Theoretical framework

This study draws on the broaden-and-build theory [22], which proposes that positive emotions expand individuals’ cognitive and behavioural repertoires, enhancing flexibility, creativity, and the ability to manage complex or adverse situations [7]. In clinical settings, these processes support psychological well-being, reduce vulnerability to burnout, promote work engagement, and strengthen decision-making [9]. Positive emotions can also spread across the team through emotional transmission, fostering collective resilience and improving interprofessional cooperation and communication [9]. Conversely, when these dynamics are absent, nurses may experience disengagement, increased stress, and reduced team cohesion, leading them to conserve rather than invest their psychophysical resources [23].

Integrating these concepts offers insight into how nursing resilience develops through the interaction of personal resources and the work environment, while team resilience is shaped by interpersonal dynamics, mutual trust, communication quality, and leadership style [3,9]. These factors directly influence adherence to best practices, error prevention, and patient safety [7].

A qualitative approach was adopted to capture nurses’ experiences and explore aspects of IPC practice that remain under-researched, particularly in the management of critically ill patients infected with MDROs. The study investigated how nurses interpret and adapt IPC protocols during patient isolation, implement necessary precautions, organise cohorting, and ensure appropriate environmental disinfection while maintaining safety for staff and other patients despite clinical and organisational constraints [14].

The analysis was framed within organisational context rather than individual experiences, following Mills’ [24] concept of sociological imagination, which emphasises the interaction between personal experience and broader social structures [25]. This lens was applied to interpret the organisational challenges observed during two critical care processes: (a) the admission of a patient potentially infected with an MDRO without a definitive microbiological diagnosis, and (b) the MRI transfer of a critically ill patient infected with carbapenem-resistant Klebsiella pneumoniae, conducted without adequate communication between the medical–nursing team and with the radiology department.

By integrating psychological theory [22], organisational analysis [24,25], and IPC guidelines for MDRO management [4,14], this study provides a robust interdisciplinary perspective [26] that enhances understanding of how nursing resilience supports adherence to infection prevention practices in complex clinical settings. The purpose of this study is to explore how resilience among ICU nurses emerges, manifests, and is mobilised during the management of critical events involving patients infected or potentially infected with MDROs. Specifically, the study aims to examine how individual, team, and organisational dimensions of resilience influence adherence to IPC protocols under conditions of uncertainty, urgency, and organisational pressure.

Objective

This study aimed to investigate individual and team resilience among ICU nurses, examining the role of personal resources, professional competencies, and interpersonal dynamics in caring for critically ill patients with MDRO infections. It further aimed to analyse the strategies used when IPC protocols are insufficient, assessing trade-offs between decision-making speed, patient safety, and emotional or operational load. Finally, it aimed to examine the interaction between resilience and organisational support, exploring how culture, leadership, resource availability, and structural processes shape adherence to IPC protocols and overall care quality in ICUs.

Research questions

1. 1 How do nurses demonstrate individual resilience when caring for critically ill ICU patients with MDRO infections? Which personal resources and professional competencies are activated?
2. 2. What strategies do nurses employ when IPC protocols prove insufficient during critical events? How are trade-offs between decision-making speed, patient safety, and emotional/organisational load managed?
3. 3. How do leadership, organisational culture, resource availability, and structural processes influence nursing resilience? How do these interactions support adherence to IPC protocols and overall care quality in ICUs?

Design

A descriptive qualitative approach was adopted to capture participants’ perspectives on everyday challenges in managing IPC protocols in ICUs [27], allowing their narratives to remain closely aligned with their own language and lived experiences, offering a clear, realistic, and contextually grounded account of what was observed in practice [28].

This methodology enabled in-depth exploration of nurses’ experiences, including those that are implicit or difficult to quantify, and how these intersected with care practices, IPC adherence, and team collaboration, allowing for a rich understanding of ICU operational processes.

The study was conducted and reported in accordance with the Standards for Reporting Qualitative Research (SRQR) [29] (see S1File).

Study setting and sampling

The study was conducted in two ICUs (cardiac surgery and neurosurgery) within a university hospital in northern Italy with advanced infection control and antimicrobial stewardship programmes in place.

The cardiac surgery ICU contained 18 beds, including four single rooms primarily used for heart transplant recipients and for patients infected with MRSA following cardiac surgery. The neurosurgical ICU included 12 beds, also with four single rooms, occasionally used for organ donor patients requiring specific isolation conditions.

