Evaluating the Effectiveness of the Flourishing Wellbeing Programme for Nurses and Midwives: A Qualitative Study

Background

Nurses form the backbone of health-care systems internationally, yet a substantial and growing body of evidence indicates that they experience disproportionately high levels of occupational stress, burnout and compromised wellbeing. These challenges have farreaching implications, affecting not only nurses’ personal health and career sustainability, but also patient safety, quality of care and organisational performance [1-3]. In the context of global nursing shortages and increasing service pressures, nurse wellbeing has been identified by international workforce bodies as a critical strategic priority [3-4].

Wellbeing in nursing is increasingly recognised as a multidimensional construct encompassing psychological, physical, relational and professional domains. While burnout has been extensively examined, particularly during and following the COVID-19 pandemic, it represents only one dimension of nurses’ broader wellbeing experience [5]. A way to understand these experiences within nursing is to approach wellbeing as shaped by the balance between the pressures of the role, such as workload, emotional labour, time pressure, and the exposure to distress, versus the supports available e.g. staffing adequacy, leadership support, autonomy, and collegial relationships [6-7].

Empirical evidence consistently identifies inadequate staffing levels and excessive workload as central determinants of nurses’ wellbeing. Systematic reviews have demonstrated that higher patient-to-nurse ratios, heavy workloads and insufficient staffing are consistently associated with increased burnout, emotional exhaustion, job dissatisfaction and intention to leave the profession [8,9]. More recent evidence continues to demonstrate that inadequate staffing contributes to poorer psychological wellbeing among nurses while also compromising patient outcomes, reinforcing staffing as a critical organisational determinant of both workforce and care quality [1,10]. Organisational culture and leadership further shape wellbeing outcomes, with supportive, participatory and psychologically safe environments associated with greater work engagement and lower emotional exhaustion [7].

Workplace violence represents an additional and significant threat to nurses’ wellbeing. A systematic review and meta-analysis reported high prevalence of verbal and physical violence against nurses across healthcare settings, with documented associations with psychological distress, job dissatisfaction and intention to leave the profession [11]. International professional bodies have repeatedly highlighted the impact of unsafe work environments on nurses’ mental health and retention [3,4].

The COVID-19 pandemic further intensified these existing pressures. A rapid systematic review and meta-analysis identified high levels of burnout and psychological distress among nurses working during epidemic and pandemic conditions, underscoring the cumulative impact of sustained high demands and constrained resources [5]. Despite extensive documentation of these challenges, the literature remains largely focused on problem description, with comparatively limited qualitative evidence examining nurses’ experiences of structured wellbeing interventions.

This gap provided the rationale for the development of the Flourishing wellbeing programme, which was designed to support nurses personally and professionally in navigating these complex and challenging healthcare environments. The Flourishing programme is a 12-week self-paced online Continuing Professional Development (CPD) programme that consists of a wide range of evidence-based topics to improve participants’ understanding of the personal and professional factors that influence wellbeing. All 12 topics are based on the latest available evidence, are delivered by subject experts and presented in succinct and engaging formats. The programme supports participants to understand and make sustained lifestyle changes to improve their wellbeing. Participants also receive access to a range of practical resources. The subject experts come from multidisciplinary perspectives including- nursing, midwifery, psychology, psychotherapy, nutrition, physical activity, physiotherapy, occupational health and digital health literacy. This research was undertaken to explore programme participants’ experiences of and impact of the Flourishing programme. A mixed- methods approach was used with pre and post surveys and focus group interviews. The quantitative findings of the study are presented in a separate publication. This paper focuses on the qualitative findings of the study.

Methods

Study Design

This study employed a qualitative descriptive design, using online focus groups to explore nurses’ experiences of participating in the Flourishing wellbeing programme. Qualitative description was selected as it is well suited to capturing participants’ perspectives in their own words and producing findings that are close to the data and readily applicable to practice, particularly in programme evaluation contexts. The Flourishing wellbeing programme for nurses and midwives is a 12-week, online, asynchronous wellbeing intervention. It is self-paced and designed to support nurses’ and midwives’ wellbeing through evidence-based information, reflective and experiential activities. Participants accessed the programme remotely and completed it alongside their existing professional roles.

