Internationally, “emergency” levels of staff burnout and stress have recently been described and are linked to decreased job satisfaction, absenteeism, and increasing numbers of health care staff leaving their professions [1]. Health care professionals are facing increased pressure to provide high-quality, complex patient care while dealing with staff and infrastructure shortages and chronic, excessive workloads [2-4]. The potential impact of continued exposure to workplace environmental and psychological stressors on the mental health of health care professionals is substantial and is associated with increased depression, substance misuse, sleep disorders, and posttraumatic stress [5]. This picture exists across global health care settings, with staff burnout linked to poor quality health care and reduced patient safety outcomes [6]. The challenges outlined have intensified over the last 18 months owing to the COVID-19 pandemic, with the shock waves initiated undermining the resilience of health systems and the people working within them [7]. Health care professionals have had to support the delivery of expert patient care while rapidly responding to considerable health care challenges, such as understaffing, sickness, personal protective equipment requirements, rapidly changing clinical care policies, and increased patient care demands [8,9]. The psychological impact of delivering health care during COVID-19 has been substantial, with health care professionals working during the pandemic reporting increased levels of stress, distress, anxiety, fear, and depression [10-13]. Rates of burnout among nurses have risen as high as 80% globally during the pandemic [14] and an American study found that physicians’ feelings of burnout reached 61% [15]. As such, the development of strategies to improve the psychological health and well-being of health care staff and mitigate future burnout have been highlighted as key priorities [16,17]. A recent commentary published by the Lancet recommended a series of actions to mitigate this crisis among the health care workforce. These actions included health care practitioners being provided with regular Balint group sessions to discuss clinician-patient relationships with colleagues in comfortable environments, as well as access to resilience training programs for frontline health care staff [18].

The concept of resilience for health care professionals as a tool for negotiating workplace adversity has gained profile over the last decade, with increased importance placed on its benefits [5,19,20]. The term resilience is a dynamic construct that has been framed in several different ways [21]. However, conceptualizing resilience as “coping successfully despite adverse circumstances” recognizes that the tools that health care professionals use to remain resilient are affected by the daily challenges they encounter [22]. The purpose of this review is to measure changes in resilience that relate to relevant psychological constructs such as workplace stress and anxiety. As such, resilience can be defined as an individual’s ability to “adjust to adversity, maintain equilibrium, retain some sense of control over their environment, and continue to move on in a positive manner” [22,23]. Fostering resilience has been highlighted as important in promoting psychological health and well-being, as well as having additional benefits for the recruitment and retention of health care staff [5,22,24]. The protective role of resilience for health care professionals in coping with the ongoing pressures of the COVID-19 pandemic has also been identified [17,25-28].

In England, the National Health Service (NHS) Health and Wellbeing Framework sets the standards for how NHS organizations should support staff to feel well, healthy, and happy at work and advocate for delivering evidence-based staff health and well-being plans [29]. Several interventions have been developed to enhance resilience among health care professionals in both group and individual programs [21,30-36]. Resilience training programs and interventions aimed at health care professionals, such as resilience-building wellness apps [37], have also been developed so that they can be delivered in a range of contexts, including both face-to-face and web-based platforms, and using blended models of delivery [38]. The development of effective, evidence-based digital interventions was identified as playing a potentially important role during the COVID-19 pandemic when the introduction of new infection and prevention control measures constrained the provision of face-to-face interventions within health care organizations and the wider community [39].

A recent Cochrane review of interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic, found a lack of evidence to inform the selection of interventions that are beneficial to the resilience and mental health of frontline workers and identified that research to determine the effectiveness of interventions is a high priority. However, the review did not specifically focus on web-based interventions in enhancing resilience among health care professionals [23]. Similarly, a systematic review of interventions aimed at reducing workplace stress in health care workers found limited evidence for reduction in stress levels [40]. Another systematic review found that mindfulness-based stress reduction techniques were associated with improvement in burnout, stress, anxiety, and depression in health care staff [41]. These reviews did not focus specifically on web-based interventions. In addition, another Cochrane review examining the effectiveness of psychological interventions in fostering resilience in health care professionals suggested positive effects of resilience training but low certainty evidence that it resulted in higher levels of resilience and lower levels of depression, stress, or stress perception [38]. None of the reviews focused specifically on web-based training interventions.

