace health: management practices. NG13. London: National Institute for Health and Care Excellence; 2015.

Seaman JB, Cohen TR, White DB. Reducing stress on clinicians working in the ICU. JAMA. 2018:320(19):1981-82.

Van Mol MM, Kompanje EJ, Benoit DD et al. The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PLoS One. 2015:10(8):e0136955.

Why was this study needed?

Intensive care unit (ICU) nurses work in increasingly pressured environments and are often exposed to heightened levels of occupational stress. Psychological distress, posttraumatic stress disorder and burnout can be the result, and higher levels have been reported in this professional group. A recent UK survey of ICU nurses and physicians found raised levels of moral distress amongst the staff. Reasons included better patient survival rates but at a substantial cost to quality of life.

Workforce stress is of key concern for health service employers. It can lead to sickness, absence and high staff turnover resulting in poorer quality of service provision and reduced cost-effectiveness. There have been calls to address this problem. This study aimed to identify if a multimodal education program was effective in reducing job stress in ICU nurses.

What did this study do?

This randomised controlled trial involved 198 nurses from eight adult ICUs in France. An intensive five-day course including simulation, role play and debriefing was given to 101 randomly-selected nurses.

Outcomes were compared to a control group of the remaining 97 nurses who did not receive the course. A valid and reliable measure known as the Job Content Questionnaire was used to assess stress levels in both groups before, and six months after the course. 

Any lasting effects of the education programme beyond six months are not captured by this study. It is also unclear which components of the training course had a direct impact on the overall outcomes of the study, and further investigation of this is suggested.

What did it find?

  • After six months, job strain was 13% in the group receiving the education programme and 67% in the group not receiving training (mean difference [MD] -54%, 95% confidence interval [CI] -40 to -64). This was based on levels of perceived psychological demand and decision latitude – the use of personal skills, autonomy and varied tasks.
  • During the six month follow-up period, absenteeism was 1% in the group who received the education programme compared to 8% in the control group (MD - 7%, 95% confidence interval [CI] -1 to -15).
  • Four nurses in the education group left the ICU compared to 12 in the control group over the six month follow-up period (MD - 8, 95% confidence interval [CI] 0 to 17).
  • The five-day intervention cost the employer 2000 Euros per nurse.

What does current guidance say on this issue?

The NICE 2105 guideline on workplace health provides generic advice focussing on the fostering of supportive work environments to promote positive health and wellbeing.  The UK Health and Safety Executive management 2018 standards for work-related stress provide risk management strategies for employers to use in mitigating for poor health and wellbeing in the workplace. 

Whilst there is a considerable amount of published literature identifying high stress in ICU staff, there are currently no specialist guidelines on how to ease stress within this specific group.

What are the implications?

This study worked on the assumption that training focused on clinical competence and resilience would improve the ability to cope with work-related stress. The results show potential for favourable outcomes in achieving reduced job strain, absenteeism and retention of ICU nurses. An understanding of what components of the program contribute to the outcomes is still needed.

It is noteworthy that the costs to NHS employers of this type of staff training are likely to considerably outweigh the costs of absenteeism and possibly poor staff retention. Training for nurses before and after registration is different in France compared to the UK, and use of simulation is widespread in this country. However, it is useful to see experimental studies of workplace interventions that address common problems of staff wellbeing and retention in this way. 

Citation and Funding

El Khamali R, Mouaci A, Valera S et al; SISTRESSREA Study Group. Effects of a multimodal program including simulation on job strain among nurses working in intensive care units: A randomized clinical trial. JAMA. 2018;320(19):1988-97.

This research was funded by grant PHRIP 14-0061 from the French Ministry of Health (Programme Hospitalier de Recherche Infirmière et Paramédicale [PHRIP]) and by funding from the Assistance Publique–Hôpitaux de Marseille.  No conflicts of interest were declared.

Bibliography

Azoulay E, Herridge M. Understanding ICU staff burnout: the show must go on. Am J Respir Crit Care Med. 2011:184(10):1099-1100.

Colville GA, Dawson D, Rabinthiran S et al. A survey of moral distress in staff working in intensive care in the UK. J Intensive Care Soc. 2018:0(0):1-8.

HSE. What are the management standards? London: Health and Safety Executive; 2018.

