key: cord-0716438-qtcirstv
authors: Grabbe, Linda; Higgins, Melinda K.; Baird, Marianne; Pfeiffer, Katherine M.
title: Impact of a Resiliency Training to Support the Mental Well-being of Front-line Workers: Brief Report of a Quasi-experimental Study of the Community Resiliency Model
date: 2021-04-06
journal: Med Care
DOI: 10.1097/mlr.0000000000001535
sha: 68e9a5bd0e10bb42cc6d2549f26f7f9a4caf342e
doc_id: 716438
cord_uid: qtcirstv

Front-line workers (FLW) are at risk for secondary traumatic stress, burnout, and related psychiatric sequelae: depression, anxiety, suicidality, posttraumatic stress disorder, and sleep and substance use disorders. FLW are in need of self-care programs to support their mental health. METHODS: Quasi-experimental study to assess the impact of a simple mental well-being and emotional regulation training, the Community Resiliency Model (CRM), using a convenience sample of FLW. Baseline scores of mental well-being and stress measures were compared with follow-up scores at 3 time points. Outcomes were psychological wellness (World Health Organization-5 Well-being Index); resilience (Connor-Davidson Resilience Scale-10); traumatic stress (Secondary Traumatic Stress Scale); physical symptoms (Somatic Symptom Scale-8). RESULTS: Of the 104 participants who enrolled and attended the CRM training, 73 (70.2%) completed at least 1 posttest. Well-being scores increased at 1 year with a small-moderate effect size (Cohen d=0.32). Resilience scores increased with a small-moderate effect size by 1 year (Cohen d=0.36). Secondary traumatic stress scores declined, with the largest effect at 1 week (Cohen d=0.49). Somatic symptoms decreased at each posttest, with the largest change occurring from baseline to 1 week (d=0.39). Participants reported an awareness of body sensations helped them when overwhelmed as a means of calming themselves. CONCLUSIONS: After a 3-hour CRM training, participants reported improved mental well-being and decreased secondary traumatic stress and somatic symptoms. This simple body awareness intervention may be a good resource during the COVID-19 pandemic.

N urses, physicians, police, fire fighters, social service workers, mental health providers, and pharmacists are front-line health care workers (FLW) who regularly interface with distressed persons, and are at risk for secondary traumatic stress, burnout, and related psychiatric sequelae: depression, anxiety, suicidality, posttraumatic stress disorder (PTSD), and sleep and substance use disorders. [1] [2] [3] [4] [5] When FLW suffer psychologically, they may become emotionally depleted, disengaged, have difficulty making decisions, retire early, or engage in self-harm. 6 ,7 These problems have been documented in law enforcement, 2 nursing and medical students, 3, 4 pharmacists, 5 first responders, [8] [9] [10] and health care providers. 7, 11 Resiliency, that is, thriving and growing despite stressors, is a known protective factor against stress, but many resiliency interventions require multiple sessions and have a cognitive focus. 12, 13 Because autonomic reactions to stress and trauma cause somatic responses, 14 an argument may be made for a preventative, body-based wellness intervention. [15] [16] [17] [18] Bodybased resiliency approaches take advantage of interoception (awareness of sensations in the body).

The Community Resiliency Model (CRM) is a noncognitive variant of mindfulness, emphasizing attunement to interoceptive and exteroceptive signaling cues for regulation of autonomic responses to stress. 17 CRM was derived from somatic psychotherapy and developed by Miller-Karas and colleagues after survivors of natural disasters received brief, somatically based, self-stabilization interventions using their own body sensations to improve mood; lower rates of PTSD occurred subsequently. 15, 17, 19, 20 In the 2008 Sichuan Earthquake, 350 FLW learned CRM and the majority later used these skills for their own emotion regulation and with the disaster survivors. 15 Marginalized groups with cumulative traumas have also demonstrated significant improvement in mental wellneess with daily use of CRM. 21 Finally, in CRM's only randomized controlled trial of hospital nurses, the CRM group demonstrated significantly reduced secondary traumatic stress and physical complaints and improved well-being and resiliency after a single 3-hour CRM session; participants used CRM's simple interoception techniques (eg, noticing the sensation of touching their scrubs) during tense or chaotic clinical situations, codes, and with dying patients. 22 We examined the impact of a 1-time CRM intervention on a heterogeneous convenience sample of FLW including nurses, physicians, student nurses, hospital pharmacists, chaplains, and community mental health/social service providers in a large Southeastern US city. This study was conducted as an add-on to the above-mentioned randomized controlled trial because of space availability and included nurses from other institutions.

