Free Developing resilience: the role of nurses, healthcare teams and organisations
Caroline Barratt Lecturer, School of Health and Human Sciences, University of Essex, Colchester, Essex, England
» To understand the individual’s and organisation’s role in developing and supporting resilience, and how this may lead to improvements in job satisfaction for staff, workforce sustainability and patient care
» To engage in activities that support reflection on your resilience and strategies that you can use to improve your resilience and that of others
» To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)
» To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Discussions about the sustainability of the healthcare workforce have placed considerable emphasis on improving the resilience of healthcare professionals. However, when discussed in relation to individuals, the contextual aspects of resilience are often lost. This means that individuals are burdened with the responsibility of increasing their resilience so that they can better manage the challenges they experience, rather than examining the external and environmental factors that can affect resilience. This article explores the concept of resilience and suggests ways in which resilience can be developed by individuals and in collaboration with others, resulting in resilient healthcare teams and organisations capable of supporting individuals effectively. It aims to assist healthcare professionals to develop their resilience, while also improving their understanding of the complex factors that can affect their coping capacity, as well as how community influences the resilience of everyone.
Nursing Standard. doi: 10.7748/ns.2018.e11231Citation
Barratt C (2018) Developing resilience: the role of nurses, healthcare teams and organisations. Nursing Standard. doi: 10.7748/ns.2018.e11231Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Published online: 28 August 2018
burnout - compassion - mental health - mindfulness - morale - organisational culture - patient experience - patients - personal development - professional issues - public health - staff welfare - wellbeing - workforce
Aims and intended learning outcomes
This article aims to improve nurses’ understanding of the concept of resilience. It provides the opportunity for nurses to reflect on their resilience and outlines strategies that they can use to improve their resilience and that of others. After reading this article and completing the time out activities you should be able to:
• Describe what is meant by resilience.
• Reflect on how resilient you feel you are and the factors that might be influencing this.
• Understand and discuss how resilience is affected by external factors such as the work environment and relationships with colleagues, and how this can affect nursing practice.
• Develop skills to increase your resilience and support the resilience of others.
• There is concern that focusing on the resilience of individuals to manage adversity and precarious circumstances diverts attention from the collective responsibility of society to protect individuals. This means that failure to cope with challenges is constructed as a failure of the individual, who is considered to have not developed sufficient resilience, rather than taking into account contextual factors, such as social attitudes or public policy (Traynor 2017, Gill and Orgad 2018)
• While the psychological characteristics of an individual contribute to their resilience, it is also influenced by various external and environmental factors. For example, if a challenging issue occurs, the financial, social and physical resources that an individual possesses to cope with it will affect how resilient they are and how quickly they can recover
• Southwick et al (2014) emphasised that ‘it is critical to understand that humans are embedded in families, families in organisations and communities, and communities in societies and cultures’, and that their resilience will be affected by factors at each of these levels. Therefore, the link between resilience and workplace culture should also be taken into account when identifying what can be done individually and collectively to contribute to resilient healthcare teams and organisations
• Trueland (2018) asserted that ‘resilience is not about trying harder’, and suggested that resilient healthcare organisations should be created, which can support staff members effectively
The rate at which nurses are leaving the profession is a significant cause for concern in relation to workforce sustainability in healthcare. The Nursing and Midwifery Council (NMC) (2017) reported that more than 29,000 UK nurses and midwives left the register in 2016-17, which is a 9% increase compared with figures for 2015-16. The House of Commons Health Committee (2018) reported that: ‘In too many areas and specialties, the nursing workforce is overstretched and struggling to cope with demand. Over the course of our inquiry, we heard concerns about the impact of these pressures on morale, retention and standards of care for patients and patient safety.’
An NMC (2017) survey of nurses who had left the profession between June 2016 and May 2017 identified that 44% left because of working conditions, for example staffing levels and workload. A total of 27% stated that they left because of disillusionment with the quality of care offered to patients. These findings are reflected in Koy et al’s (2015) literature review, which identified that job dissatisfaction and burnout contributed to the ‘intention [of nurses] to leave, absenteeism, turnover, and adverse outcomes in hospital care’. Additionally, Koy et al (2015) emphasised that nurse burnout is not only detrimental for nurses, but has also been associated with lower levels of patient satisfaction and quality of nursing care. Therefore, the ability of nurses to cope with their professional role has become an area of interest and concern.