Participants and Recruitment

The evaluation study was conducted in August 2025. A total of 13 registered nurses who took part in and completed the pilot Flourishing programme participated in the study across three focus group sessions. Participants were based in Ireland, the United States, the United Kingdom and Italy and represented a range of senior clinical, leadership, academic and specialist nursing roles. All participants identified as female and were mid- to late-career nurses and retired. Group composition varied to reflect participants’ availability and geographical location. The diversity of roles and contexts supported rich discussion regarding the applicability and perceived value of the programme across different nursing settings.

Data Collection

Three focus groups were conducted via Microsoft Teams, each lasting approximately 60 minutes. Focus groups were facilitated using a semi-structured topic guide, allowing consistency across groups while providing flexibility to explore emergent topics. Two researchers were present at each session: one acted as facilitator and the other as observer and note-taker. All focus groups were video audio-recorded and transcribed verbatim. Data collection continued until all participants who volunteered were accommodated within the three sessions.

Data Analysis

Data were analysed using thematic analysis using NVivo software (version 15, Lumivero), following Braun and Clarke’s sixstep approach [12]. Transcripts were read repeatedly to achieve familiarisation. Initial codes were generated and iteratively refined, before being grouped into broader themes that captured shared patterns across the dataset. Analysis was conducted by the research team, with ongoing discussion between researchers to enhance interpretive rigour and reflexivity.

Ethics approval

Ethical approval was obtained from the Royal College of Surgeons in Ireland (RCSI) Research Ethics Committee (Ref: 202407025). All participants provided written informed consent prior to participation. Confidentiality and anonymity were maintained throughout; identifying details were removed from transcripts. Audio recordings and transcripts were stored on encrypted devices, accessible only to the researchers directly involved in the study.

Results

Thematic analysis of the focus group data identified five main themes capturing participants’ experiences of the Flourishing wellbeing programme. These themes reflect how participants engaged with the programme design and content, the learning processes it facilitated, perceived behavioural and experiential outcomes and limitations and opportunities for future refinement.

Theme 1: Programme design and delivery

Programme design and delivery were consistently described as central to participants’ engagement with the Flourishing wellbeing programme. The self-directed, online format was widely viewed as compatible with the unpredictable schedules and workload pressures characteristic of healthcare practice. Participants emphasised that flexibility enabled them to engage meaningfully with the content. In addition to flexibility, participants highlighted the ‘bite-sized’ structure of the programme as facilitating engagement. Breaking content into manageable sections reduced the burden and allowed participants to integrate learning incrementally into busy professional lives.

“You could kind of log in when you could, as opposed to it having to be [somewhere] once a week on a Tuesday at whatever time.” (FG1 P2)

“I suppose I found the online course quite robust from a technological point of view anyway.” (FG2 P4) “It was online, which was a positive thing and there is no set time. You gave us the flexibility to do the course

over a few weeks period, which was good.” (FG2 P3)

“I think the good thing for me about the course was that it was bite-sized pieces that let me do a couple of things together.” (FG3 P3)

The perceived quality and credibility of facilitators and speakers also emerged as a key aspect of programme delivery. Participants described speakers as knowledgeable and professionally relevant, contributing to trust in the programme and reinforcing its legitimacy within healthcare contexts.

“The speakers were amazing. There were very high calibre speakers and they imparted a lot of useful information.” (FG3 P4)

Participants also identified specific contents, such as burnout, sleeping, compassionate leadership, digital footprint and healthy eating, as particularly practical and relevant to their professional and personal contexts.

“…the section was very, what can I say, it was very reflective and then all the tools they gave us, I could use it at that time. So it was great.” (FG2 P2)

“I think the burnout session, you know, talking about burnout was really insightful and it’s kind of things that we do on a regular basis, but actually that kind of emphasises the need or reminding us of the benefits of looking after each other, checking each other, helping and supporting each other.” (FG2 P3)

“For the rest of my career and for future, I can definitely lean into the talk that was had on compassionate leadership.” (FG2 P1)

“I agree with the burnout section because I was going through it at the time. And the other thing is the sleeping and some healthy eating, because I think we are not very good at it. I mean, like a proper lunch break, I don’t think we are doing it and sleeping also.” (FG2 P2)

Theme 2: Learning, knowledge, and skills development

Participants described learning within the Flourishing wellbeing programme as an active and reflective process rather than a straightforward acquisition of information. Engagement with the programme was frequently described as helping participants organise, make sense of and prioritise wellbeing-related knowledge in a more structured way.