This review aimed to assess the effectiveness of web-based interventions in enhancing resilience or reducing anxiety, depression, psychological distress, and trauma in health care professionals. It also seeks to identify whether specific components of web-based interventions effectively enhance resilience, evaluate the acceptability and tolerability of web-based interventions, and assess their potential economic impact. The review included studies dating back to 1990, with an expectation that the findings will be of use in developing mental health interventions for health care professionals during the pandemic.

We searched PubMed, CINAHL, PsycINFO, and Ovid SP for published and unpublished evidence on web-based interventions to enhance resilience in health care professionals, with keywords relevant to “internet,” “resilience,” and “health care professionals.” Details of the full search strategy are presented in Textbox 1. We restricted the search to records published between 1990 and July 2021, given that internet interventions did not exist before this year [43]. We inspected relevant reviews and reference lists of the included studies as additional sources of potentially eligible studies for inclusion in the review.

Titles and abstracts of the identified records were screened independently by at least 2 members (JH, BA, and ZD) of the review team. The full texts of the potentially eligible studies were subsequently reviewed (JH, BA, MJA, CH, and EO). Any discrepancies were resolved by consensus with a third review team member. Non-English papers were assessed by individuals proficient in that language. Where needed, the original authors were contacted to clarify eligibility and data availability further.

Two review team members (JH and BA) independently extracted study characteristics and outcome data using a digital data extraction form. Any discrepancies were resolved by consensus with a third review team member.

The quality of the included studies was assessed using the Risk of Bias 2 tool for randomized studies [44] and the Joanna Briggs Institute critical appraisal tool [45] for nonrandomized studies.

We conducted a quantitative synthesis by performing a random-effects pairwise meta-analysis. Where not possible, as specified a priori in our study protocol, a qualitative synthesis of the data set was undertaken. Data from the data extraction forms were synthesized and categorized according to the headings in the data extraction table. The qualitative synthesis process followed the recommendations of the Synthesis Without Meta-analysis reporting items PRISMA checklist extension [46].

A total of 4166 papers were identified from the database search, and their titles and abstracts were screened for eligibility based on the inclusion and exclusion criteria. This resulted in 32 remaining studies. The full texts of these studies were screened against the eligibility criteria, leaving 8 studies for inclusion. The screening process is outlined in the PRISMA diagram shown in Figure 1. Of the 8 studies included in this review, all had either randomized controlled trial (n=4, 50%) or pre-post study (n=4, 50%) designs.

Study start dates ranged from 2014 to 2020; one study did not provide this information. The study durations ranged from 1 week to 15 months; one study did not report this information [47]. Studies were conducted across a variety of international settings; 4 were conducted in the United States [48-50], whereas the remainder were conducted in Iran [47], Germany [51], Australia [52], and the Netherlands [53]. Study participants included a range of health care professional disciplines (n=1573), and studies were carried out in academic university settings [49,50,54] or on study programs within health care settings [48,51-53]; one study did not provide this information [47]. Of the 4 health care settings, 1 (25%) study was conducted in a rural primary care setting [52], 1 (25%) was conducted in hospital and ambulance departments [51], 1 (25%) was conducted across 2 urban hospitals and police and fire departments [48], and 1 (25%) was conducted across a variety of health care institutions [51]. The risk of bias for all studies was low, adding to our confidence in the study findings. Characteristics of the included studies are detailed in Table 1.

Of the 4 randomized controlled trial studies included in the review, all aimed to evaluate the impact of a web-based resilience, or proxy resilience, intervention in health care professionals directly involved in delivering patient care. One study focused on an intervention aimed at health care workers in general [53], one focused on physicians [52], one focused on nurses [51], and one focused on medical personnel and first responders during the COVID-19 pandemic [48]. The duration of the interventions varied, ranging from 1 week to 1 month.

The interventions of the studies were delivered via a variety of formats. These included web-based groups [52], mobile apps [48,53], and other web-based platforms [51]. Some studies adopted specific therapeutic approaches or techniques, including the Balint groups [52], the Mental Contrasting with Implementation Intentions technique [51], and a daily coping toolkit [48]. One study introduced ways to manage emotions and experiences, but the exact content or method implemented was unclear [53].

A total of 470 participants were recruited to the randomized controlled trial studies included in the review. However, there was variation in the number of participants recruited to individual studies, ranging from 26 [52] to 287 [53]. The recruited health care workers included nurses, physicians, and first responders.