Developing resilience among nurses is important from three main perspectives: ensuring the well-being of nurses; workforce sustainability; and quality of care. However, it is important to note that the increased use of the term ‘resilience’ has been subject to growing criticism. There is concern that focusing on the resilience of individuals to manage adversity and precarious circumstances diverts attention from the collective responsibility of society to protect individuals. This means that failure to cope with challenges is constructed as a failure of the individual, who is considered to have not developed sufficient resilience, rather than taking into account contextual factors, such as social attitudes or public policy (Traynor 2017, Gill and Orgad 2018).
Resilience and nursing
To understand the issue of resilience in nursing, it is important to first determine what is meant by resilience. Resilience has been conceptualised in various ways and is used in a range of disciplines. In nursing research, the term resilience is often specifically related to the professional challenges that nurses experience, and is viewed as a personal capacity that enables nurses to manage the demands of the workplace (Hart et al 2014).
There have also been several psychological conceptualisations of resilience, reflected in the development of various psychological measures of resilience. For example, the Connor-Davidson Resilience Scale (Connor and Davidson 2003) comprises 25 items to assess a range of factors that can affect resilience, including self-esteem, sense of control, commitment, adaptability, health and humour. This measure may be useful because understanding what contributes to resilience can enable the identification of ways to improve it. Another measure is the Brief Resilience Scale (Smith et al 2008), which was developed as a means of measuring resilience specifically – an individual’s ability to ‘bounce back’ or recover from stress – as opposed to measuring the factors that may contribute to resilience. However, both the definition from Hart et al (2014) and the psychological conceptualisations of resilience focus on the resilience of the individual, without taking into account the contextual factors that affect a person’s capacity to cope with adversity.
Masten (2015) defined resilience as the capacity to positively and successfully adapt to challenging circumstances or adversity, describing how this capacity manifests at various levels, including individuals, families and communities. Southwick et al (2014) described how ‘determinants of resilience include a host of biological, psychological, social and cultural factors that interact with one another to determine how one responds to stressful experiences’. As a result, the resilience of an individual is not considered a feature of their character or as a personality trait. While the psychological characteristics of an individual contribute to their resilience, it is also influenced by various external and environmental factors. For example, if a challenging issue occurs, the financial, social and physical resources that an individual possesses to cope with the issue will affect how resilient they are and how quickly they can recover.
Aspects of nursing practice that might negatively affect resilience
Caring for people who are unwell or injured, as well as addressing the needs of their family and friends, places considerable demands on professional caregivers. Nurses are expected to manage their feelings and emotions so that they appear ‘professional’ at all times, finding a balance between showing empathy and compassion while ensuring that strong reactions that may arise from these circumstances remain under control. The need to manage emotions in line with professional expectations is referred to as ‘emotional labour’ (Wharton 2009).
Delgado et al (2017) explored how the emotional labour of nurses affected their resilience, emphasising that emotional labour is a component of all nursing practice, including providing care for patients and their family and friends, as well as working with colleagues. In particular, they emphasised how ‘emotional dissonance’ (the discord between the emotions an individual experiences and the emotions they express to demonstrate conformity to a professional identity) that arises from pretending that they feel other than they do, can be particularly burdensome and contributes to stress and burnout. The dissonance arises from nurses having to continually act professionally, containing their emotions and appearing calm while internally potentially feeling upset and anxious. However, it is not only the nature of nursing practice that might pose a threat to the well-being of nurses; the organisational, social and political contexts in which they work are also relevant.
Sir Robert Francis QC, chair of the inquiry into care failings at Mid Staffordshire NHS Foundation Trust, stated that (House of Commons Health Committee 2018): ‘A huge number of staff are working in, frankly, unacceptable and unsafe conditions. I believe that must impact particularly on nurses, because of their role in the front line, being professionally responsible for the standard of care delivered on a minute-by-minute basis to patients, allied sometimes to the feeling that they cannot do it… and the stress of not being able to deliver what a nurse or a professional knows should be delivered. That must make life impossible.’ This quote illustrates that several other factors compound the challenges experienced by healthcare professionals, resulting in tension between the care they have been trained to provide and the care they are actually able to provide.
Time out 1
Becoming aware of the emotional labour involved in nursing practice is important for resilience. Such awareness encourages nurses to appreciate the work they do and the demands that it places on them. Reflect on the following questions:
• Does the role you undertake frequently involve emotional labour?
• What is it about emotional labour that you find particularly rewarding or challenging?
