The well-being, including the resilience, of OR nurses might be at risk, leading to high staff turnover and possible low standards of patient care as a result of their adverse working conditions (Woldehawariat 2012). A comprehensive approach is necessary to contribute to a more positive work environment for OR nurses (Näslund Andréasson 2011; Registered Nurses Association of Ontario 2006) and to strengthen OR nurses’ resilience (Koen & Du Plessis 2011). As part of a research programme to strengthen the resilience of health caregivers – the RISE programme – Koen and Du Plessis (2011) suggest that it might be valuable to explore and describe SST as an intervention to strengthen nurses’ resilience.

OR nurses in a private hospital in the North West Province seemed to experience a very low morale and decreased productivity because of shortages of experienced OR nurses and a high workload. These OR nurses need an opportunity to develop resilient attributes in order to ultimately improve quality in health care. It was not clear if SST might be effective to strengthen the resilience of nurses, leading to the following research question: Can the resilience of OR nurses be strengthened by means of SST?

A literature review was conducted to explore concepts related to this research. Databases and search engines were used, namely Science Direct, Sabinet, PubMed and EbscoHost, using the following key words: well-being, resilience, OR nurses and SST.

As no research has previously been conducted regarding the implementation of SST in an OR as part of an approach to strengthen resilience a quasi-experimental design (Polit & Beck 2012) was used. The researcher decided on the specific design for the following reasons: A small sample size was available for the study. Thus, non-randomisation was applied. Furthermore, a natural environment was used for the study so that the findings can be generalised to similar departments in the hospital environment. Although the sample size was small, the findings may be generalised to specific related departments in the hospital. The intervention was implemented over a time period of 2 consecutive months. A pre- and post-test contributed to accurate results after the implementation of the intervention.

Using a pilot, intervention and a comparison groups, pre- and post-intervention data were collected from all three groups to evaluate the impact of the SST intervention and to rule out internal validity threats (Christensen, Johnson & Turner 2011; Polit& Beck 2012).

Pilot study: A pilot study was conducted with 8 subjects in a smaller OR in a private hospital to ensure that instructions and the resilience questionnaire were clear and to determine unanticipated effects (Polit & Beck 2012). The subjects indicated that they found the questionnaire clear and they did not suggest any changes. Thus, the resilience scale questionnaire was deemed feasible, reliable, valid and useable in this specific population. The data collected by means of the pilot study could be included as comparison group data, as it was highly similar to data collected from the actual comparison group.

Pretest: All three participating groups completed a resilience questionnaire developed by Wagnild and Young (1993) as the pretest to determine their resilience levels. The resilience questionnaire has been validated in previous studies (Girtler et al. 2010; Nishi et al. 2010; Wagnild 2009; Wagnild & Young 1993), and permission to use the questionnaire was obtained from the original authors.

Resilience has five imperative characteristics on which Wagnild and Young developed the resilience scale, namely purpose, perseverance, self-reliance, equanimity and existential aloneness (Wagnild 2010). Questions are scored on a 7-point scale, ranging from 1 = disagree to 7 = agree. Final scores on the resilience scale can vary between 25 and 175. The higher the score, the more resilient an individual is. The following are various resilience levels: 25–100 very low, 101–115 low, 116–130 moderate low, 131–145 moderate high, 145–160 high and 161–175 very high (Wagnild & Young1993).

The scale represents a high degree of internal consistency (Abiola & Udofia 2011). During the pretest in this research, a good internal consistency with a Cronbach’s alpha coefficient of 0.88 was also obtained.

In addition, a structured self-report questionnaire was completed by the intervention group only, to determine their need for SST and suggestions regarding SST. The self-report questionnaire was compiled by the researcher, based on the objectives of the research and with the guidance of research supervisors. This questionnaire contained open and closed-ended questions with regard to subjects’ pre-knowledge of SST, previous participation in SST, their need for SST in the OR and their suggestions with regard to SST in the OR. These suggestions were taken into consideration when developing the SST intervention.