A purposive snowball sampling approach [30] was used to recruit nurses, support staff, head nurses, and anaesthetists with at least six months of ICU experience.

Inclusion and exclusion criteria

Inclusion criteria ensured that participants were sufficiently familiar with organisational dynamics and able to articulate how nurses maintained IPC adherence under external pressures. Selection criteria included: (a) at least six months’ ICU experience, and (b) representation across a range of ages and professional seniority to reduce bias and enhance transferability and reliability.

Participation was voluntary. Eligible staff were contacted via institutional email following approval from nursing management. Before enrolment, participants received detailed information regarding study aims, procedures, and confidentiality. Recruitment continued until data saturation was reached, defined as the point at which no new significant insights emerged [31].

Instrument with validity and reliability

Rigour was ensured using strategies consistent with established qualitative reliability criteria [32]. Credibility was supported by the involvement of a multidisciplinary research team experienced in qualitative methods and nursing practice. Interviews were conducted by a researcher with expertise in qualitative methods and ICU infection risk management, and the data were independently analysed.

Coding processes were discussed and compared within the research team to support confirmability and analytical reliability [33]. Transferability was enhanced through purposive sampling and detailed contextual description, enabling readers to assess applicability to similar settings.

Data collection

Data collection was conducted between 1 March and 30 June 2025 through non-participant observations and semi-structured interviews, which were informed by WHO guidelines [14] and hospital IPC procedures.

Phase 1: Non-participant observations.

Non-participant observations focused on staff behaviours and interactions (Table 1), offering an initial understanding of organisational context and care processes related to managing MDRO-infected patients [4,34].

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Table 1. Guide for Non-Participant Observations.

https://doi.org/10.1371/journal.pone.0348081.t001

Observations targeted two specific care processes. The sequences of events observed were documented as narrative case studies and used during the semi-structured interviews as contextual reference tools to facilitate discussion with healthcare professionals about the organisational challenges identified. For the purposes of this manuscript, these case studies have been transformed into two observational vignettes, Fig 1 and 2 [35] that synthesise the key organisational challenges encountered. Observations were conducted by experienced ICU nurses external to the hospital to ensure independence. Each ward was observed for an average of three hours across different shifts (morning/afternoon), totalling 30 hours.

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Fig 1. Observational vignette 1-ICU admission in the context of suspected MDRO infection.

Illustrative storyboard synthesising the key organisational challenges (Points 1–11) observed by the researcher during non-participant observation sessions in the Intensive Care Unit. The vignette was used as a contextual reference tool to facilitate semi-structured interviews with healthcare professionals, enabling participants to articulate their experiences around IPC adherence, workload management, and interprofessional communication without requiring disclosure of personal information. The visual format was produced using an AI-assisted illustration tool (SciSpace; https://scispace.com) on the basis of a structured textual description provided by the research team. No individual patient data are represented or reported. ICU: Intensive Care Unit; MDRO: Multi-Drug-Resistant Organism; IPC: Infection Prevention and Control; PPE: Personal Protective Equipment.

https://doi.org/10.1371/journal.pone.0348081.g001

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Fig 2. Observational vignette 2- Intra-hospital transfer of an MDRO patient to Radiology.

Illustrative storyboard synthesising the key organisational challenges (Points 1–11) observed by the researcher during non-participant observation sessions in the Intensive Care Unit. The vignette was used as a contextual reference tool to facilitate semi-structured interviews with healthcare professionals, enabling participants to articulate their experiences around IPC adherence, workload management, and interprofessional communication without requiring disclosure of personal information. The visual format was produced using an AI-assisted illustration tool (SciSpace; https://scispace.com) on the basis of a structured textual description provided by the research team. No individual patient data are represented or reported... ICU: Intensive Care Unit; MDRO: Multi-Drug-Resistant Organism; IPC: Infection Prevention and Control; MRI: Magnetic Resonance Imaging; PPE: Personal Protective Equipment.

https://doi.org/10.1371/journal.pone.0348081.g002

Data analysis

Data were analysed using qualitative content analysis, a systematic method for coding and categorising text to identify recurring patterns and themes [36]. Transcripts were independently read multiple times for familiarisation.

An inductive process was used to identify meaningful units of text and to develop initial codes reflecting emerging ideas. Codes were refined to reduce redundancy, grouped into broader categories, and then synthesised into subthemes based on frequency, structural similarity, and logical relationships. Subthemes were collaboratively reviewed to ensure that they aligned with the study’s objectives.