• In what ways does your working environment support you in undertaking emotional labour? In what ways does your working environment make undertaking emotional labour challenging?
You may wish to note down your answers individually or discuss them with a colleague
Resilience, well-being and burnout
Having established that there are components of a nurses’ professional role that might compromise their resilience, it is important to consider the effects that suboptimal resilience might have on nurses’ well-being and patient care. One area of research where the evidence is most tangible regards the link between resilience and burnout.
Research has shown that a high level of resilience among nurses working on an intensive care unit is significantly associated with lower rates of post-traumatic stress disorder, anxiety and depression, and burnout (Mealer et al 2012). Rushton et al’s (2015) study of burnout and resilience explored the relationship between resilience and the three components of burnout: lack of personal accomplishment, emotional exhaustion and depersonalisation. They found that nurses who scored higher on the resilience measure experienced less emotional exhaustion and a greater sense of personal accomplishment in their work. Greater physical well-being was also positively related to personal accomplishment. Similarly, research by Gillespie et al (2007a, 2007b) found that positive mental states such as self-efficacy, hope and coping were related to increased resilience, with a particularly strong correlation between hope and resilience. Therefore, developing resilience among nurses and other healthcare professionals is about preventing burnout and protecting their well-being, as well as improving how they respond to stressors as they continue to work in challenging roles.
Time out 2
Thinking about the definitions of resilience, spend 10-15 minutes reflecting on how resilient you feel you are at the moment. Use the following prompts to assist you:
• When you experience a challenging or stressful situation, how able do you feel to respond to it and recover from it?
• Do you find it more challenging to cope with stress now than you did previously? What has changed?
• When you leave work, how able are you to not think about work? How does this affect you?
Developing individual resilience
There are various ways that resilience can be improved. While the actions an individual might take to increase their resilience should be considered, Southwick et al (2014) emphasised that ‘it is critical to understand that humans are embedded in families, families in organisations and communities, and communities in societies and cultures’, and that their resilience will be affected by factors at each of these levels. Therefore, the link between resilience and workplace culture should also be taken into account when identifying what can be done individually and collectively to contribute to resilient healthcare teams and organisations.
Becoming aware of how one expends one’s energy, and the balance between activities undertaken that are draining and depleting, compared with those that are restoring and nurturing, is an important part of developing resilience and identifying opportunities for improved self-care. Nurturing activities are those that bring enjoyment or satisfaction, restore energy and provide a sense of well-being, while depleting activities are those that are draining, that one may feel obligated to complete and are not accompanied by a sense of well-being.
Time out 3
Sit down in a quiet space. Using the table that follows, or on a separate notepad, list the activities that you engage in in your life that you find nurturing in the left column and those that you find depleting in the right column. Complete this task quickly, without thinking too much or censoring yourself.
Take some time to reflect on the two lists you have written down. Is there anything that surprises you? Are there any actions you could take to increase the time you spend on nurturing activities, or to reduce the time you spend on depleting activities? Note that it is unlikely that you will be able to remove all depleting activities from your life; the purpose of this exercise is to enable you to identify the balance you have between these two types of activities
One suggestion for improving resilience is the development of greater emotional intelligence. Karimi et al (2014) stated that emotional intelligence refers to ‘the ability to identify, assess, manage and control self and reactions to others’ emotions’. In their study on the relationship between resilience and emotional intelligence, Karimi et al (2014) found that emotional intelligence was shown to moderate nurses’ responses to stressful events. Similarly, Armstrong et al (2011) demonstrated that emotional self-awareness, expression and self-management minimise the effects of adverse events, and suggested that emotional self-control also has a role in reducing these effects.
Interventions aimed at increasing emotional intelligence typically involve education on the theoretical underpinning of emotional intelligence, along with training in practical skills for day-to-day life and the use of personal reflection to develop nurses’ awareness of how they manage situations. Nelis et al (2009) described the emotional intelligence training intervention they used in their research as focusing ‘on teaching theoretical knowledge about emotions and on training participants to apply specific emotional skills in their everyday life’. The results from their study showed a significant increase in emotion identification and emotion management abilities in the intervention group, which persisted at follow-up after six months.
Mindfulness is often associated with emotional intelligence, and several emotional intelligence interventions include mindfulness training as a component. The evidence has not yet demonstrated a clear understanding of the relationship between emotional intelligence and mindfulness, but there is some evidence to suggest that improved self-awareness resulting from mindfulness practice can support the development of emotional intelligence (Snowden et al 2015).