SST intervention: An SST intervention, namely a sensory stimulation room, was put in place and implemented with the intervention group for a period of 2 consecutive months. The sensory stimulation room was designed and implemented in the OR where the intervention group was situated, based on the intervention group’s needs and suggestions as well as according to relevant literature on SST. The sensory stimulation room was equipped with the following stimulating equipment: Bean bags and a massage chair to stimulate tactile senses, bubble tubes, laser optics, fibre optics and a disco ball continuously reflecting against the walls and mirrors stimulating individuals’ visual and tactile senses. It also included a nature wall unit with calm and relaxing effects to stimulate visual senses; aroma therapy with different aromas to stimulate the olfactory senses and soft, calming background music stimulating the auditory senses. Coffee, tea and sweet savouries were provided occasionally to stimulate subject’s gustatory senses. Dim lighting in the room had a relaxed and calm effect. Figure 1 illustrates the SST used in this study.

The use of the SST room was monitored by means of an anonymous attendance list. Each subject reported their visit to the SST room by writing the date and time spent in the room using an anonymous code on the attendance list. Subjects’ codes were only known by themselves and the researcher. A total of 396 visits were recorded during the 2 consecutive months. The most visits by one subject were 25 times and the least visits were 0 because of resignation and sinus reactions caused by the aroma therapy. The longest time spent in the SST room was approximately 30 min.

Post-test: After the implementation of the SST intervention, post-test data were collected from the intervention and comparison groups. Both groups once again completed the resilience questionnaire. The intervention group was also requested to write a short narrative on their experience in the SST room, in order to enrich results.

Descriptive inferential statistics were appropriate methods to analyse the gathered data and included measures such as frequency distribution, central tendency, variability and measures of relationships (Kremelberg 2011).

ANOVA theory was used with inferential statistics (Kremelberg 2011). Before the intervention, the different resilience levels of the groups were determined by ANOVA. ANOVA compares the statistical significance between two or more groups (Christensen et al. 2011).

A dependent t-test applied to each group in order to compare the method between the groups before and after the intervention. If p > 0.05 there will be no significant change. If p < 0.05, there will be a definite change.

To compare the method between the groups after the intervention an ANCOVA test was used where results were controlled for pre-resilience scores.

A statistical consultant assisted the researcher with the analyses of the data by means of STATISTICA (version 10) and SPSS (version 20, released 20.0.0) programmes (SPSS 2011; StatSoft 2011).

The self-report questionnaire and narratives were analysed by means of thematic coding (Howitt & Cramer 2010).

The results of the self-report questionnaire were that subjects of the intervention group all indicated that they have never participated in an SST intervention before and it was a first-time experience for them. All the subjects identified the same area for implementation of the SST room in the OR, namely a tea room. Subjects made valuable suggestions with regard to the SST room. To stimulate tactile senses, they suggested the use of bean bags, a massage chair, bubble tubes and fibre optics. For gustatory senses they suggested that coffee, tea, and snacks and biscuits should be available. They suggested the use of aromatherapy to stimulate olfactory senses, and calming background music to stimulate auditory senses. To stimulate visual senses they suggested bubble tubing, laser and fibre optics, moving lighting balls, mirrors and wall units. These suggestions were taken into consideration when setting up the SST intervention.

Subjects of all three groups were females with an average age of 43, and a standard deviation of 10.23. The minimum age of subjects was 21 and the maximum age 64. According to a p-value of 0.29 there was no significant difference in age.

In the pilot group, the average age of subjects was 48 with a standard deviation of 10.49. The average age of the comparison group was 44 with a standard deviation of 8.34, and the average age of the intervention group was 42 with a standard deviation of 10.91.

The health of subjects before the intervention was good overall: 21% of subjects’ health was excellent, 17% of subjects’ health was very good, 49% of subjects’ health was good and 13% of subjects’ health was fair. Results before the intervention indicated that 30% of subjects never felt depressed, whilst 6% of subjects felt depressed all the time. 29% of subjects indicated that they sometimes felt depressed and 35% frequently felt depressed.