“The programme provided a unique opportunity really to think in a structured way, so it guided the thinking about.” (FG1 P4)

Participants valued both the opportunities to learn new concepts and to revisit and refresh existing knowledge. For some, the programme introduced unfamiliar areas, such as trauma-informed care, circadian rhythm and digital wellbeing, which broadened their understanding of how wellbeing operates across both professional and personal contexts. For others, learning was experienced less as discovery and more as reinforcement. Participants described being reminded of concepts they had previously encountered but had not consistently applied in practice, including sleep hygiene, nutrition and stress management.

“I did not know trauma even existed in the way it affects your body and it gives you these stomatic disorders and things like that. And I didn’t know terms like doom- scrolling and screen apnea. All of this was very new to me. I learned a lot of new things.” (FG3 P1) “I found it refreshed a lot of stuff for me”. (FG1 P3)

“Some of it I knew already, but I had forgotten to apply it or forgotten that I already knew it.” (FG2 P4)

Several participants noted that learning was not limited to factual knowledge but also involved developing new ways of recognising and interpreting their own experiences. Concepts such as flowstate helped participants make sense of moments of engagement or satisfaction at work, reframing how they understood enjoyment and productivity within professional roles.

“This kind of activity takes me to a flow state, which does happen at work as well, which is really fascinating. I did not know that you could pleasurably enjoy your work.” (FG3 P1)

Learning outcomes were also described as extending beyond the individual participant. Several participants mentioned applying programme content in teaching, mentoring or leadership contexts, suggesting that the knowledge and skills gained were perceived as transferable and relevant within wider professional settings.

“I gained certain new knowledge which I am actually trying to implement in my teaching, and students are loving it.” (FG2 P3) Theme 3: Behavioural and habitual change

Participants described behavioural and habitual change as a gradual and ongoing process rather than a sudden or transformative shift. Changes were commonly framed in terms of sustainability, with participants emphasising the importance of embedding wellbeing practices into existing routines so that they could be maintained alongside professional and personal responsibilities. Reported changes included modifications to sleep routines, physical activity, screen use and self-care practices.

“I think the biggest thing was the reminder that it doesn’t have to be an hours on end at the day. So the way it was presented was a useful way to incorporate lots of different things into my life that is sustainable.” (FG3 P3)

“One thing I can say for sure is that I am using the strategies to reduce my screen time.” (FG2 P3)

“I also started doing lunchtime walks with my colleague which helped me and these are the small things I’m doing.” (FG3 P1)

“So that’s a big change that has happened and I can feel the change in my life, I can feel the well-being in me.

You know, I can feel much more healthy.” (FG3 P1)

Behavioural change was linked to increased self-awareness and intentionality. Participants frequently highlighted the role of habit formation in maintaining change over time, describing routines as mechanisms that supported consistency and reduced reliance on motivation alone. Participants described becoming more attentive to their own needs and more deliberate in prioritising basic wellbeing practices.

“You’re building it into your routine… and many good suggestions on how to do that itself.” (FG1 P1) “I want to stick to them — especially the sleep, the exercise, the simple things.” (FG3 P1) Theme 4: Perceived benefits and positive experience

Participants consistently described the Flourishing wellbeing programme as both personally meaningful and professionally beneficial. Across all three focus groups, engagement with the programme was described as a rare and valued opportunity to prioritise personal wellbeing within professional environments that typically emphasise caring for others over self-care. Participants described the programme as enjoyable, useful and transferable to both professional and personal contexts.

“I think it’s pretty conclusive from all of us that it was very enjoyable and very useful and very transferable.” (FG2 P4)

“And it’s a really good course, self-paced and it really targets your well-being.” (FG3 P1) “I would highly recommend it, definitely without question.” (FG1 P3)

Perceived benefits were highlighted across personal and professional levels. On a personal level, participants described increased self-awareness, self-compassion and a sense of feeling understood. Several participants reflected on how the programme prompted them to reconsider their own needs and limits, particularly following periods of stress or burnout.