A concerning trend in relation to resilience, and in self-help literature more broadly, is that individuals are often encouraged to move on quickly from any challenging experiences – replacing any negatives with positives. Gill and Orgad (2018) noted the ‘oppressive speed with which suffering and pain are white washed’, and were critical of an individualised model of resilience that emphasises ‘psychological elasticity and bouncing back, and the requirement to reframe adversity as an opportunity for growth’ because it strongly suggests that individuals can make a choice to be happy and well, with challenging or negative experiences ‘outlawed’ or overcome as quickly as possible. This is likely to be particularly challenging for nurses who are already experiencing considerable emotional dissonance in their practice, for example having to suppress difficulties in the moment in order to cope with, and care for, patients and colleagues.
Practising mindfulness involves developing a willingness to be present with one’s experience, even when that experience is unpleasant or challenging, and learning to respond skilfully to whatever is happening. While mindfulness has been associated with decreased anxiety and depression (Hofmann and Gómez 2017), it is thought that this relief has not occurred through denying negative feelings or emotions, but through having a different relationship with them, in which the individual is not as closely identified with the experience.
Mindfulness practice can be developed in several ways, and some workplaces provide training in this area. Research suggests that even undertaking short mindfulness practices regularly can have a positive effect (Gauthier et al 2014). For a detailed discussion of mindfulness in nursing, see Barratt (2017) or Barratt and Wagstaffe (2018).
Self-compassion can be a challenging concept for some nurses, particularly when they have been trained to focus on caring for others. Halifax (2008) discussed the need to ‘see my own limits with compassion’, which is especially important in maintaining resilience.
Neff (2003) described three components of self-compassion: mindfulness, self-kindness and common humanity. Developing self-compassion is about improving one’s awareness of oneself and others, and increasing one’s capacity to be kind towards everyone, including oneself. It may be beneficial for nurses to review their response to Time out 3 to identify opportunities to act compassionately towards themselves. They could consider if there are opportunities to reduce the number of depleting activities they currently engage in, or to increase their engagement with nurturing activities.
Self-compassion is not just about what an individual does; fundamentally, it is about the quality of the relationship the individual has with themselves. Developing awareness of negative cycles of thought and self-talk is important for improving nurses’ resilience, enabling them to become a source of support and kindness for themselves, even in the face of challenging external circumstances. Gilbert and Choden (2013) observed that critical and negative self-views are associated with mental health issues and that such views contribute to feelings of threat – for example, an individual feeling ‘attacked’ when their manager points out a mistake they have made – all of which negatively affect resilience.
Resilience, colleagues and workplace culture
This article has emphasised the importance of understanding that external factors unavoidably affect the resilience of individuals. Trueland (2018) asserted that ‘resilience is not about trying harder’, and suggested that resilient healthcare organisations should be created, which can support staff members effectively. The suggestions for improving resilience outlined in this section are not only for nurses to consider as individuals; they should be shared with colleagues, and managers should take steps to embed these within their healthcare organisation. This would assist in ensuring that the task of improving resilience is shifted beyond the level of the individual.
Establishing a supportive workplace culture
How colleagues work together is fundamental to establishing a supportive workplace culture, and feeling supported in the workplace is important for resilience (Koy et al 2015). Senior staff members with managerial responsibility might have an understanding of how their relationships with colleagues can contribute to the resilience of others, resulting from their responsibilities and experiences of supporting colleagues having challenging experiences. How nurses treat their colleagues can have significant effects on the well-being and resilience of the healthcare team. While effective leadership is important in establishing supportive work environments, all healthcare staff contribute to the atmosphere of the workplace.
Time out 4
Given that all individuals contribute to each other’s well-being and resilience, it is important to consider how we communicate with and treat others. When an individual feels stressed, their communication can deteriorate and have subsequent effects on others. The workplace culture also influences the quality of communication between colleagues, as well as opportunities for open and honest communication. Consider the following:
• How do you speak to your colleagues at work? What tone and language do you use? Does this change when you are feeling stressed?
• Do you feel you work in a supportive atmosphere? What is it that makes it feel supportive or unsupportive? How do you contribute to this atmosphere?
• Are there issues that need to be addressed to encourage a supportive atmosphere? Do you feel you have a space at work in which to raise your concerns in a constructive way?