There was also variance in the proportion of health care workers directly involved in delivering patient care. Three studies involved only health care workers involved in providing direct patient care [51-53]. The fourth study also included participants (31%) who were not directly involved in care delivery, including support staff and health care professionals [48]. One study reported a 100% participant retention rate [48]. The participant completion rates in the remaining studies varied between 64% and 81%.

Differences in outcome measures and intervention designs prevented undertaking a quantitative meta-analysis. One study [53] used an outcome measure, the Resilience Evaluation Scale, to directly measure resilience and found that resilience levels were enhanced in health care workers following implementation of the web-based intervention (Table 2). Three studies used proxy resilience measurement scales to measure the psychological concepts linked to resilience, such as stress, work engagement, professional isolation, and positive outcomes. These included the Burnout Screening Scales II Inventory [51], the Perceived Stress Questionnaire [51], Warr Work-Related Affect Scale [52], the Psychological Medicine Inventory [52], the Professional Isolation Scale [52], posttraumatic stress disorder symptoms using the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [53], and the Peritraumatic Cognitions Inventory [53]. All studies found improvements in these outcome measures after the intervention (Table 2). Some studies used nonstandardized Likert scales to measure specific emotions and concepts such as stress and resilience [48,54], with one study measuring self-rated positive and negative emotion ratings in health care workers [48]. The findings showed that positive emotions significantly increased by 9.4% and negative emotions decreased by 7.8% between the intervention and control groups.

All pre-post test studies aimed to evaluate the impact of an intervention, delivered either partially or fully on the web, on resilience or related symptoms in health care professionals directly involved in delivering patient care. The duration of interventions generally lasted a few weeks, but one study allowed web-based access to a resilience curriculum throughout an academic year [54].

The interventions in the studies were delivered via a variety of formats including web-based videoconferencing platforms [47], web-based platforms [49], web-based resilience training, peer groups, and wellness newsletters [50,54]. Some studies adopted specific therapeutic approaches or techniques including Balint groups [47] and mindfulness-based interventions [49,50]. One study introduced a way to manage emotions and experiences, but the exact content or method implemented was unclear [54].

Three studies used an outcome measure that directly measured resilience, including the Connor-Davidson Resilience Scale, Brief Resilience Scale, and self-rating of resilience on a visual analog scale [47,50,54]. Other outcomes measured psychological concepts linked to resilience, including the Perceived Stress Scale [50], the Corona Disease Anxiety Scale [47], and Maslach Burnout Inventory [49]. One study used nonstandardized Likert scales to measure specific emotions and concepts such as stress and resilience [54].

In total, 1103 participants were recruited to the pre-post studies; however, across studies, this ranged from 10 [47] to 1031 [50]. Two studies focused recruited health care workers in general [47,50], one focused on recruiting physicians only [54], and one focused on recruiting nurses only [49]. Of the 4 studies, 3 (75%) studies included only health care workers involved in providing direct patient care [47,49,54], but 1 (25%) study included participants who were not directly involved in care delivery [50].

The participant completion rate in the pre- and poststudies varied between 50% and 85%. One study involved a web-based module where the completion rate was 50% when defined as the completion of at least a single module; however, this dropped to a completion rate of 4% when considering all the modules [50]. One study did not provide this information [47].

Of the 4 studies, 3 (75%) studies [47,49,50] that directly measured resilience as an outcome measure found that resilience levels were enhanced in health care workers following the implementation of web-based interventions (Table 2). The remaining study used a proxy resilience measurement Likert scale of self-rated stress [54]. The study reported improved psychological well-being for resident physicians, with a postintervention 50% self-reported reduction in stress. However, data analysis included participants who attended in-person groups and had access to web-based resources, with no information reported on the extent of their web-based resource use. Therefore, the extent to which the results were because of the in-person element or the web-based content is unclear. However, one participant commented that “The online resilience curriculum and wellness newsletters were appreciated, and the in-person peer groups were extremely well received.” This suggests that the web-based content was well received, but no further details about its direct benefits were provided [54].