“I reflected a lot in every session so it really helped me personally, especially I just come back from burnout and I really realised actually I have to look after myself to look after other people.” (FG2 P2)

“I felt like that he (the lecturer) was just talking to me when he covered that topic and it was massive to feel it included and to understand that you know, sometimes you’re not as bad as you think you are.” (FG2 P1)

Participants also described shifts in perspective, noting that the programme provided language and conceptual tools that enabled them to view challenges differently, even when the content was not entirely new.

“It’s given me different tools to look at things in different ways. It wouldn’t necessarily be information I didn’t know, but I suppose it was just maybe more language and more skills, so I thought it was amazing.” (FG2 P4)

Professionally, participants reported enhanced reflective capacity, improved focus and greater intentionality in how they prioritised tasks and responsibilities. These benefits were frequently described as extending beyond the individual, influencing interactions with colleagues and broader workplace cultures. Several participants also highlighted the programme’s longer-term value, particularly in relation to compassionate leadership, resilience and traumainformed care. These elements were viewed as vital aspects of practice that participants expected to carry forward into future professional roles and personal wellbeing.

“It helped me personally and professionally… it really helped me focus my day and prioritise what was necessary.” (FG2 P1)

“I do feel that’s a huge part of what I have taken from this course and that I’ll bring into the future-compassionate leadership, resilience and trauma informed care, they’re just the three main elements that I can see from now and what I can definitely use into the future” (FG2 P1)

“I think that goes on to the people around you as well.” (FG3 P5) “And I mean maybe even like, you know, emotional supports, the employee assistance. You know, we generally get them when they’re needed, but should we be doing something better to be proactive now when they’re needed, put the supports in place beforehand, so maybe they won’t be needed at that point.” (FG1 P2)

“But going back to myself, I just need to do maybe a little bit less for others and more for myself, but I’m happy when everybody else is happy, so I suppose I can’t change myself too much that way, because then I end up stressed because I haven’t got my things done, but I suppose maybe at weekends and stuff about doing a little bit more on myself.” (FG2 P4)

Theme 5: Recommendations for improvement

Participants offered a range of constructive recommendations which help strengthen future refinement of the Flourishing wellbeing programme. While overall perceptions were positive, suggestions focused on enhancing opportunities for connection, improving clarity and usability of the platform, and supporting sustained application of learning beyond programme completion.

A recurring recommendation across focus groups was the inclusion of optional opportunities for peer interaction and shared reflection. Participants felt that incorporating spaces for informal discussion could deepen learning, provide emotional support, and reduce feelings of isolation associated with fully self-directed learning.

“In a way, whether it is through a chat or something else, I think for me and my personality style probably would have been very helpful.” (FG2 P1)

“I think what I would have loved during it was even if it was where the participants that there was an hour, we could just have the webinar like on (MS) Team, you connect up and just chat about what (was covered).” (FG1 P3)

Participants emphasised that peer connection and informal knowledge exchange were important components of learning. Opportunities to share experiences, reflect collectively, and learn from others were viewed as particularly valuable within wellbeingfocused programmes.

“And sometimes if you just talk to others who are doing it like it’s anything, it’s the networking, it’s that community interaction between each other where a lot of the learning happens as well.” (FG1 P3)

Participants also highlighted the need for clearer guidance on platform navigation and functionality. Suggestions included the provision of simple instructional materials, such as tutorial videos or frequently asked questions, to support early engagement and reduce frustration related to usability. Participants also suggested the development of downloadable resources or toolkits to support ongoing application of learning beyond programme completion. And clearer indications of the time required for each session, regular reminders to encourage ongoing participation, and the provision of structured self-assessment components to support reflection and motivation.

“Maybe something very basic, like a step-by-step video.” (FG1 P2)

“I think it would be a good place that could be readily available all through, you know, sort of like a reference point. It could be just an FAQ, really, a set of FAQs.” (FG1 P4)

“I think that it would be nice if for each section that there was something that like, you will be doing your meditation and your journaling plus an actual exercise that you would be using in your work like both professionally and personally.” (FG2 P1)

“I’m hopeful that future iterations of the programme will encourage the learner to store, to file, to organise their own toolkit. You know, and maybe some guidance on how to do that, because that’s what’s really enabled long term impact.” (FG1 P4)

“The other thing which I thought might increase in individuals committing to the course is some sort of a self-assessment” – FG3

P4

In addition to recommendations related to peer interaction and platform usability, participants suggested further strengthening the programme through greater tailoring and alignment with career stage and professional context. Several participants suggested that the programme could be more closely tailored to specific professional roles, particularly for those working in specialist or isolated positions. Participants noted that individuals in roles with limited team interaction may experience the programme differently and could benefit from content or delivery approaches that acknowledge professional isolation. There were also suggestions to strengthen contextual relevance, with participants recommending that some content be more explicitly aligned with the Irish healthcare context.