• If you are a team leader or have a managerial or supervisory role, how might you be able to create a space in which concerns can be shared in a safe environment? Could you share this exercise with your colleagues to explore these issues collaboratively?
As well as individual reflection, collective reflection has also been shown to support resilience. Schwartz Rounds are a form of group reflection developed for healthcare organisations, and have been shown to support staff well-being, teamwork and effective care (Chadwick et al 2016). These provide a reflective space in which staff share and reflect on their experience of working within the healthcare organisation, with a particular focus on their emotional experiences. The aim of sharing experiences in this way is not to problem-solve, but to make the emotional effects of their work more explicit. This encourages emotional resonance by providing colleagues with an insight into each other’s emotional experience, enabling them to feel less isolated and more trusting of each other, resulting in clear communication and improved care (Farr and Barker 2017).
Attending Schwartz Rounds in the workplace can be an effective means of support for nurses, developing a sense of community and increasing understanding between colleagues, whatever their role in the healthcare organisation. If Schwartz Rounds are not available in their healthcare organisation, nurses may wish to suggest this as a possible intervention. More information on Schwartz Rounds is available at: www.pointofcarefoundation.org.uk
Working for change and remaining hopeful
Gillespie (2007a) noted that there is a relationship between hope and resilience, and emphasised the importance of healthcare team cohesion for maintaining hope: ‘…our ﬁndings revealed a highly signiﬁcant statistical association between hope and resilience… it seems likely that it may be enhanced in a supportive work environment… In short, a supportive workplace may well reduce the effects of potential stressors and enhance hope as an explanatory variable of resilience… nurses may well lose hope if they experience recurrent failures in relation to professional and social integration in context.’
Remaining hopeful when faced with challenging circumstances assists nurses to manage such situations effectively, and having supportive relationships with their colleagues can enable them to remain hopeful.
Another important component of hope is being able to see how situations might change for the better. This may involve implementing change in healthcare teams and organisations, or empowering individuals to speak out when they observe suboptimal practice and be able to voice their wider concerns and needs without fear of repercussions. However, the need to cultivate hope among nurses as a means to support their resilience also encourages exploration of wider questions about their political engagement. Cuthill (2016) described a lack of skills and confidence in this regard among the nursing community, noting that ‘nurses in both academia and practice understand the texture of social and structural constraints, but often lack the skills to challenge them’. In finding the confidence to collectively challenge these issues, hope can arise.
It might be challenging for some nurses to find the energy and time to contribute to these wider debates. However, connecting with others who are politically engaged can remind nurses of the contribution they make to society more broadly, enabling them to place local frustrations and challenges in a wider context. Traynor (2017) described how social media is acting as a democratising force ‘enabling nurses to overcome [these] individualising, or ‘responsibilising’ forces’ through community.
It is important for nurses to remember the importance of self-care and not becoming overwhelmed by taking on too much. While social media can be a positive source of support and a space to share ideas, it can be detrimental to one’s well-being if used excessively or inappropriately. Nurses should also remember to think carefully before sharing anything online.
Time out 5
Spend ten minutes reflecting on what you have learned from reading this article and completing the time out activities. List three points you wish to explore further or take action on in relation to resilience. Consider sharing this article with your colleagues or manager to promote discussion about the issues it raises
Improving resilience among nurses is not only likely to enhance the well-being of individuals, but may also contribute to an increasingly supportive workplace culture, as individuals become less stressed and better able to relate positively to colleagues and patients. Supporting the development of increasingly resilient individuals, healthcare teams and organisations may lead to improvements in job satisfaction for staff, workforce sustainability and patient care.
It is important to emphasise the need to be kind to oneself and each other. The way that well-being has been constructed in society and in the media suggests that individuals should always have the capacity to cope, be healthy and gain strength from adversity. However, this has meant that the extent of challenges that individuals can experience might be overlooked. Therefore, it is important that the need to become resilient does not become another source of self-criticism or blame. This does not mean that individual nurses cannot take responsibility for improving some aspects of their well-being, but that wider organisational, social and political contexts affect resilience; therefore, it is important not to burden individuals with a task for which they are only partly responsible. It is crucial to appreciate that individuals cannot be resilient independently of each other and the world around them; each has an effect on the resilience of the other.
Time out 6
Consider how developing resilience and maintaining your well-being relates to The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives (NMC 2015) or, for non-UK readers, the requirements of your regulatory body
Time out 7
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account
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