The exploratory study findings reported in this review indicate that web-based interventions designed to enhance resilience in health care professionals may be effective in clinical practice settings across a range of health care professional groups. The findings from all included studies showed that web-based interventions significantly improved either resilience or proxy measures of resilience, such as anxiety, depression, well-being, stress, work engagement, or positive emotions. However, the heterogeneity and limited number of randomized controlled trial studies included means that these findings should be interpreted with caution because of a lack of definitive evidence. More randomized controlled trials are needed to produce a robust evidence base on which to develop recommendations related to building resilience among health care professionals. Nonetheless, our review provides a snapshot of the evidence related to this important topical area [18]. The findings may have positive implications regarding the potential of certain types of web-based resilience enhancement interventions in providing support to health care professionals experiencing acute and prolonged stressful conditions in the workplace. This may have long-term benefits in terms of protecting the safe functioning of health systems by preserving the mental health and well-being of staff [7]. The interventions included in this review were tested on health care professionals directly involved in clinical care, demonstrating their potential applicability to clinicians working on the frontline, which warrants further testing in future studies. The included studies were conducted across a range of international settings, ranging from university to hospital, community, urban, and rural environments, and included a wide range of health care professional disciplines, increasing the generalizability of the findings.

The study findings indicate that web-based resilience enhancement interventions may be tolerable and acceptable to a wide range of health care professionals; the importance of resilience enhancement interventions has been cited in recent literature [18]. However, the review findings should be interpreted with caution, with only 50% (4/8) of the included studies having a randomized controlled trial design and 25% (2/8) using nonvalidated outcome measure tools. All interventions were conducted in real-life settings, showing that they are feasible to implement across a variety of health care contexts. In addition, most health care professional participants remained in the study until study completion, with 2 studies having a 100% completion rate, indicating that web-based interventions can be sustained over time and incorporated into the workplace environment. One study included qualitative comments indicating that the web-based components of the intervention were very well received [54]. These findings are important and indicate that web-based interventions can be implemented across health care systems as a valuable, effective, and feasible mechanism for supporting health care professionals to cope with the daily stressors imposed on them. This is especially important in the post–COVID-19 pandemic era, where many face-to-face interventions are impractical, challenging, and pose a potential safety risk. As such, the relevance of web-based training tools and interventions is gaining prominence, and this review provides clear evidence that they can be an important tool for supporting increased resilience in the health care workforce.

Regarding whether specific components of web-based interventions enhance resilience in health care professionals, our findings demonstrated that various formats and therapeutic approaches could effectively improve resilience levels. A range of web-based formats, including videoconferencing, modules, and curricula, were successfully implemented. In addition, a range of intervention techniques, including Balint-style groups, mindfulness, and reflecting on emotions, led to positive changes in resilience or proxy resilience. Although most studies took a purely web-based approach, one was mixed and incorporated additional face-to-face peer group sessions with web-based resilience curricula and wellness newsletters [54]. This suggests that a variety of web-based components can be used to enhance resilience in health care professional groups. However, many of the interventions included interactions with peers or intervention facilitators, suggesting that person-to-person interaction, whether face-to-face or on the web, may increase the likelihood of successful outcomes. This corresponds to previous studies that have demonstrated the benefits of web-based learning [36,55]. The findings point to the benefits of interactive person-to-person features as the key to enhancing intervention acceptability and effectiveness. Future studies should consider ways to incorporate this interactive element within web-based resilience intervention designs to maximize the potential for effectiveness. In addition, consideration should be given to the context within which resilience enhancement interventions are delivered, as health care workers are likely to respond differently when placed under acute versus chronic stressors, as evidenced during the COVID-19 pandemic [56]. The varying durations of interventions included in this review are an indicator of these differing contexts and environments. Thus, interventions that may be effective in acutely stressful environments may have design-different features to interventions that are designed for staff working under chronically stressful conditions; effective interventions offering support for health care workers should account for these differences [56]. None of the studies included in the review measured the economic impact of the intervention within the setting in which it was implemented; therefore, no firm conclusions can be drawn about this. Future research should directly assess the extent to which the implementation of web-based resilience interventions can be cost-effective by considering their long-term impact on staff retention and recruitment, sickness and patient care outcomes, and safety. This aligns with key policy priorities, such as the NHS Long Term Plan and the NHS People Plan, which emphasize that health care staff should be valued, supported to thrive, and treated with respect in the workplace [57,58].