Ethical considerations

The study adhered to the Declaration of Helsinki [37]. Ethical approval was obtained from the Territorial Ethics Committee – South-West Veneto Area (IPC-coordinf – Prog. 422CET). All participants received full information about the study and provided written informed consent prior to participation. Anonymity was ensured through the use of unique identifiers. All personal data were removed from transcripts, and audio files were securely stored on a secure institutional server.

Characteristics of the sample

In total, 21 participants were interviewed, including nine Nurses (N), two Head Nurses (HN), four Nurse Assistants (NA), and six Doctors (D). Participants ranged in age from 26 to 60 years, and 70% were women. Overall professional experience varied from 1 to 35 years, while tenure within the same ICU ranged from 1 to 30 years (Table 2).

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Table 2. Participants’ characteristics.

https://doi.org/10.1371/journal.pone.0348081.t002

Thematic analysis identified three main themes, further divided into eleven categories (Table 3), aligned with the study’s aim to explore the role of nursing resilience in managing critically ill patients infected with MDROs and in adhering to IPC protocols.

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Table 3. Themes, categories, and codes emerging from inductive content analysis of semi-structured interviews with intensive care unit staff.

https://doi.org/10.1371/journal.pone.0348081.t003

General overview of results

Overall, the findings indicated that resilience cannot be understood solely as an individual attribute. Rather, it develops through the interplay of personal resources, professional collaboration, and organisational conditions. The three themes reflect three distinct but interconnected levels of resilience: (a) individual and team-based dimensions of nurses’ resilience, (b) adaptive strategies employed by nurses in intensive care settings, and (c) dynamic interactions between nurse resilience and organisational support. This interdependence directly influenced patient safety and the effectiveness of MDRO infection prevention and control practices (Fig 3). Alongside protective factors, a less discussed dimension of resilience also emerged: a “dark zone” marked by forced adaptation, frustration, overload, and risk of burnout; reflecting processes described by Hobfoll’s [23] conservation of resources theory.

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Fig 3. Thematic overview of resilience processes and adaptive strategies in ICU nursing for MDRO management.

The figure illustrates three interconnected themes, individual and team resilience of nurses, nurse adaptive strategies in ICU, and the interaction between nurse resilience and organisational support, converging around the central construct of resilience in managing infectious risk and IPC practices. Each theme is detailed by its constituent categories, highlighting the multilevel and dynamic nature of resilience in high-complexity clinical settings. ICU: Intensive Care Unit; MDRO: MultiDrug-Resistant Organism; IPC: Infection Prevention and Control.

https://doi.org/10.1371/journal.pone.0348081.g003

Theme 1: Individual and team resilience of nurses

The first theme described how ICU nurses mobilised personal resources, professional competencies, positive emotions, and interpersonal dynamics [8,38] to ensure patient safety and continuity of care when managing critically ill patients infected with MDROs. Consistent with Hartmann et al.‘s framework [9], these individual and team-level resources represent the foundational layer of resilience, upon which adaptive strategies and organisational responses are built.

1.1 Self-Efficacy: personal efficacy and situational initiative.

Nurses demonstrated high levels of self-efficacy and initiative in enforcing isolation measures, including with staff external to the ward. In several instances, prompt implementation and reinforcement of IPC protocols proved decisive, as recounted by a head nurse:

“A newly hired nurse caring for a patient reminded the cardiac surgeon and their trainees to comply with PPE use to respect isolation rules for the infected patient” [HN2].

Similar assertiveness was reported across other high-complexity situations, including intra-hospital patient transfers (Table 4).

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Table 4. The most representative quotes by category and theme discussed in the results.

https://doi.org/10.1371/journal.pone.0348081.t004

Theme 2: Nurse adaptive strategies in the ICU

The second theme highlighted how nurses developed adaptive strategies to manage uncertainty, structural limitations, and organisational pressures when caring for MDRO-infected patients. These strategies stemmed from individual experience and professional training [6,39].

Theme 3: Interaction between nurse resilience and organisational support

The third theme illustrated how leadership, structural resources, and organisational culture significantly impacted IPC protocol compliance in the ICU.