In relation to the target audience, several participants reflected that the programme may be particularly valuable for individuals at earlier stages of their careers. Undergraduate students and newly qualified staff were identified as groups who could benefit from early exposure to wellbeing concepts before entering high-pressure clinical environments. Participants suggested that embedding the programme within early-career transition period, such as the first months following qualification could maximise its impact and relevance.

“I think if you’re aiming it at let’s say nurses that are kind of in specialist roles or has been mentioned particularly by FG3 P3 and FG3 P2 that are in roles where there’s quite a bit of isolation maybe the course could be certainly tailored a little bit.” (FG3 P4)

“I suppose because I work with the undergraduate students, I feel that they really need this course when they are finished and when they are entering as a new nurse” (FG3 P1)

“Yeah, I suppose I felt that it was more aimed at undergraduate or postgraduates newly qualified staff rather than people.” (FG3 P2)

I suppose what I thought about it at one stage was, it would be good if all newly qualified staff did it, say in the first six months after they qualify and they go out into their first jobs or whatever. I could see that there’d be huge benefit for them there. – FG3 P2

Discussion

This study provides insight into nurses’ experiences of engaging with a structured, asynchronous wellbeing programme within the context of demanding professional environments. The findings suggest that the Flourishing wellbeing programme was perceived as both accessible and meaningful, supporting participants’ awareness, reflection and gradual behavioural change. Flourishing wellbeing programme can be understood as an intervention that strengthens personal and professional resources, this aligns with the theory of the Job Demands–Resources (JD-R) model [6,7]. Bailey et al. (2025) implemented a psychoeducational programme for nurses and found similar results to this study, with high satisfaction among participants but also a secondary organisational impact on the professional resource.

A key finding relates to the importance of programme design in facilitating engagement. Flexibility and self-paced delivery were consistently identified as enabling participation, particularly in the context of unpredictable workloads and time pressures. This aligns with existing literature- West & Dawson [13] and Brand et al., [14], emphasising that interventions targeting healthcare professionals must be adaptable and minimally disruptive to clinical demands to achieve meaningful uptake. The ‘bite-sized’ structure further supported engagement, suggesting that micro-learning approaches may be particularly suited to workforce wellbeing initiatives [15].

This study also highlights the role of reflective, experiential learning in supporting wellbeing. Participants did not describe learning as passive acquisition of knowledge but rather as an active process of making sense of their experiences, revisiting existing knowledge and integrating new perspectives. These findings resonate with broader evidence suggesting that reflective practice is central to professional development and emotional processing in nursing [16,17]. Importantly, participants reported that the programme provided language and conceptual frameworks, such as burnout, flow and trauma-informed care, that enabled them to reinterpret their experiences in more constructive ways.

Behavioural change emerged as incremental and grounded in sustainability rather than transformation. Participants described small, manageable adjustments to daily routines, including sleep, physical activity and screen use. This reflects current understanding within behaviour change literature, which emphasises the effectiveness of gradual habit formation over large-scale change. Increased self-awareness appeared to underpin these changes, suggesting that interventions that prioritise insight and reflection may be particularly effective in supporting long-term wellbeing.

Participants’ accounts indicate that enhancing individual-level capacities, such as self-awareness, coping strategies and reflective ability, may positively influence both personal wellbeing and professional functioning. Participants described improved focus, prioritisation and leadership approaches, with some reporting ripple effects on colleagues and workplace interactions. These findings support the notion that wellbeing interventions may have indirect organisational benefits, even when delivered at the individual level [18,19].