This systematic review has been undertaken rigorously and to a high standard; however, some limitations remain. First, it was not possible to conduct a meta-analysis because of the heterogeneity of the study outcome measurement tools, participant demographics, and study settings. The variation in the characteristics of individual study populations and interventions makes it difficult to draw meaningful comparisons between the included studies, reducing the external validity of the findings. Only 50% (4/8) of the studies included in the review were randomized controlled trial designs. Furthermore, 25% (2/8) of the included studies used nonvalidated scales as outcome measures; this is a potential limitation as it reduces the internal validity of the findings. In addition, 2 studies included a proportion of participants who were not health care workers involved in direct care delivery. For these 2 studies, it was not possible to break down the study findings between direct care and nondirect care staff; therefore, the study findings need to be interpreted with caution as the outcomes could be diluted or exaggerated as a result. Generally, retention rates across the studies were high, demonstrating widespread acceptability of the web-based interventions; however, no data were presented on participants who dropped out of the study and their reasons for this. This information would be helpful to identify any barriers to completion, which could be used to enhance the design features, content, and format of any interventions in the future.

The study findings complement other work in this area that has examined both the effectiveness of resilience enhancement interventions in the health care setting and web-based interventions. Several face-to-face and web-based resilience enhancement interventions for health care professionals have been tested in the workplace environment, with previous systematic reviews finding that they can positively improve psychological well-being [19,23,38,59-63]. McDonald et al [32] successfully developed and implemented a work-based educational intervention to support the development of personal resilience in nurses and midwives in Australia. The intervention led to improvements in colleagues’ levels of honest communication regarding workplace issues, greater respect for each other’s skills and experiences, and a collaborative learning environment, something which is conducive to improved teamwork. It also benefitted participants’ personal and professional lives by enhancing their confidence, self-awareness, assertiveness, and self-care [32]. Henshall et al [21] developed a resilience enhancement program for nurses, consisting of various workshops and tackling areas such as building hardiness, maintaining a positive outlook, achieving work-life balance, reflective and critical thinking, and enabling spirituality. Levels of personal resilience were significantly higher after the program than before the program, with nurses reporting a marked impact on their resilience, self-awareness, confidence, and professional relationships [21].

Many studies have focused on the benefits of interventions in promoting mental health in health care professionals, by reducing depression and anxiety, increasing well-being, and reducing stress, with positive findings. A systematic review exploring interventions to address mental health issues in health care workers during infectious disease outbreaks found that some digital interventions were effective in improving confidence, self-efficacy, anxiety, posttraumatic stress disorder, and ways of coping [61]. Another review found that mindfulness-based interventions had the potential to reduce stress among health care professionals, though the review was not limited to web-based interventions and the quality of the evidence was mixed [59]. A third systematic review to examine the mental health impact of the COVID-19 pandemic on health care workers, and interventions to help them, identified a perceived need and preferences from health care workers for interventions aimed at preventing or reducing negative impacts on mental health. The review included some web-based interventions, but no data on their effectiveness in improving the mental health of participants were collected [60]. These findings reinforce the need for, and potential value of, interventions targeted at health care staff to improve their mental health and promote well-being, something that has been identified in this review.

Despite much literature emphasizing the important benefits of resilience enhancement interventions and web-based learning tools among the health care workforce, no studies to our knowledge have specifically examined the value of web-based resilience enhancement interventions for health care professionals. Our study, therefore, adds to the body of evidence in this field by indicating that web-based resilience interventions can be valuable tools for supporting the psychological well-being of health care professionals working in clinical care settings and can be considered effective, feasible, and acceptable mechanisms for use across a variety of health care settings.

This review has identified that web-based resilience interventions for health care professionals may be effective tools for enhancing resilience in this population group, are acceptable to the health care workforce, and can be implemented across a range of health care settings and environments. It has been highlighted that a variety of intervention components may be successfully used, but interactive person-to-person features are important design features that should be considered for enhancing success of the intervention. The review findings are important for health care practice as they indicate that simple, yet effective, web-based interventions may play an important role in increasing resilience in the health care workforce. This, in turn, may play a role in protecting health care workers from the pressures and challenges they face in delivering care. Hospital managers, clinicians, and well-being leads should carefully consider using these interventions to enhance resilience and staff well-being in the workplace; however, more web-based interventions need to be tested to enhance confidence in their value and the evidence base. The development of credible resilience enhancement web-based interventions may, in the future, lead to widespread improvements in staff motivation, retention, and recruitment, ultimately improving patient care outcomes.