Individual resilience, team dynamics, and leadership in the management of patients with MDROs

Participants described resilience as a combination of self-efficacy, advanced clinical skills, emotional regulation, and proactive engagement in complex contexts. These findings, detailed in Theme 1, show that nurses maintained composure, reorganised tasks, and supported colleagues even in the most demanding clinical situations. These elements reflect the principles of the broaden-and-build theory [22] which argues that positive emotions expand cognitive and behavioural repertoires, thereby supporting flexibility, creativity, and rapid decision-making in high-pressure situations [7]. In practical terms, fostering emotional regulation and self-efficacy in ICU nurses may represent a key target for resilience-building interventions in clinical practice. These findings have direct implications for ICU nurse recruitment and onboarding. Organisations should invest in structured induction programmes that explicitly develop self-efficacy, emotional regulation, and assertiveness in newly hired staff, rather than relying on informal socialisation processes that may perpetuate hierarchical imbalances.

In the highly pressurised ICU environment, these processes also occurred at the team level, influencing collective attitudes and behaviours and promoting trust, cohesion, and psychological safety, although at times these were hindered [8,9]. Mutual support, such as “timely sharing of information, assistance with invasive devices, or redistribution of tasks when a colleague was overloaded” [N6] (Theme 2), enabled teams to manage complex scenarios without individual isolation or overload. Supervision and mentoring further facilitated adherence to IPC among newer staff members, illustrating how individual and team resilience are interdependent [8,9,21]. At the team level, these results suggest that structured interprofessional briefings and debriefing sessions, particularly after critical events, could formalise the informal coordination mechanisms observed in this study, reducing cognitive load and preventing the accumulation of unaddressed tensions [16,17]. The interaction between individual resilience, team cooperation, and strong clinical leadership was found to form the basis of organisational resilience [9,11], particularly evident in the management of clinically unstable MDRO patients, where nurses needed to balance rapidly changing clinical conditions with IPC requirements. Without a supportive organisational culture, the effectiveness of resilience was reduced, heightening both emotional and operational pressures [3,12].

Nurse well-being, stressors, and advanced clinical practice

Findings from Theme 1 (category 1.4) showed that nurse well-being emerged as a central component in sustaining resilience and clinical safety [7]. Participants described numerous, multidimensional stressors, including decision-making under uncertainty, urgent clinical situations, simultaneous management of complex protocols, persistent structural deficiencies, delayed communication about potentially infected patients, limited risk awareness among consultants, and high responsibility for invasive devices and medication management. These factors align with established predictors of burnout and moral distress [20], which are an inherent part of everyday ICU work [6].

Nurses responded with resilient behaviours characterised by initiative, coordination, and emotional stability. Advanced clinical skills, anticipation of problems, autonomous management of non-conformities, interdisciplinary coordination, situational mentoring, and patient- and context-specific adaptation of IPC protocols helped maintain a “sense of control and mastery” [N3], essential for psychological well-being [17].

These findings suggest that supporting nurses’ advanced clinical practice and role recognition may be essential to sustaining resilient behaviours over time. However, several narratives revealed the “dark side” of resilience: the perceived need to endure at all costs, pressure to hide fatigue and vulnerability, difficulties seeking support, feelings of isolation and demotivation due to limited role recognition, and persistent fear of errors or contamination. Nurses also expressed frustration at inconsistent practices in other units or by other professionals, which sometimes reduced their willingness to maintain resilient behaviours. These accounts illustrate what the literature has termed “forced” or “dark side” resilience [23] a condition in which the sustained effort to maintain performance conceals underlying distress and increases vulnerability to burnout. This has direct implications for practice: organisations must move beyond expecting resilience as an individual capacity and instead create structural conditions that prevent forced adaptation.

It is important to acknowledge a critical limitation of resilience as both a theoretical and practical framework. When resilience becomes an institutional expectation rather than a personal resource, it risks functioning as a mechanism through which systemic failures are displaced onto individual practitioners, normalising structural deficiencies by valorising adaptive capacity as a professional virtue. Drawing on Hobfoll’s conservation of resources theory [23], this process can be understood as a form of resource depletion: when nurses are repeatedly required to compensate for organisational shortcomings, their personal and professional resources are progressively exhausted, increasing vulnerability to burnout and moral distress. The present findings provide empirical support for this concern, as several participants described feeling obligated to “always endure”, suggesting that resilience had shifted from a protective resource to an additional occupational burden.