However, the findings also highlight important limitations of fully self-directed, asynchronous interventions. Participants reported a sense of isolation and expressed a desire for greater peer interaction and shared reflection. This suggests that while flexibility is valuable, the relational dimension of learning remains critical, particularly in a profession grounded in interpersonal connection. The absence of community elements may limit the depth of engagement and reduce opportunities for collective meaning-making, which has been identified as an important component of wellbeing in healthcare settings. Opportunities for peer engagement arising from these findings are now actively embedded into the programme, with optional monthly online meet-up sessions.

Finally, participants’ recommendations regarding tailoring and early-career integration are noteworthy. The perception that the programme may be particularly beneficial for newly qualified nurses aligns with existing evidence indicating that transition periods are associated with heightened stress and vulnerability [20,21]. Embedding wellbeing interventions at these critical points may enhance resilience and support retention within the profession [22].

Implications for Practice

The findings of this study have several practical implications for the design and implementation of wellbeing interventions in nursing and midwifery contexts. First, flexibility and accessibility should remain central design principles, particularly given the constraints of clinical work environments. However, this should be balanced with opportunities for optional peer interaction, such as facilitated discussions or reflective forums, to enhance connection and shared learning.

 Second, interventions should prioritise reflective and experiential components, enabling participants to engage actively with content and integrate learning into their personal and professional lives. The inclusion of practical tools and strategies that can be embedded into daily routines appears particularly important for sustaining behavioural change. Third, consideration should be given to tailoring interventions to different career stages and professional contexts. Early-career nurses may benefit from structured wellbeing support during transition periods, while those in leadership or specialist roles may require content that reflects their specific challenges and responsibilities.

Finally, organisational support remains critical. While individuallevel interventions can enhance personal resources, parallel efforts to address systemic issues such as staffing, workload, and workplace culture should also be implemented. Wellbeing programmes should therefore be positioned as one component of a broader, multi-level strategy to support the nursing workforce.

Limitations

This study has some limitations that should be considered when interpreting the findings. First, the sample size was small (n = 13) and comprised participants who had completed the programme and volunteered to take part in focus groups. This introduces the potential for self-selection bias, as individuals with more positive experiences may have been more likely to participate.

Second, all participants were female and predominantly mid- to late-career nurses, which limits the transferability of findings to more diverse populations, including midwives, male nurses and those at earlier career stages. While participants represented a range of roles and international contexts, the absence of earlycareer perspectives is notable, particularly given the identified relevance of the programme for newly qualified nurses.

Third, the study relied on self-reported data collected through focus groups, which may be influenced by social desirability bias or group dynamics. Participants may have felt inclined to present their experiences in a positive light, particularly in a group setting. Finally, as an evaluation of a single programme, findings are context-specific and may not be directly generalisable to other interventions or healthcare settings. However, the detailed qualitative insights provided may support analytical transferability to similar contexts.

Conclusion

This study contributes to the growing body of literature on nurse wellbeing by providing qualitative insights into the experiences of nurses and midwives engaging with a structured, asynchronous wellbeing intervention. The findings suggest that the Flourishing wellbeing programme was perceived as accessible, relevant and supportive of reflection, learning, and gradual behavioural change. Participants valued the flexibility and practicality of the programme, as well as its focus on self-awareness and sustainable wellbeing practices. The findings also highlight the importance of incorporating opportunities for connection and tailoring interventions to different professional contexts and career stages.

While individual-level interventions such as Flourishing can enhance personal resources and support nurses in navigating demanding work environments, they should be complementary to systemic change within healthcare systems. A comprehensive approach to nurse wellbeing requires alignment between individual, organisational and policy-level strategies. Future research should explore the long-term impact of such interventions, including their influence on retention, job satisfaction and patient care outcomes, as well as their applicability across diverse nursing and midwifery populations and settings.

Acknowledgements

The authors would like to acknowledge support from the contributors in the Flourishing programme, and the participants for their engagement in the programme and participation in the study.

Declaration of Interests

The authors declare no conflict of interest.

Author Contributions

J.P.: Investigation, Writing – Original draft, Visualization; S.Y.: Investigation, Formal analysis, Writing – Review & Editing; K.S.: Conceptualisation, Methodology, Writing – Review & Editing; M.R.S: Conceptualisation, Methodology, Writing – Review & Editing, Supervision.

Funding

This is a self-funded study by the Faculty of Nursing and Midwifery, RCSI.

