Adapting a self-affirmation intervention to support nurse wellbeing and patient safety

Research demonstrates that nurses often experience low levels of wellbeing and high burnout, and that this has been exacerbated throughout the COVID-19 pandemic. This is costly not only in terms of the emotional impact on individual staff, but also in terms of the financial implications resulting from staff absences and high turnover. Importantly, poor levels of wellbeing and high burnout have been shown to have implications for patient safety and patient care quality. Whilst there have been interventions implemented to help improve nurse wellbeing, many of these have been face-to-face and thus resource-intensive to administer. Therefore, there is a requirement for low-cost interventions to be available such as those in a self-administered format to facilitate ease of implementation and enhance accessibility for the nursing workforce. An intervention that is usually self-administered is self-affirmation. This intervention focuses upon values reflection. Self-affirmation interventions have been used in research previously to help improve levels of wellbeing, but have yet to be implemented to support nurse wellbeing.
This PhD aimed to explore the potential of a self-affirmation intervention in terms of nurse wellbeing and perceptions of patient care and safety. First, a systematic review and meta-analysis (chapter 2) was conducted to explore self-affirmation interventions and wellbeing outcomes in any population. The systematic review and meta-analysis found no overall impact of the intervention on improving mood outcomes. However it did suggest a potential buffering effect of self-affirmation for stress and burnout, indicating self-affirmations may benefit people experiencing stress only. The review did not include any studies with healthcare professionals as the population of interest. Nurses often experience high levels of stress and burnout, and may potentially benefit from an intervention such as self-affirmation. Therefore, study 1 aimed to explore the potential value of a values-based intervention such as self-affirmations in nurses. Semi-structured telephone interviews were conducted with registered nurses (study 1; chapter 3). The findings highlighted the importance of values and value congruence for nurse wellbeing and patient care and safety; supporting the potential of a values focussed intervention (i.e., self-affirmation) for registered nurses. In study 2 (chapter 4), nurses participated in a workshop to aid the adaptation of the self-affirmation intervention content and Think Aloud interviews helped refine the intervention and ensure acceptability and feasibility.
The initially planned final study of the PhD was a randomised controlled study to assess the effectiveness of the intervention alongside a qualitative evaluation. However, these plans were amended to explore the effectiveness of the intervention with the general population within the COVID-19 context to avoid adding any further demands on nurses. The randomised controlled study (chapter 5) found no effect of the intervention for improving wellbeing or patient care and safety proxy measures, demonstrating that self-affirmation is not effective for the purpose of boosting mood. These findings and their relation to the use of the intervention for supporting nurse wellbeing and patient care and safety are discussed (chapter 6).