Research questions: (1) What is the impact over time of a brief CRM class on the participants' sense of well-being, resiliency, secondary traumatic stress symptoms, and somatic symptoms, and (2) What are participant perceptions regarding the utility and applicability of the intervention?

Participants were a convenience sample of community and hospital FLW who met inclusion criteria as health care, public safety, or social service providers, and who responded to an e-mail invitation sent to over 200 persons for a free CRM training. Some participants heard about the training and asked to attend. One hundred four persons responded to the invitation and completed the informed consent and a pretest survey. The majority of participants attended a single 3-hour long CRM class in Winter through Summer of 2018; some participants attended a shorter, more intensive session due to time constraints. Given the completion of 55 or more participants at the 3-month follow-up, the study was powered at 80% to detect moderate effect sizes ( 

The CRM intervention is a manualized set of self-care skills and concepts 17 which were taught in a classroom. Participants received psychoeducation on the biological responses to stress and trauma (physical signs and symptoms) and gained tools to recognize and diminish these reactions. They learned CRM's concept of the Resilient Zone (RZ), an individual's bandwidth for stress tolerance, where it is possible to think clearly and work effectively. Leaving this internal state of balance is due to common stress responses of either excess sympathetic or parasympathetic discharge (Fig. 1) . Learners developed an awareness of their autonomic nervous system state to identify and override the unpleasant sensations associated with distress, and, using CRM's 6 techniques, learned to shift into a restorative, parasympathetic state. Through practice, learners may experience greater self and other compassion because of a widened RZ and know how to return to their RZ when distressed. 17 Not only are CRM skills useful for self-calming (which may help calm others), but they may be used to teach patients, even in a conversational manner ("What is a source of strength for you right now?…As you talk about that, what do you notice happening in your body?").

The class was interactive in nature-with practice trying out the skills, for example, resourcing in pairs and eating a snack using the 5 senses. Three of the investigators, Certified CRM teachers, taught the class. See Table 1 CRM app (iChill), narrated by Miller-Karas, which covers all of CRM's concepts and skills.

The pre-post survey included 4 valid and reliable quantitative instruments of physical and emotional health, collected before the training, and at 1 week, 3 months, and 1 year posttraining. The measures included:

The World Health Organization-5 Well-being Index (WHO-5); 5-items 0-5; higher scores = greater well-being; range: 0-25; total scores multiplied by 4 to rescale from 0 to 100; cut-point of poor mental well-being < 50. 23 The Connor-Davidson Resilience Scale-10 (CD-RISC); 10-items 0-4; higher scores = greater resilience and stress tolerance; range 0-40; low resilience ≤ 29. 24, 25 The Secondary Traumatic Stress Scale (STSS); 17-items of frequency of stress symptoms 1-5; higher scores = greater frequency; range of total STSS 17-85; higher total score = more secondary trauma; cutoff score of 38 or higher suggests that individuals are experiencing PTSD. 26 The Somatic Symptom Scale-8 (SSS-8); 8-items 0-4; range 0-32; cut points indicate none to mimial (0-3), low (4-7), medium (8) (9) (10) (11) , high (12) (13) (14) (15) , or very high (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) somatic symptom burden. 27 Participant feedback regarding the learning experience was gathered at the end of the classes. Qualitative data were gathered electronically at each posttest, including frequency and type of skill use, and responses to the following: Can you give an example of how CRM was helpful to you? In what settings did you use CRM? The authors used simple cut and paste techniques to organize themes and examples of the responses.