Ethics approval and consent to participate information

Ethical approval was obtained from the Royal College of Surgeons in Ireland (RCSI) Research Ethics Committee (Ref: 202407025). All participants provided written informed consent prior to participation. Confidentiality and anonymity were maintained throughout; identifying details were removed from transcripts. Audio recordings and transcripts were stored on encrypted devices, accessible only to the researchers directly involved in the study.

References

1. Dall’OraC, Saville C, Rubbo B, Turner L, Jones J, et al. (2022) Nurse staffing levels and patient outcomes: a systematic review of longitudinal studies. International Journal of Nursing Studies 134: 104311.
2. Dall’Ora C, Rubbo B, Saville C, Turner L, Ball J, et al. (2023) The association between multi-disciplinary staffing levels and mortality in acute hospitals: a systematic review. Human Resources for Health 21: 30.
3. World Health Organization (WHO) (2025) State of the World’s Nursing 2025: Investing in Education, Jobs, Leadership and Service Delivery. 2025.Geneva: World Health Organization ISBN: 978-92-4-011023-6.
4. International Council of Nurses (ICN) (2025) International Nurses Day 2025: Caring for Nurses Strengthens Economies. 2025. Geneva: ICN.
5. Serrano-Ripoll MJ, Meneses-Echavez JF, Ricci-Cabello I, FraileNavarro D, Fiol-deRoque MA, et al. (2020) Impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis. J Affect Disor 277: 347-357.
6. Bakker AB, Demerouti E (2007) The Job Demands-Resources model: state of the art. Journal of Managerial Psychology 22: 309-328.
7. Bakker AB, Demerouti E, Vergel AIS (2023) Job Demands-Resources Theory: Ten Years Later. Annual Review of Organizational Psychology and Organizational Behavior 10: 1-26.
8. Pearson A, O’Brien-Pallas L, Thomson D, Doucette E, Tucker D, et al. (2006) Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments. Int J Evid Based Healthc 4: 337-384.
9. Halter M, Boiko O, Pelone F, Beighton C, Harris R, et al. (2017) The determinants and consequences of adult nursing staff turnover: A systematic review of systematic reviews. BMC Health Serv Res 17: 824.
10. Griffiths P, Saville C, Ball J, Jones J, Pattison N, et al. (2020) Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion. Int J of Nurs Stud 103: 103487.
11. Varghese A, Joseph J, Vijay VR, Khakha DC, Dhandapani M, et al. (2022) Prevalence and determinants of workplace violence among nurses in the South-East Asian and Western Pacific Regions: a systematic review and meta-analysis. J Clin Nurs (7-8): 798-819.
12. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative research in psychology. 3: 77-101.
13. West M, Dawson J (2012) Employee engagement and NHS performance. The King’s Fund.
14. Brand SL, Coon JT, Fleming LE, Carroll L, Bethel A, et al. (2017) Whole-system approaches to improving the health and wellbeing of healthcare workers: A systematic review. PLoS ONE 12: e0188418.
15. De Gagne JC, Park HK, Hall K, Woodward A, Yamane S, et al. (2019) Microlearning in health professions education: A scoping review JMIR Med Educ 5: e13997.
16. Schön DA (1983) The Reflective Practitioner: How Professionals Think in Action.
17. Mann K, Gordon J, MacLeod A (2009) Reflection and reflective practice in health professions education: A systematic review. Adv Health Sci Educ Theory Pract 14: 595-621.
18. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD (2016) Interventions to prevent and reduce physician burnout: A systematic review and metaanalysis. Lancet 388: 2272-2281.
19. Melnyk BM, Kelly SA, Stephens J, Dhakal K, McGovern C, et al. (2018) Interventions to improve mental health, wellbeing, and resilience in nurses: A systematic review. Am J Health Promot 34: 929-941.
20. Duchscher JB (2009) Transition shock: The initial stage of role adaptation for newly graduated registered nurses. J Adv Nurs 65: 1103-1113.
21. Phillips C, Kenny A, Esterman A, Smith C (2017) A secondary data analysis examining the needs of graduate nurses in their transition to practice. Nurse Educ Pract 23: 19-25.
22. Rush KL, Adamack M, Gordon J, Lilly M, Janke R (2019) Best practices of formal new graduate nurse transition programs: An integrative review. Int J of Nurs Stud 94: 139-158.