Kumar A, Sore P, Gupta S, Wani A. Level of stress and its determinants among intensive care unit staff. Indian J Occup Environ Med. 2016:20(3):129-32.

Moss M, Good VS, Gozal D et al. An official critical care societies collaborative statement: burnout syndrome in critical care health care professionals: a call for action. Am J Crit Care. 2016:25(4):368-76.

NICE. Workplace health: management practices. NG13. London: National Institute for Health and Care Excellence; 2015.

Seaman JB, Cohen TR, White DB. Reducing stress on clinicians working in the ICU. JAMA. 2018:320(19):1981-82.

Van Mol MM, Kompanje EJ, Benoit DD et al. The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PLoS One. 2015:10(8):e0136955.

Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care Units: A Randomized Clinical Trial

Published on 26 October 2018

El Khamali, R.,Mouaci, A.,Valera, S.,Cano-Chervel, M.,Pinglis, C.,Sanz, C.,Allal, A.,Attard, V.,Malardier, J.,Delfino, M.,D'Anna, F.,Rostini, P.,Aguilard, S.,Berthias, K.,Cresta, B.,Iride, F.,Reynaud, V.,Suard, J.,Syja, W.,Vankiersbilck, C.,Chevalier, N.,Inthavong, K.,Forel, J. M.,Baumstarck, K.,Papazian, L.

Jama , 2018

Importance: Nurses working in an intensive care unit (ICU) are exposed to occupational stressors that can increase the risk of stress reactions, long-term absenteeism, and turnover. Objective: To evaluate the effects of a program including simulation in reducing work-related stress and work-related outcomes among ICU nurses. Design, Setting, and Participants: Multicenter randomized clinical trial performed at 8 adult ICUs in France from February 8, 2016, through April 29, 2017. A total of 198 ICU nurses were included and followed up for 1 year until April 30, 2018. Interventions: The ICU nurses who had at least 6 months of ICU experience were randomized to the intervention group (n = 101) or to the control group (n = 97). The nurses randomized to the intervention group received a 5-day course involving a nursing theory recap and situational role-play using simulated scenarios (based on technical dexterity, clinical approach, decision making, aptitude to teamwork, and task prioritization), which were followed by debriefing sessions on attitude and discussion of practices. Main Outcomes and Measures: The primary outcome was the prevalence of job strain assessed by combining a psychological demand score greater than 21 (score range, 9 [best] to 36 [worst]) with a decision latitude score less than 72 (score range, 24 [worst] to 96 [best]) using the Job Content Questionnaire and evaluated at 6 months. There were 7 secondary outcomes including absenteeism and turnover. Results: Among 198 ICU nurses who were randomized (95 aged </=30 years [48%] and 115 women [58%]), 182 (92%) completed the trial for the primary outcome. The trial was stopped for efficacy at the scheduled interim analysis after enrollment of 198 participants. The prevalence of job strain at 6 months was lower in the intervention group than in the control group (13% vs 67%, respectively; between-group difference, 54% [95% CI, 40%-64%]; P < .001). Absenteeism during the 6-month follow-up period was 1% in the intervention group compared with 8% in the control group (between-group difference, 7% [95% CI, 1%-15%]; P = .03). Four nurses (4%) from the intervention group left the ICU during the 6-month follow-up period compared with 12 nurses (12%) from the control group (between-group difference, 8% [95% CI, 0%-17%]; P = .04). Conclusions and Relevance: Among ICU nurses, an intervention that included education, role-play, and debriefing resulted in a lower prevalence of job strain at 6 months compared with nurses who did not undergo this program. Further research is needed to understand which components of the program may have contributed to this result and to evaluate whether this program is cost-effective. Trial Registration: ClinicalTrials.gov Identifier: NCT02672072.

Expert commentary

This multi-centre French study provides valuable preliminary evidence supporting the use of a simulation-based intervention to mitigate the risks of burnout and reduce the number of nurses leaving the speciality.

This is an important area of investigation for UK healthcare, with nursing vacancies now exceeding 40,000 and it is reasonable to suppose that study findings also apply to a UK context. The addition of some qualitative data would, however, have helped explain why this intervention was successful and what components were valued most.

The intervention was estimated to cost approximately 2,000 Euros per nurse, a significant investment, which can only be justified with greater clarity around the factors likely to impact its success.

Dr Suzanne Bench, Associate Professor, London South Bank University