Participants entered presurvey and postsurvey data directly into the REDcap (Research Electronic Data Capture) system for data collection and management. 28, 29 Descriptive statistics were computed for all demographics and final instrument scores at each survey time point. Internal consistency reliability was assessed for each instrument by computing Cronbach α for item responses at baseline. Multilevel linear models were used to model the changes over time for repeated measures and adjust for missing data due to attrition over time, followed-up by post hoc tests performed using Sidak pairwise error rate adjustment. 30 P-values for statistical tests are reported; however, emphasis has been placed on reporting effect sizes and clinically descriptive differences 31 ; effect sizes (Cohen d) were computed based on the change scores from baseline to each follow-up time point 32 to evaluate small (d = 0.2), moderate (d = 0.5), and large (d = 0.8) effect sizes to interpret clinically meaningful improvements. Percentages of subjects whose scores improved from baseline were also reported. All computations were performed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp, Armonk, NY).

Participants were highly engaged in the trainings, and enthusiastic about using the simple skills, many wanting a longer class; 4 (physician, chaplains, and nurse) subsequently certified as CRM teachers themselves with the Trauma Resource Institute. Characteristics of participants are reported in Table 2 Across all 3 time points, the most-reported used skill was grounding, followed by tracking and resourcing. Use of the iChill app ranged from 10% (posttest 2) to 22% (posttest 3). Daily or weekly use of skills ranged from 49% (posttest 2) to 63% (posttest 1). Participants reported using the skills in personal and work situations and responses were related to better self-understanding, monitoring body sensations, regulating emotions, work-life balance, and use with patients. Themes and sample quotes are included in Table 4 .

In this study, a simple, somatic awareness training improved FLW well-being; after receiving the 1-time CRM intervention, study participants demonstrated significantly improved mental well-being and decreased secondary traumatic stress and somatic symptoms; these outcomes were sustained over 1 year. FLW experience barriers in accessing mental health care because of cultures of stoicism and selfreliance, stigma over psychological "weakness," and fears of loss of confidentiality and job security. 8 For these reasons, FLW may be willing to engage in a simple strength-based resiliency training that explains distressing trauma responses as biological in nature and not due to mental weakness. In the COVID-19 pandemic, severe pressure, inadequate resources, moral conflicts, and fears of infection may lead FLW to moral injury, shame, guilt, disgust, low self-esteem, and chronic mental health problems. 33 Five health care workers' needs from their organizations during the COVID-19 pandemic are: to be heard, protected, prepared, supported, and cared for. 34 Now may be an opportune moment for organizations to integrate trauma and resiliency competencies into medical, nursing, law enforcement, and first-responder training and professional development. These competencies, already developed by a national panel of nursing experts, may be adapted for other professions. 35 The level of exposure to trauma among FLW has dramatically increased during the COVID-19 pandemic. Bolstering mental well-being for FLW via the least resource-intensive, prevention-focused interventions is crucial. [36] [37] [38] Programs to organizations to create a common language around resilience and shift to a model of systemic empathy.

This research was conducted with a nonrandom, noncontrolled sample, using only self-report measures. The posttest sample sizes diminished over time, lowering the statistical power to detect significant differences. The study was insufficiently powered at the 1-year point, so those data are descriptive only; a future larger study needs to be done to determine long-term effects with better statistical power. Motivational factors contributing to selection bias are unknown. Few men, paramedics, and police enrolled in the study; few participants accessed the iChill app. Finally, heterogeneity of the sample reduced specificity of the research findings.

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The authors wish to thank the study participants, Connie Buchanan, Richard Higgins, and Drs Jordan Murphy, Sandra Dunbar, Anita Nelson, and Terence Chorba for their encouragement and support. The authors wish to acknowledge the Mundito Foundation for earlier funding that inspired this study.