After the completion of the resilience questionnaire Cronbach’s reliability coefficient was 0.875 with an average inter-item correlation of 0.232, indicating that the resilience questionnaire was reliable. Therefore, individual items are not discussed, but the total resilience of all three participating groups. Before the intervention the average resilience of all three participating groups was 137.83 with a standard deviation of 15.17 and a minimum of 99 and a maximum of 172. All three participating groups thus demonstrated moderate high levels of resilience. After the intervention the average resilience of all three participating groups was 142.27 with a standard deviation of 14.85 and a minimum of 96 and a maximum of 174. Thus, it reflects moderate high levels of resilience, as seen in Wagnild and Young’s (1993) differentiation of the various levels of resilience.

The short narratives written by the subjects in the intervention group confirm that their resilience might have been strengthened through the SST intervention. Themes emerging from the narratives included that SST created a warm, welcoming atmosphere, and that subjects experienced an immediate relief of tension when utilising the SST room.

Subjects shared that SST created a welcoming atmosphere and positive experience, especially when they could spend time in the SST room and experience a change from the clinical environment of the OR to a warmer atmosphere. A subject shared the following in a narrative: Die kere wat ek daar was het dit n mens rustig gemaak. Was n ontvlugting gewees van die werk. Het gevoel of n mens in die woud gaan stap met jou eie gedagtes. (The times I spent there made one quiet. Was an escape from work. Felt as if one walks in the forest with your own thoughts).

Immediate relief of tension was experienced, namely decreased stress levels, relaxation between cases, willingness to return positively to work conditions and increased resilience were reported after visits to the SST room. For example, one subject described her experience in the SST room as ‘a total escape from all the stress and high work demands’. Another subject shared the following: Ek kan met eerlikheid se dat die sensoriese kamer het wondere verrig vir my emosionele toestand. Dit was n kans om weer jouself by mekaar te kry en om rustig te wees en te oordink. Dit was n tyd om jouself weer te vind. (I can say with honesty that the sensory room did wonders for my emotional condition. It was a chance to get yourself together again and to be quiet and to reflect. It was a time to find yourself again).

Subjects also commented on the SST, namely that the time available to spend in the SST room was limited because of the nature and amount of theatre procedures. Subjects reported that the equipment used, according to their specific needs and suggestions, were sufficient. Although limited space allowed only a few visitors at a time, it still complied with the requirements for an SST room.

The Cronbach’s alpha reliability coefficients and Clark and Watson’s inter-item correlation coefficient (Clark & Watson 1995; Cronbach 1951) determined the internal consistency and reliability of the resilience questionnaire. The strength of the relationship between the variables was analysed by means of Cohen’s d effect size indicator before and after the intervention. Cohen’s criteria can be interpreted as d – 0.2 = small, d – 0.5 = medium and d – 0.8 = large (Christensen et al. 2011; Cohen 1988). As mentioned earlier, the Cronbach’s reliability coefficient was 0.875 with an average inter-item correlation of 0.232 in this research, indicating that the resilience questionnaire was reliable to measure the resilience of OR nurses.

Rigour is affected by four types of validity, namely statistical validity, internal validity, construct validity and external validity (Polit & Beck 2012). Statistical validity and construct validity were ensured by using an already existing and validated resilience questionnaire. Because this was a quasi-experimental study, internal validity could not be fully ensured, but it was strengthened through competent decisions with regard to the most appropriate design and method for the study, a thorough description of the intervention and monitoring of the use of the intervention. Furthermore, the themes obtained from the narratives confirmed that it might have been possible that the intervention contributed to strengthening the resilience of the subjects.

External validity was ensured to a limited extent, taking the relatively small sample size into consideration, through being able to apply the results in similar settings, namely other OR settings in private hospitals in the North West Province. In addition, intervention validity was ensured through conducting information sessions, continuously implementing the intervention, monitoring the utilisation of the intervention and daily maintenance of the SST room.