Several ICU-specific barriers to sustainable resilience were identified in this study, including chronic understaffing, inadequate isolation infrastructure, fragmented inter-departmental communication, and inconsistent IPC training across professional groups (Theme 3, categories 3.2 and 3.3). These barriers are consistent with those reported in recent literature on ICU nursing complexity and workload [6,16,17], on the organisational determinants of HAI prevention [2,11,12], and on the relationship between nurse staffing, turnover, and care quality [19]. Taken together, these findings suggest that resilience-based interventions, in the absence of concurrent structural investment, are unlikely to produce lasting improvements in safety or staff well-being.

These findings both align with and extend existing evidence. Consistent with Hassan and Elsayed [7], nurses in this study demonstrated continuous adaptation, collaborative unity, and emotional balance as core resilience mechanisms. However, unlike studies conducted in less acute or less infection-intensive settings, the present research highlights a tension distinctive to ICU environments: the simultaneous management of life-threatening clinical instability and strict infection control requirements amplifies both the demands placed on resilience and the consequences of its failure [1,2,4]. This dual pressure, clinical and infectious, represents a specific burden not fully captured in existing resilience frameworks [8,9] and warrants targeted attention in future research and organisational policy [15].

Balancing IPC protocols and clinical urgency: resilient strategies in ICUs

A persistent tension emerged between IPC protocols and clinical urgency, where rapid decision-making and immediate interventions often made strict adherence to guidelines, usually designed for ideal conditions, challenging. As illustrated in Theme 2 (categories 2.1 and 2.2), nurses described situations in which the immediate need to save a patient’s life required temporary deviation from standard IPC sequences, followed by careful restoration of protocols once the emergency had passed. Protocols assume precise operational sequences, immediate resource availability, timely communication, and adequate isolation spaces and pathways [4,14]. Yet these conditions were frequently unmet because of structural constraints, inefficient logistics, incomplete or delayed information, sudden critical deterioration, and staffing shortage [18,19]. In response, nurses developed situation-specific adaptive strategies that went beyond procedural adjustments [3].

These strategies, documented across Theme 2 and Theme 3, included rapid micro-decisions to limit exposure, reorganisation of care pathways, temporary demarcation or repurposing of spaces, immediate sanitisation, mutual supervision, and constant negotiation with external services. Such adaptations enabled acceptable safety levels even under suboptimal conditions, demonstrating that MDRO management requires ongoing reinterpretation and optimisation of protocols through resilient skills, initiative, coordination, and creative problem-solving.

Without a supportive organisational culture, these adaptive strategies become more demanding, affecting psychological well-being and the sustainability of resilient practices. Nonetheless, the need for adaptation also highlighted resilience’s transformative potential: integrating technical skills, situational leadership, and team collaboration to enhance patient safety, foster operational innovation, and improve organisational efficiency [6,39]. These findings suggest that IPC training programmes should incorporate resilience-based approaches, preparing nurses not only to follow protocols but to safely navigate situations where strict adherence is temporarily compromised. At the organisational level, the findings point to the urgent need for integrated communication systems, adequate nurse-to-patient ratios, and clear protocols for intra-hospital patient transport involving MDRO-infected patients. These are not merely logistical improvements but prerequisites for sustaining safe and resilient nursing practice. In the absence of such support, resilience is unlikely to be sustained, leading to negative consequences for staff well-being and quality of care [23].

The findings of this study carry concrete practical implications for three interconnected areas of ICU organisation. First, regarding staffing: adequate nurse-to-patient ratios are a prerequisite, not a luxury, for resilient ICU practice. The data demonstrate that chronic understaffing does not merely increase workload [16,17] it fundamentally undermines the conditions under which individual and team resilience can develop and be sustained, with direct consequences for IPC adherence and MDRO containment [1,2]. Healthcare organisations should therefore treat staffing levels as a patient safety variable rather than a purely administrative one [19]. Second, regarding mentoring: the findings highlight the pivotal role of experienced nurses and head nurses in supporting newly hired staff through hierarchically complex and infection-sensitive situations [11]. Formalising mentoring relationships, particularly during the first months of ICU practice, could systematically transfer the tacit resilience competencies observed in this study, reducing both clinical risk and the emotional isolation reported by junior nurses [8,9]. Third, regarding mental health support: the “forced resilience” dynamic identified in this study, characterised by pressure to conceal fatigue, minimise vulnerability, and maintain performance at personal cost, represents a significant and under-addressed occupational health risk [20,23]. Healthcare organisations should implement proactive, non-stigmatising psychological support programmes for ICU staff, including structured peer support, access to clinical psychology services, and regular well-being monitoring, as integral components of any organisational resilience strategy [7,18].