A mixed methods process evaluation of the Promoting Resilience in Nurses (PRiN) randomised controlled trial

Background: Mental health nursing work can involve substantial stressors including occupational violence, heavy workloads and caring for consumers with trauma and mental distress. These stressors may negatively impact nurses’ wellbeing and practice and affect workforce retention. Psychological resilience is the dynamic process of positive adaptation and recovery of wellbeing following stress and adversity. Of importance, resilience can be developed and strengthened through targeted interventions. However, few resilience interventions have been reported in mental health nursing. Further, there are no prior parallel process evaluations of resilience interventions reported in the mental health nursing literature. To address this gap, this thesis comprises a mixed methods process evaluation conducted alongside a partially clustered randomised controlled trial of the Promoting Resilience in Nurses (PRiN) program with mental health nurses (MHNs) in a large Australian public mental health service during the COVID-19 pandemic. The PRiN program is an evidence-based manualised program delivered by trained facilitators in the workplace, with aims to promote nurses’ resilience, mental health, and wellbeing. Aim and Objectives: The overall aims of this thesis (with publication) were to 1) identify factors that may help explain variation in participant outcomes (between the intervention and control arms) in the randomised controlled trial of the PRiN program, and 2) evaluate the PRiN program implementation. Specific objectives were to: 1.Describe mental health nurses’ and managers’ perspectives on, and satisfaction with, the PRiN program. 2.Identify barriers and facilitators to implementation of the PRiN program. 3.Identify the extent to which the PRiN program was delivered as intended. 4.Explore and describe mental health nurses’ experiences of the PRiN program, and how they applied the knowledge and skills learnt in the program to their personal life and practice. 5.Explore the experience and impacts of the COVID-19 pandemic on the resilience of nurses in mental health settings. 6.Explore factors in implementation of the PRiN program that may help explain variation in trial outcomes between the intervention and control groups. Methods: A process evaluation methodology using a convergent mixed methods approach to data collection and analysis was employed. Data collection included program participant satisfaction surveys; follow-up semi-structured interviews with selected PRiN program participants; unit/team manager surveys on barriers and facilitators to staff participation in the program, and a program fidelity survey. Quantitative data were analysed descriptively, and qualitative data were subjected to thematic analysis. To address the first thesis aim, findings from each dataset were integrated with trial outcomes using joint display to generate meta-inferences. To address the second thesis aim, process evaluation findings were mapped to the Normalisation Process Theory (NPT) to deepen understanding of barriers and facilitators that influenced program implementation. Findings: The process evaluation produced several new findings. The PRiN program was successfully implemented in the health service with strong fidelity (95% full delivery). Nurses (n = 60) reported high satisfaction (mean = 4.5/5) with the program, and nurses and managers (n = 17) found PRiN valuable for nurses and supported its wider implementation. In the context of COVID-19, program nurses reported significant negative impacts on their wellbeing and practice but were able to develop and maintain resilience by drawing on their professional commitment and knowledge and skills gained from the PRiN program. Eight meta-inferences were generated from integration of trial outcomes and process evaluation findings. They indicated that positive changes to program nurses’ mental health, wellbeing, resilience and practice outcomes in the trial related to the program providing nurses with cognitive and emotional self-regulatory and stress management skills, new coping strategies, and interpersonal skills that helped them cope successfully with work and life challenges. Conclusion: This is the first parallel process evaluation of the PRiN program. The findings indicated the program was effective in strengthening MHNs’ wellbeing and resilience due to the knowledge and skills they developed. Recommendations include healthcare organisations routinely providing MHNs with resources and support for their wellbeing, including effective resilience interventions such as the PRiN program. Individual nurses are encouraged to utilise personal resources (e.g., coping strategies) and external support (e.g., peer support) to maintain their wellbeing and practice. The implementation of the PRiN program across settings and over time requires ongoing top-down support from leadership as well as bottom-up support from local leaders and champions (e.g., managers and senior nurses). PRiN can be situated within existing professional development structures to address the associated resources and costs and offered as a continuing professional development activity to encourage nurses to participate.